Git Endoscopic Ultrasound

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  • Endoscopic Ultrasound (EUS) A Survey of Typical ApplicationsKlaus Gottlieb, MDClinical Associate Professor; University of WashingtonVadim Brjalin Lne-Tallinna Keskhaigla

    Updated by:Dr.Mohammad Shaikhani, Asistan profesor.Sulaymanyiah University, College of Medicine.Department of Medicine.Sulaymanyiah GIT/Hepaatology center.

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  • EUS

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  • EUS Indications

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  • EUS:EUS a new methode in the diagnosis of oesophageal, gastric, biliopancreatic, anal disorders and intramural lesions of the gastrointestinal tract;It helps staging of the GI cancer; It also allows to stage the lung cancer and detect lymph nodes in the mediastinum; it allows to perform different interventional diagnostic (FNA, drainage) and therapeutic procedures(celiac axis neurolysis, injection of activated lymphocytes into pancreatic tumor). Ideally suited to the TNM classification for tumor staging as it can accurately assess the depth of tumor penetration, the presence of locoregional nodal metastases and can detect vascular invasion. EUS-guided FNA biopsy allows for cytopathological diagnosis of malignant primary tumors and is superior to other imaging modalities for confirmation of nodal metastases

  • EUS Indications (1)1. Staging of esophageal, gastric and rectal cancer 2. Evaluation of abnormalities of the gastrointestinal wall or adjacent structures (submucosal masses, extrinsic compression) 3. Evaluation of thickened gastric folds 4. Diagnosis (FNA) and staging of pancreatic cancer 5. Evaluation of pancreatic abnormalities (suspected masses, cystic lesions including pseudocysts, suspected chronic pancreatitis)

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  • EUS Indications (2)6. Staging of ampullary neoplasms 7. Diagnosis and staging of cholangiocarcinoma 8. Evaluation of suspected choledocholithiasis 9. Celiac plexus neurolysis for chronic pain due to intra-abdominal malignancy or chronic pancreatitis 10. Lung cancer diagnosis and staging

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  • Staging of Esophageal Gastric& Rectal CancerTNM System

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  • Celiac LN in T3 Esophageal Cancer

  • T3 Esophageal Cancer Aorta

  • Normal stomach

  • MALTOMA in stomach:

  • MALTOMA in stomach:

    MALT involving Muscularis

  • Bi-lobed leomyma in stomach:

    MALT involving Muscularis

  • Gastric Cancer: T1

    *This is an 84 year old patient who was found to have multiple millimeter-sized gastric carcinoids and a 1.7 cm plaque like lesion along the lesser curvature. Biopsies were positive for adenocarcinoma. Preoperative endoscopic ultrasound staging was performed. The lesion is clearly limited to the mucosa barely involving the submucosa (T1). No lymphadenopathy was seen. At the time of surgery the T1 stage was confirmed histologically. Unfortunately, one out of 12 resected lymph nodes was positive for adenocarcinoma. The lymph node involved was only 3 mm in size.

  • Gastric Cancer: T1

    *This is an 84 year old patient who was found to have multiple millimeter-sized gastric carcinoids and a 1.7 cm plaque like lesion along the lesser curvature. Biopsies were positive for adenocarcinoma. Preoperative endoscopic ultrasound staging was performed. The lesion is clearly limited to the mucosa barely involving the submucosa (T1). No lymphadenopathy was seen. At the time of surgery the T1 stage was confirmed histologically. Unfortunately, one out of 12 resected lymph nodes was positive for adenocarcinoma. The lymph node involved was only 3 mm in size.

  • Gastric Cancer: T2

    *This is an 84 year old patient who was found to have multiple millimeter-sized gastric carcinoids and a 1.7 cm plaque like lesion along the lesser curvature. Biopsies were positive for adenocarcinoma. Preoperative endoscopic ultrasound staging was performed. The lesion is clearly limited to the mucosa barely involving the submucosa (T1). No lymphadenopathy was seen. At the time of surgery the T1 stage was confirmed histologically. Unfortunately, one out of 12 resected lymph nodes was positive for adenocarcinoma. The lymph node involved was only 3 mm in size.

  • Gastric Cancer: T3

    *This is an 84 year old patient who was found to have multiple millimeter-sized gastric carcinoids and a 1.7 cm plaque like lesion along the lesser curvature. Biopsies were positive for adenocarcinoma. Preoperative endoscopic ultrasound staging was performed. The lesion is clearly limited to the mucosa barely involving the submucosa (T1). No lymphadenopathy was seen. At the time of surgery the T1 stage was confirmed histologically. Unfortunately, one out of 12 resected lymph nodes was positive for adenocarcinoma. The lymph node involved was only 3 mm in size.

