The update: endoscopic ultrasound in the diagnosis and treatment of gastroenterology disease

THE UPDATE: ENDOSCOPIC ULTRASOUND IN 
THE DIAGNOSIS AND TREATMENT OF 
GASTROENTEROLOGY DISEASES
THE FIRST NATIONAL ULTRASOUND 
CONFERENCE
Prof.Tran Van Huy - Dr.Vinh Khanh
Department of Internal Medicine - Hue University of Medicine and Pharmacy 
OBJECTIVES
1
2
Overview of endoscopic ultrasound
1
The role of EUS in the diagnosis 
2
3 The role of EUS in the treatment
3
Conclusion5 4
6
hinhanhykhoa.com
OBJECTIVES
1
2
Overview of endoscopic ultrasound
1
The role EUS in the diagnosis 
2
3 The role EUS in the treatment
3
Conclusion5 4
6
Interventional Endosonography (2017)
1st TTS EUS Probe (1976)
ENDOSCOPIC ULTRASOUND
The way to progress
• Integrated EUS scopes (1980) 
• Color Doppler
• Single frequency scopes (1980)
• 1st EUS guided cholangiography (1996)
• Variable frequency scopes (1985)
• 1st EUS – FNA (1991)
• Large Channel Scopes 
• 1st EUS guided CD-stomy (2002) 
hinhanhykhoa.com
ENDOSCOPIC ULTRASOUND
Radial
For diagnosis
Linear
Diagnosis and intervention
Mini probe
12MHz – 20 MHz
LL
GI Atlas, Wiley
Imaging 
perpendicular to the 
endoscope
Imaging parallel to 
the endoscope
Radial EUS
Linear EUS
RADIAL - LINEAR
hinhanhykhoa.com
Radial EUS
Linear EUS
OBJECTIVES
1
2
Overview of endoscopic ultrasound
1
The role of EUS in the diagnosis 
2
3 The role of EUS in the treatment
3
Conclusion5 4
6
hinhanhykhoa.com
hinhanhykhoa.com
1. SUBMUCOSA TUMORS
hinhanhykhoa.com
1. SUBMUCOSA TUMORS
• Approximately 1 in 300 patients.
• Diagnosed by endoscopy.
• EUS: location, layer, size, contour, echogenicity, vascularity.
- Follow up
- Accuracy: 90%.
1. Alexander J. Eckardt, Christian Jenssen (2015), Current endoscopic ultrasound-guided approach to incidental subepithelial lesions: optimal or optional?, Annals
of Gastroenterology 28, 1-13.
2. Hwang JH1, Saunders MD, Rulyak SJ, et al. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastrointest
Endosc 2005;62:202-208.
1.Kazuya Akahoshi (2012),Practical Handbook of Endoscopic Ultrasonography.
hinhanhykhoa.com
SUBMUCOSA TUMORS
CYST
2. GASTROINTESTINAL CANCER
Staging
Prognosis 
Observe of 
chemo-
radiotherapy
EUS
hinhanhykhoa.com
THE ROLE OF EUS IN TMN 
STAGING 
TMN
T
N
EUS - FNA
M
Accuracy: 74-
92%
ACCURACY OF EUS v. CT BY STAGE 
OF ESOPHAGEAL CANCER
0
20
40
60
80
100
EUS CT
S
t
a
g
i
n
g
A
c
c
u
r
a
c
y
(
%
)
T1 or T2 T3 T4 N0 N1
hinhanhykhoa.com
ACCURACY OF EUS v. CT IN THE 
STAGING OF GASTRIC CANCER
85
78
42
48
0
10
20
30
40
50
60
70
80
90
T STAGE N STAGE
EUS
CT
ESOPHAGUS CANCER
T3N1Mx
hinhanhykhoa.com
3. COMMON BILE DUCT STONE
Ultrasound CT-Scanner
ERCP MRCP
DIAGNOSIS
EUS
EUS v. MRCP IN THE DIAGNOSIS CBDs
EUS
100%
95.4%
90.9%
100%
96.9%
RCP
EUS (%) MRCP (%)
Sensitivity 100 100
Specificity 95,4 72,7
Positive
predictive value
90,9 62,5
Negative 
predictive value
100 100
Accuracy 96,9 82,2
De Ledinghen V GIE 1999
hinhanhykhoa.com
4. CHRONIC PANCREATITIS
Chronic 
pancreatitis
Morphology Function
Difficulties
Early 
chronic 
pancreatitis 
hinhanhykhoa.com
DIAGNOSIS OF CHRONIC 
PANCREATITIS

 Diagnosis of chronic pancreatitis on EUS
Conventional classification
Rosemont classification

