Eus beyond mucosa and beyond gastroenterology

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introductory about EUS, indications and frontiers

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  • Bowel wall seen with 5 alternating hyperechoic and hypoechoic layers – first interface between superficial mucosa and water, second mucosa and muscularis mucosae, third submucosa, fourth muscularis propria, fifth serosa and perirectal fat Carcinomas hypoechoic and degree to which disrupt and penetrate rectal wall suggests local stage First picture - , second radial echoendoscope
  • Not only we that we can see but also we can toutch
  • Eus beyond mucosa and beyond gastroenterology

    1. 1. EUS beyond mucosa and beyond Gastroenterology Ahmed Alwassief MD
    2. 2. • A novel technology that combines visualisation of the mucosa and radiologic power to see beyond “ deep to the mucosa” • The role of EUS has continued to expand with the introduction of EUS-guided fine needle aspiration (FNA) of mural, extra-mural, and pancreatic lesions. • In the year 2000 guidelines for the use of EUS were established
    3. 3. • Equipment • Technique • Indications • Staging cancers • Benign disease
    4. 4. Equipment • Radial • Linear
    5. 5. Technique • Preparation – As for normal upper GI endoscopy • Sedation – Alfentanyl and midazolam – Propofol • Antibiotic prophylaxis – Usual indications + biopsy / therapeutics
    6. 6. Indications • Staging cancers – Oesophageal, gastric, rectal & pancreatico-biliary Specifically for nodal disease and FNA • Confirming EMR potential – T1 disease, excluding sub-mucosal involvement • Diagnosis and follow up of benign lesions – GIST, lipoma, cysts • Investigating RUQ pain “Choledocholithiasis” • Investigating pancreatitis • Therapeutic Techniques: celiac neurolysis, fudicial placment, cyst gastrostomy , Hepatico-gastrostomy, pancreatico- doudenal fistulotomy
    7. 7. Staging
    8. 8. Hyperechoic mucosa Hypoechoic muscularis mucosa Hyperechoic submucosa Hypoechoic muscularis propria Hyperechoic serosa
    9. 9. • T lesion, adenocarcinoma in lower thoracic esophagus with central depression shown by yellow arrow (a); endoscopic ultrasound (EUS) • image showing submucosal invasion but no involvement of muscularis propria (MP) shown by yellow arrow (b).
    10. 10. • T3N2Mx lesion
    11. 11. • Gastric lymphoma causing a linitis plastic appearance. This patient with a diffusely infi ltrating B - cell lymphoma has poorly distensible thickened abnormal - appearing gastric folds on endoscopy (a). On endoscopic ultrasound (b), there is preservation of the fi ve - layer pattern but markedthickening of the gastric wall to 10.9 mm with a thickened muscularis propria to 2.5 mm (normal 1 mm or less).
    12. 12. Gastrointestinal Subepithelial Masses
    13. 13. Gastric varices
    14. 14. Pancreatic masses “ Solid & cystic” • The detection of pancreatic masses < 2cm in diameter was higher for EUS:  EUS (100%)  ERCP (57%)  TUS (29%)  CT (29%)  Angiography (14%)
    15. 15. Pancreatic cysts • Pseudocyst • Serous • IPMN • Mucinous Can be diagnosed by 1.Morphology 2.FNA and cyst fluid analysis of Amylase and CEA levels
    16. 16. 8 cm Pseudocyst + debries
    17. 17. T3 Pancreatic Adenocarcinoma
    18. 18. T3 Pancreatic Tumor
    19. 19. Fine Needle AspirationFine Needle Aspiration
    20. 20. Pancreatic Mass
    21. 21. Liver Metastasis
    22. 22. EUS-Guided FNA Reported Complications: • Infection (cysts >>solid mass) • Pancreatitis (<1- 2%) • Bleeding
    23. 23. Biliary diseases
    24. 24. Therapeutic EUS • CPN and CPB • Botulinum injection in achalasia • EUS-guided Ablation of tumors and cysts Radiofrequency, or alcohol injection • EUS-guided placement of radiographic markers • EUS-guided drainage procedures “ cysts, abscesses, CBD, hepatic duct and pancreatic duct”
    25. 25. Chronic Abdominal Pain& CPB or CPN? • Can be a clinically challenging problem especially if narcotic analgesia is indicated At that point CPN or CPB can help in • Pain relief • Improving quality of life
    26. 26. Celiac Plexus BlockCeliac Plexus Block
    27. 27. EUS Guided radio-frequency or ETOH tumor ablation
    28. 28. EUS GUIDED Hepatico-Gastrostomy Panc. cancer
    29. 29. EUS GUIDED CHOLEDOCHO-DUODENOSTOMY
    30. 30. Extra Gastrointestinal applications EUS guided Mediastinal LN biopsy PA LA

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