  • Rectum: normal

    *Progression of rectal cancer from T2N0 to T3N1: This is a 53 year old man who was diagnosed with rectal cancer. EUS staging revealed this to be a T2N0 lesion. Cancer of the rectum is a highly treatable and often curable disease when localized. Surgery is the primary treatment and results in cure in approximately 45% of all patients. The prognosis of rectal cancer is clearly related to the degree of penetration of the tumor through the bowel wall and the presence or absence of nodal involvement. Unfortunately, the patient refused - despite the urgings of his physicians - standard treatment and chose "natural" treatments instead which at least in part consisted of tea enemas. These were not effective. Four months later he had a restaging EUS done. This was performed to encourage him to change his mind. Indeed, the cancer had advanced to a T3N1 stage. Eventually he could be convinced to have radiation and chemotherapy. EUS is an accurate method of evaluating tumor stage (up to 95% accuracy) and the status of the perirectal nodes (up to 74% accuracy). Accurate staging can influence therapy by helping to determine which patients may be candidates for local excision rather than more extensive surgery and which patients may be candidates for preoperative chemotherapy and radiation therapy to maximize the likelihood of resection with clear margins.

  • Rectal Cancer:T2N0

    *Progression of rectal cancer from T2N0 to T3N1: This is a 53 year old man who was diagnosed with rectal cancer. EUS staging revealed this to be a T2N0 lesion. Cancer of the rectum is a highly treatable and often curable disease when localized. Surgery is the primary treatment and results in cure in approximately 45% of all patients. The prognosis of rectal cancer is clearly related to the degree of penetration of the tumor through the bowel wall and the presence or absence of nodal involvement. Unfortunately, the patient refused - despite the urgings of his physicians - standard treatment and chose "natural" treatments instead which at least in part consisted of tea enemas. These were not effective. Four months later he had a restaging EUS done. This was performed to encourage him to change his mind. Indeed, the cancer had advanced to a T3N1 stage. Eventually he could be convinced to have radiation and chemotherapy. EUS is an accurate method of evaluating tumor stage (up to 95% accuracy) and the status of the perirectal nodes (up to 74% accuracy). Accurate staging can influence therapy by helping to determine which patients may be candidates for local excision rather than more extensive surgery and which patients may be candidates for preoperative chemotherapy and radiation therapy to maximize the likelihood of resection with clear margins.

  • Same Rectal Cancer T3N1:Untreated, 4 months later

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  • Rectal ca

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  • A large perirectal mass is seen invading the rectal wall. FNA biopsy (Pentax FG-32UA) of the mass confirmed recurrence of prostatic cancer (inset).

  • Abnormalties of GI tract wallThe 5 layers

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  • Submucosal Gastric Tumor

    *EUS is a superb method for the evaluation of submucosal masses of the gastrointestinal tract. This is a patient with a history of upper GI tract bleeding. Surface endoscopy shows a submucosal lesion with overlying central ulceration in the body of the stomach. EUS shows a hypoechoic well-circumscribed tumor that connects to the muscularis propria. This tumor was surgically removed and the final pathology confirmed GIST.

  • Biopsy this?

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  • Gastric Varix: Biopsy not recommended

    *This is a 79 year old patient S/P Billroth II surgery for gastric cancer (T3N3) who developed melena several weeks following the surgery. An isolated gastric varix was seen which was not bleeding at the time of the endoscopy.

  • Thickened Gastric FoldsHyperacidic statesHypoproteinemia Lymphoma Eosinophilic gastroenteritisVaricesMenetriers diseaseCrohns

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  • Linitis Plastica

    *Linitis plastica is a proliferative condition of the connective tissue. It is triggered by the presence of malignant signet-ring cells which diffusely spread through the layers of the gastric wall. Malignant cells are usually absent from otherwise grossly abnormal appearing gastric mucosa. The desmoplastic reaction gives the stomach a rigid appearance and this has been called leather bottle stomach in the past. The prognosis is generally very poor. This 58 year old man presented with nausea and weight loss. Initial endoscopy showed thickened gastric folds suspicious for the condition but biopsies (performed on two separate occasions) were non-diagnostic. Based on the CT and EUS appearance linitis plastic was strongly suspected and the patient referred for laparotomy at which time the diagnosis was confirmed with a full thickness biopsy.

  • MALT Lymphoma

    *This is a 59 year old patient with a history of peptic ulcer which had healed upon follow-up endoscopy. However, the endoscopist noted severe hemorrhagi