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Indications, preparation, and adverse effects

Key points The primary indications for diagnostic endoscopic ultrasound (EUS) are cancer diagnosis and staging; assessment (usually combined with EUS fine-needle aspiration [FNA]) of lymph nodes; and evaluation for pancreatic disease, bile duct pathology, and subepithelial lesions of the gastrointestinal tract. Typically, diagnostic EUS is indicated when there is potential additive value after noninvasive imaging has been performed. Common indications for therapeutic EUS include drainage of…

Training and simulators

Key points Endoscopic ultrasound (EUS) is an advanced endoscopic procedure that is operator dependent, and training in a structured program is required for the development of cognitive, technical, and integrative skills beyond those required for standard endoscopic procedures. The consensus opinion on the ideal format for EUS training is through a structured, hands-on experience with patients in a supervised setting. Self-education, reliance on animal models, computer-based…

Equipment

Key points Endoscopic ultrasound (EUS) guided interventions using the linear echoendoscope comprise a much larger space within EUS services; however, traditional radial EUS scopes and miniprobes are still required. Core biopsies have largely supplanted fine-needle aspiration for solid tissue. Obtaining portal pressures within the field of “endohepatology” has been an exciting advance. Needle-based probes along with refinements in the processor offer detailed pancreatic cyst imaging. Further…

Principles of ultrasound

Key points Ultrasound is mechanical energy in the form of vibrations that propagate through a medium such as tissue. Ultrasound interacts with tissue by undergoing absorption, reflection, refraction, and scattering and produces an image representative of tissue structure. Imaging artifacts can be recognized and understood based on a knowledge of the principles of ultrasound. Basic ultrasound physics Sound is a mechanical energy in the form of…

Palliation of Malignant Pancreaticobiliary Obstruction

Introduction Pancreaticobiliary malignancies comprise a mixed bag of cancers including pancreatic cancer, carcinoma of the ampulla of Vater, duodenal carcinoma, gallbladder carcinoma, and cholangiocarcinomas. When they are located at the level of the liver hilum, cholangiocarcinomas are referred to as Klatskin's tumors . Although there are marked differences in biologic behavior and clinical outcome, the overall prognosis of these tumors is dismal. At the time of…

Evaluation and Staging of Pancreaticobiliary Malignancy

EUS for the Evaluation and Staging of Pancreatic Tumors Introduction Examination of the pancreas and biliary structures by endoscopic ultrasound (EUS) can be technically challenging to master due to the need to recognize patterns of normal, benign, and pathologic anatomy. However, once these skills are learned, EUS permits the most detailed nonoperative view of the pancreas and the bile ducts. This chapter summarizes the role of…

Pancreatic Cystic Lesions

Pancreatic cysts are relatively rare lesions, and their diagnosis has increased with the widespread availability and use of cross-sectional imaging. In many cases pancreatic cysts are detected on imaging performed for another indication; however, they can also be seen in patients with symptoms such as abdominal pain or jaundice. Pancreatic cysts are reported to be found in 3% of computed tomography (CT) scans and 20% of…

The Indeterminate Biliary Stricture

Introduction Indeterminate biliary stricture (IDBS) remains one of the biggest challenges that pancreaticobiliary endoscopists face. While a strict definition of IDBS is frequently not adhered to in the literature, this term refers to biliary strictures with no overt mass on noninvasive imaging such as computed tomography (CT) or magnetic resonance cholangiopancreatography, and that cannot be distinguished as malignant or benign after standard diagnostic procedures such as…

Chronic Pancreatitis

Introduction Chronic pancreatitis (CP) is an inflammatory condition that results in fibrosis causing destruction of pancreatic parenchyma and ducts. These permanent structural changes can lead to impairment of exocrine and endocrine function, biliary strictures, and may increase the chances of developing pancreatic cancer. This disorder contrasts with acute pancreatitis in that the latter is non-progressive, and the gland returns to histologic and functional normalcy once the…

Pancreatic Fluid Collections and Leaks

Introduction Pancreatic fluid collections (PFCs) and leaks develop due to main or secondary pancreatic ductal disruption caused by acute or chronic pancreatitis, trauma, or pancreatic surgery. PFCs include acute fluid collections, acute necrotic collections, pseudocysts, and walled-off necrosis. Most nonnecrotic PFCs resolve spontaneously without need for drainage. Fluid collections that have become infected, or those that cause persistent symptoms, warrant drainage. Drainage of PFCs has historically…

