Endoscopic Ultrasound (EUS)

Endoscopic Ultrasound + Fine Needle Aspiration (FNA)

One member of my family is now admitted in Chulalongkorn Hospital, Thailand, awaiting for "repeat" EUS operation. So I would like to take this opportunity make notes on EUS. ( excerpts rewrite/taken from WebMD )

What is EUS?

Endoscopic Ultrasound (EUS) combines endoscopy and ultrasound in order to obtain images and information about the digestive tract and the surrounding tissue and organs. Endoscopy refers to the procedure of inserting a long flexible tube via the mouth or the rectum to visualise the digestive tract, whereas Ultrasound uses high frequency sound waves to produce images of the organs and structures insider the body such as ovaries, uterus, liver, gallbladder, pancreas, aorta, etc.

Traditional ultrasound sends sound waves to the organ(s) and back with a transducer placed on the skin overlying the organ(s) of interest. Images obtained by traditional ultrasound are not always of high quality. IN EUS a small ultrasound transducer is installed on the tip of the endoscope. By inserting the endoscope into the upper or the lower digestive tract one can obtain high quality ultrasound images of the organs insider the body.

Placing the transducer on the tip of the endoscope allows the transducer to get close to the organs insider the body. Because of the proximity of the EUS transducer to the organ(s) of interest, the images obtained are frequently more accurate and more detailed than the ones obtained by traditional ultrasound. The EUS also can obtain information about the layers of the intestinal wall as well as adjacent areas such as lymph nodes and the blood vessels.

Other uses of EUS include studying the flow of blood insider blood vessels using Doppler ultrasound, and to obtain tissue samples by passing a special needle, under ultrasound guidance, into enlarged lymph nodes or suspicious tumours. The tissue or cells obtained by the needle can be examined by a pathologist under a microscope. The process of obtaining tissue with a thin needle is called fine needle aspiration (FNA).

note: This is what my family member has to do (FNA).

When is EUS useful?

Being a relatively new diagnostic tool the uses for EUS are still being developed and, presently, it is being utilised in some of the following situations:
  • Staging of cancers of the oesophagus, stomach, pancreas and rectum.
  • Staging of lung cancer.
  • Evaluating chronic pancreatitis and other masses or cysts of the pancreas.
  • Studying bile duct abnormalities including stones in the bile duct or gallbladder, or bile duct, gallbladder, or liver tumours.
  • Studing the muscles of the lower rectum and anal canal in evaluating reasons for fecal incontinence.
  • Studying 'submucosal  lesions' such as nodules or 'bumps' that may be hiding in the intestinal wall covered by normal appearing lining of the intestinal tract.
Staging of cancer is becoming an important use of EUS. The prognosis of a cancer victim is related to the stage of the cancer at the time of cancer detection. For example, early stage colon cancer reefers to cancer confined to the inner surface of the colon before it is spread to adjacent tissues or distant organs. Therefore early stage colon cancer can be completely resected with good chances for cure. However, if cancer is detected at later stages, the cancer tissues have already penetrated the colon wall and invaded neighbouring organs and lymph nodes, or have spread to distant organs such as liver and  lungs. Complete surgical excision becomes highly unlikely. EUS can provide information regarding the depth of penetration of the cancer and spread of cancer to adjacent tissues and lymph nodes, information useful for staging.

What is the preparation for EUS?

Doctor will want to know about patient's health status especially if patient have any allergies, other significant health problems such as heart disease, lung disease, diabetes mellitus, etc. Patient will also be inquired about allergies to iodine or shellfish as, under certain circumstances, iodine containing contrast material may be used. If there is a possibility of the needle aspiration (FNA), the doctor will want to check patient's blood for proper clotting. It is important to inform doctor of any family history of bleeding problems or if patient are taking medications that interfere with blood clotting (such as Coumadin) or platelet function (such as aspirin, Motrin, ibuprofen, Aleve, and other NSAIDs). The wisest is to inform doctor of any prescription or non-prescription medication patient might be taking. Antibiotics are usually not required except in patients with certain heart valve problems.