 Rosemont classification detect early chronic pancreatitis.
hinhanhykhoa.com
5. PANCREATIC CANCER
PANCREATIC 
CANCER
Diagnosis
Staging
Related 
pain
EUS STAGING OF PANCREATIC 
CANCER
TomislavDragovich, et al. Medscape
hinhanhykhoa.com
T staging
- EUS more accurate than CT/MRI
- Vascular invasion; EUS more sensitive than CT; CT 
more specific than EUS
N staging
- EUS similar to CT
- EUS stages smaller tumors (< 3cm) more accurately 
than larger tumors.
Jose Manuel Ramia. World J GastrointestOncol 
2014
EUS STAGING OF PANCREATIC 
CANCER
EUS – TUMOR VASCULAR INVASION
Absence of 
invasion
Irregular vascular 
wall
Vascular invasion
hinhanhykhoa.com
OBJECTIVES
1
2
Overview of endoscopic ultrasound
1
The role of EUS in the diagnosis 
2
3 The role of EUS in the treatment
3
Conclusion5 4
6
1. EUS - FNA
• EUS-FNA: 1991.
• The obtainment of a tissue biopsy specimen for histologic 
examination
1. Tharian B, Tsiopoulos F, George N, Pietro SD et al, (2012), Endoscopic ultrasound fine needle aspiration: Technique and applications in clinical 
practice,World J Gastrointest Endosc, 4(12): 532–544.
hinhanhykhoa.com
PREPARATION
• Sensitivity of up to 85%.
• Specificity of up to 100%.
• On-site cytopathologist; improves diagnostic yield by 
10-15%.
• Complicated rate of 0.5-2%; bleeding, pancreatitis
• Rarely, tumor seeding.
• Michael: 4983 patients EUS-FNA sensitivity 85%
and specificity 98% for pancreas tumor.
1. Michael JH, Mark JW, Lucia P, Panagiotis V, et al (2012), EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis, Gastrointest endosc, 75 (1).
EUS-FNA Pancreatic cancer
hinhanhykhoa.com
EUS-FNA
2. EUS DRAINAGE
EUS-Guided Pancreatic Pseudocyst
Drainage
EUS guided Cholangiography and 
drainage. 
hinhanhykhoa.com
EUS-Guided 
Pancreatic Pseudocyst Drainage
Pseudocyst
No 
symptom
Follow up
Symptom Therapy
• Puncture do not depend on the pseudocyst depression into 
the wall of the stomach.
• Avoid vessels by doppler.
• Preventing perforation.
• Observing characteristics of lesion before pseudocyst drainage.
STRONG POINTS OF EUS 
hinhanhykhoa.com
EUS-Guided 
Pancreatic Pseudocyst Drainage 
• Villa (2010): The success rate of endoscopic drainage ranges from
87%-97%, mortality rate of 1% and the mortality rate of 10%
associated with the surgical treatment.
• Varadarajalu (2007): The successful rate of endoscopic drainage
ranges 100% and treatment 95%. The successful rate of
endoscopic drainage without EUS 57% and treatment 90%.
1. Vila JJ, Carral D, Fernández-Urien I (2010), Pancreatic pseudocyst drainage guided by endoscopic ultrasound. World J Gastrointest Endosc; 2(6): 193-197.
2. Varadarajulu S, Wilcox CM, Tamhane A, Eloubeidi MA et al (2007), Role of EUS in drainage of peripancreatic fluid collections not 
amenable for endoscopic transmural drainage, Gastrointest Endosc 66: 1107-1119.
EUS-Guided 
Pancreatic Pseudocyst Drainage
hinhanhykhoa.com
EUS guided Pancreatico-
billiary drainage
EUS guided hepaticogastrostomy
hinhanhykhoa.com
EUS guided 
choledochoduodenostomy
EUS guided choledochoduodenostomy
hinhanhykhoa.com
EUS GUIDED ANTEGRADE 
STENTING 
EUS GUIDED BILIARY DRAINAGE 
Stenting / Bilio-enterostomy 
Alternative to PTC when ERCP fails 
Giovannini et al, Burmester et al (2003), Puspok et al, Kahaleh et al (2010, 2005), Kitano (2010), 
Gupta (2011), Vila (2011), Bapaye (2013), Dhir (2014), Hara (2014) 
• 1st report – Giovannnini (2002) 
• Duodenal / Gastric / Extra / Intra hepatic approaches 
• Direct stenting / rendezvous / antegrade stenting 
• Large case series – multicenter study of 241 patients 
• 85-90% success, ~10% complications 
hinhanhykhoa.com
EUS GUIDED BILIARY ACCESS 
EUS-BD vs. PTBD 
Improved rate of internal stenting, fewer complications 
Bapaye et al , UEGJ 2013 
EUS guided stenting vs. ERCP stenting 
Similar outcomes in both groups 
Dhir et al, GIE 2015 
EUS-CDS or EUS-HGS ? 
No significant difference by either approach 
Bapaye et al , UEGJ 2013; Dhir et al GIE 2014 
EUS GUIDED PANCREATIC STENTING 
• Situations when Papillary access is not possible
(Post op situations, Tight PD stricture) 
• 75-80% success 
(Francois, Giovannini, Deviere (2002, 2005) 
hinhanhykhoa.com
Gastrointest Endosc 2011;73:267-74Gastrointest Endosc 2003; 57:923-930
3. EUS-guided Celiac Plexus 
Neurolysis (CPN)
EUS GUIDED 
CELIAC PLEXUS NEUROLYSIS- CPN
EUS-CPN safer, direct & under visual control 
For Cancer pancreas 
EUS vs. CT guided CPN : 78% vs. 26%, p = 0.0001, 
effect sustained for 24 weeks 
For chronic pancreatitis 
EUS guided vs. CT guided CPN – 43% > 25%, p < 0.05 
Complication
Transient diarrhea (20-30%), orthostatic hypotension 
(10-60%), abdominal pain
Most are mild and transient
Gunaratnam et al (2001), Gress et al (1999) 
hinhanhykhoa.com
• Endoscopic Ultrasound is an essential technique in
gastroenterology diseases.
• Endoscopic Ultrasound is a new medical procedure
which is highly qualified in diagnosis of the
gastrointestinal and pancreatico- biliary diseases.
CONCLUSION 
THANK YOU AND HAPPY NEW YEAR!
hinhanhykhoa.com