Recurrent Acute Pancreatitis

Introduction Acute pancreatitis (AP) has an excellent prognosis if the severity is limited, and if the underlying cause can be identified and treated. However, AP may recur if the underlying causes are not eliminated or modified. Patients with recurrent AP (RAP) endure frequent emergency room (ER) visits and hospitalizations, costly testing, potentially risky interventions, and may eventually develop chronic pancreatitis (CP) and related functional impairment. Thus,…

Sphincter of Oddi Disorders

Introduction Functional disorders of the biliary tree and pancreas are controversial topics, with insufficient scientific evidence to provide clear guidelines for clinical practice. This chapter attempts to summarize what is known, what is unclear, and what studies need to be done. One author (PBC) was recently involved in the comprehensive Rome IV process, conclusions from which have been published. One recommendation was to change the names…

Infections of the Biliary Tract

Introduction The word cholangitis is a pathologic term that means “inflammation of bile ducts.” It is a broad term and does not imply any specific diagnosis. In clinical practice, cholangitis is defined on the basis of symptoms and signs of systemic sepsis originating in the biliary tract. The most important predisposing factor for infections of the biliary tract, including the common bile duct (CBD) and gallbladder,…

Postoperative Biliary Strictures and Leaks

Introduction Accidental injuries of the bile ducts leading to biliary leaks and strictures may occur during any surgical procedure involving the biliary tract. However, the main causes of injury of the bile ducts at the present time are laparoscopic cholecystectomy (LC) and after liver transplantation (LT). Although LC has proved to be superior to open cholecystectomy in terms of shorter hospitalization, lower overall morbidity, faster recovery,…

Gallstone Disease: Choledocholithiasis, Cholecystitis, and Gallstone Pancreatitis

Introduction Symptomatic gallbladder disease is one of the most common conditions encountered by the gastrointestinal endoscopist. It accounts for over 225,000 hospital discharges per year and over 2 billion health care dollars spent per year. Whereas gallbladder disease can manifest itself in a variety of forms, it is the development and presence of gallstones which is responsible for the majority of disease. Typically, the presence of…

Endoscopic Ultrasound–Guided Access and Drainage of the Pancreaticobiliary Ductal Systems

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) has traditionally represented the optimal approach to the bile duct and the pancreatic duct. However, ERCP is not always successful because of the inability to achieve selective cannulation or because of inaccessibility of the papilla owing to gastric outlet obstruction (GOO) and surgically altered anatomy (e.g., Roux-en-Y gastric bypass). Recently, new endoscopic drainage techniques guided by endoscopic ultrasonography (EUS) have been…

Endoscopic Ultrasound and Fine-Needle Aspiration for Pancreatic and Biliary Disorders

Introduction Endoscopic ultrasound (EUS) is a powerful technique that is integral to the management of many patients with biliary and pancreatic disease. EUS provides detailed images of the extrahepatic biliary tree and pancreas with very little risk to the patient, and is useful in the evaluation of obstructive jaundice, biliary or pancreatic ductal dilation, pancreatic masses, and pancreatitis. EUS and endoscopic retrograde cholangiopancreatography (ERCP) can be…

Difficult Cannulation and Sphincterotomy

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) requires several years of dedicated training and continuous refinement of knowledge and skill. Selective ductal cannulation is the sine qua non for diagnostic and therapeutic ERCP. General issues on cannulation have already been highlighted in Chapter 40 . In a 2017 consensus report, difficult papillary access is defined as the inability to achieve selective biliary cannulation by standard ERCP techniques within…

Cholangiography and Pancreatography

Introduction Endoscopic cannulation of the major papilla with imaging of the biliary tree and the pancreatic ductal system (endoscopic retrograde cholangiopancreatography [ERCP]) was first successfully accomplished with an end-viewing duodenoscope and reported in 1968. Subsequent development of side-viewing endoscopes with a catheter-deflecting elevator greatly advanced the technique. Diagnostic studies were supplemented by the first endoscopic sphincterotomies in the early 1970s. Overall, these developments expanded the field…

Preparation for Pancreaticobiliary Endoscopy

Introduction Pancreaticobiliary endoscopy focuses on the diagnosis and therapy of conditions involving the pancreas and biliary tree, and distinguishes itself from luminal endoscopy by a greater use of side-viewing endoscopes and echoendoscopes and the use of fluoroscopy. As discussed in Chapter 1 , endoscopic retrograde cholangiopancreatography (ERCP) was first performed in the early 1970s, and endoscopic ultrasound (EUS) was introduced in 1980 for transluminal evaluation of…