EUS is performed with sedation so patient will not be able to return to work or to drive for 24 hours. It also means that patient will need someone to take home as this is usually an out-patient procedure.

Note: for my family member's case, she needs to admitted as in-patient, as she is now 66 years-old, and it is strongly recommended by her medical team.

Patient will needs to have an empty stomach that means no oral intake for 6 or more hours. IN case of a rectal EUS, patient will probably need to take some enemas or laxatives. In either case, full instructions will be given to patient.

How is EUS performed?

Upon arrival at the endoscopy centre, the nurse or the doctor will discuss the procedure and answer any questions. Patient will then be asked to sign a consent form indicating patient were informed about the procedure, its alternatives, and its risks. Patient will undress and put on a hospital gown. An IV will be placed in a vein and kept open with a slow drip of IV fluids. This IV will be used to administer the sedatives or other required medication. Anaesthesia is rarely used. Patient will then be taken into the procedure room and, after the administration of the sedation, the EUS will be carried out. Small electrode patches will be placed on patient's skin for the monitoring of blood pressure, pulse, and blood oxygen.

Once sleepy, the special endoscope will be inserted and the procedure started. Because of the sedation, patient will only feel minimal discomfort, if any, during the entire procedure. The physician will observe the insider of patient's intestinal tract on a TV monitor and the ultrasound image on another monitor. The entire procedure generally takes 30 to 90 minutes depending on the complexity and whether fine needle aspiration (FNA) is performed.

Note: For my family member case, this is the second time to be done, as the first time, she woke up during the operation, and the tissue samples was inadequate, according to the pathologist.

After the procedure patient will be sleepy for up to one hour and be unable to drink or walk. Once patient are fully awake, the doctor will discuss with patient and, if desired the person with patient, the findings of the procedure. Barring any rare complications, when patient are fully awake, the companion will be able to take patient home where patient should rest for the remainder of the day. Light meals and fluids are allowed. The bloating which patient may feel from the insufflated air will only be temporary. Should patient's throat be mildly sore, for a day or two, salt-water gargles will provide relieve. Patient should call doctor if concerned about progress or having severe pain, vomiting, passage or vomiting of blood, chills or fever. If EUS was particularly difficult or complicated patient may be kept in the hospital overnight. The endoscopist will discuss this with patient, when patient wake up.

What are the risks of EUS?

Like other endoscopy procedures, EUS is safe and well tolerated. But no procedure is without risk, which with EUS are quite rare. Complication rate for EUS without the fine needle aspiration is about one in two thousand. This is similar to the complication rate of other endoscopy procedures. Sometimes, patients can develop reactions such as hives, skin rash or nausea to the medications used during EUS. A lump may appear in the area of the vein where the IV was placed. This usually resolves over time. SHould it persist, patient should contact physician. The main complication of serious note is perforation (making a hole in the intestinal wall) that may require surgical repair. This is quite rare and all precautions are taken to avoid it.

When FNA is performed complications occur more often but are still uncommon (0.5-1.0%). Passing a needle through the gut wall may cause minor bleeding. If unusual bleeding occurs, the patient may be hospitalised briefly for observation, but blood transfusions are rarely needed. Infection is another rare complication of FNA. Infection can occur during aspiration of fluid from cysts and antibiotics may be given before the procedure. If the FNA is performed on the pancreas, pancreatitis (inflammation of the pancreas) can rarely occur. Pancreatitis calls for hospitalisation, observation, rest, IV fluid, and medication for abdominal pain. It usually resolves spontaneously in a few days.

Visitor's Flowers

Note: For my family member, this time, the medical team must get the conclusion, other wise, other procedures may be taken such as surgical, and etc.

Operated by
  1. Dr. Pradermchai Kongkam, Chulalongkorn Hospital (EUS)
  2. Dr. Chanchai Sittipunt, Chulalongkorn Hospital (Pulmonary)

Update 1, 16th of July, 2009 : The test result for my family member prompts "Positive" for cancer, and this is sad news to my family, however, it will lead to the conclusion of her treatment technique .




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