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 18 June 2018

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Endoscopic ultrasound

Editor: Ian Penman

5. EUS: pancreatico-biliary

John Meenan

Fig. 1 Portal confluence with SMA (radial).

Fig. 2 Pancreatic body. The renal vessels can be mistaken for being the splenic vein, but they run a straighter course (radial).

Fig. 3 Cartoon of relative position of splenic and renal vessels when viewing the body/tail of pancreas (radial).

Fig. 4 Cartoon of relative scope movements to view body and tail of pancreas (radial).

Fig. 5 Celiac trunk and superior mesenteric artery (linear).

Fig. 6 Cartoon of pancreatic body (linear).

Fig. 7 Cross section of mid-pancreatic body with splenic vein and artery (linear).

Fig. 8 Cartoon of movements to view tail and neck of pancreas from the mid-body position (linear).

Fig. 9 Cartoon of the portal confluence and neck of pancreas with views through to the head of pancreas (linear).

Fig. 10 Neck of pancreas with course of pancreatic duct outlined (linear).

Fig. 11 Cartoon of the portal confluence (linear).

Fig. 12 (A) Cartoon of the portal vein and common bile duct at the liver hilum (linear). (B) Linear view from the stomach of the common hepatic/bile duct with the left and right hepatic ducts (LH, RH), lying behind the portal vein (PV). The C-shaped hilum of the liver is labeled.

Fig. 13 The major structures seen from the duodenal bulb (gallbladder, portal vein, and common bile duct) generally lie to the left of the screen (radial).

Fig. 14 The common bile duct, portal vein, and pancreatic duct fashion a type of triangle with the apex at the liver hilum and the lower right corner at the ampulla (radial).

Fig. 15 Cartoon of anatomic orientation when performing radial EUS from the duodenal bulb (radial).

Fig. 16 Views from the second part of the duodenum. The spine lies at 12 o'clock, with the major vessels immediately under this (radial).

Fig. 17 As the aorta elongates, the superior mesenteric vessels are seen to unfold to the left of the screen (radial).

Fig. 18 A coronal view of the left renal vein is seen as it crosses in front of the aorta, close to the origin of the superior mesenteric artery (radial).

Fig. 19 The pancreatic duct, followed by the common bile duct, come into view as the scope is withdrawn from the second part of the duodenum (radial).

Fig. 20 View from the duodenal bulb (linear).

Fig. 21 Cartoon showing the arc described by the portal and superior mesenteric veins (linear).

Fig. 22 Cartoon of the relatively horizontal course followed by the pancreatic duct from the portal vein to the ampulla (linear).

Fig. 23 The aorta and uncinate process are seen when the scope is in the second part of the duodenum (linear).

Fig. 24 Cartoon of the relative position of the common bile duct when seen from deep D2 or the duodenal bulb (linear).

Fig. 25 Distal common bile duct stone with acoustic shadow.

Fig. 26 Sludge in the common bile duct close to the ampulla.

Fig. 27 Biliary microcrystals in the gallbladder.

Fig. 28 Marked thickening of the common bile duct wall due to primary sclerosing cholangitis.

Fig. 29 Neuroendocrine tumor of the ampulla of Vater.

Fig. 30 Cholangiocarcinoma with adhesion to the portal vein.

Fig. 31 Salt-like microcrystals in the common hepatic duct.

Fig. 32 Lobulation of the pancreatic parenchyma (normal duct).

Fig. 33 Pancreatic serous cystadenoma. Note the cysts of varying size (medium/small).

Fig. 34 The multiple, thin septated cysts of von Hippel–Lindau syndrome.

Fig. 35 Mucinous cystadenoma of the pancreas.

Fig. 36 Chronic calcific pancreatitis.

Fig. 37 Intraductal mucinous papillary tumor of the pancreatic head with gross ductal dilatation and invasion of the parenchyma. Note 'stranding' due to mucous.

Fig. 38 Pancreatic adenocarcinoma abutting the portal vein (white interface preserved).

Fig. 39 Pancreatic adenocarcinoma with adherence to the portal vein (complete loss of interface).

Fig. 40 Pancreatic carcinoma with invasion/encasement of the portal vein.

Copyright © Blackwell Publishing, 2005

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Current applications
Therapeutic EUS
Teaching and training EUS
Radial and linear endosonographic probes
Contrast-enhanced ultrasonography
Catheter-based EUS probes (miniprobes)
  Miniprobe technique
  Miniprobes in cancer
  Other uses of miniprobes
  Miniprobe limitations
Needles and accessories for EUS
  Fine-needle aspiration
   Different types of needles
   FNA technique
   Accuracy and safety
  Core tissue biopsies
   Accuracy and safety
Outstanding issues and future trends
EUS for cancer staging
Esophageal cancer staging with EUS
  Esophageal cancer TNM staging
  Technique for performing EUS staging of esophageal cancer
  EUS of stenotic esophageal tumors
  EUS evaluation of superficial tumors
  EUS evaluation of lymph nodes
  EUS-FNA of peri-esophageal lymph nodes
  Accuracy and limitations of EUS staging of esophageal cancer
  EUS re-staging of esophageal cancer after chemoradiation
  Impact of EUS staging on esophageal cancer management
Gastric cancer staging with EUS
  Gastric cancer TNM staging
  EUS staging of advanced gastric adenocarcinoma
  EUS staging of early gastric adenocarcinoma
  EUS staging of gastric MALT lymphoma
Rectal cancer staging with EUS
  Rectal cancer TNM staging
  Pathologic staging of rectal cancer
  Surgical management of rectal cancer
  Management algorithm for rectal cancer (Fig. 17)
  Technique for performing EUS rectal cancer staging
  EUS staging of rectal cancer
  Accuracy of EUS in staging rectal cancer
  EUS vs. CT and MRI for rectal cancer staging
  EUS/FNA for rectal cancer lymph node staging
  Stenotic rectal tumors
  Rectal EUS staging after radiation therapy
  Colon cancer staging with EUS
Anal cancer staging with EUS
Pancreatic cancer
  Staging of pancreatic cancer
  EUS staging of pancreatic cancer (Figs 12,13)
  Combination of EUS and CT/MRI for pancreatic cancer staging and determining resectability
  EUS-FNA for staging pancreatic cancer
  Recommendations for EUS staging of pancreatic cancer
Ampullary cancer
Extrahepatic bile duct cancer
Future trends and outstanding issues
Endoscopic and EUS examination
  Origin and development of GISTs
  Molecular biology of GIST: c-kit
  CD34 and other immunohistochemistry
  Clinical features
  Predicting malignant behavior: role of molecular markers
  Predicting malignant behavior: role of EUS
  Tissue sampling of GISTs
  EUS-guided fine-needle aspiration
  Therapy: surgery
  Therapy: imatinib
  Clinical features and diagnosis
  EUS features
  Clinical features and diagnosis
  EUS features
Granular cell tumors
  Clinical features
  Endoscopic and EUS features
  Treatment of granular cell tumors
Duplication cysts
  Clinical features
  EUS features
  Treatment of duplication cysts
Carcinoid tumors
  Clinical features and pathology
  Endoscopic and EUS features
  Appendiceal carcinoids
  Ileal carcinoids
  Rectal carcinoids
  Gastric and duodenal carcinoids
Ectopic pancreas ('pancreatic rest')
  Clinical features
  EUS features
Extrinsic compressions
Future trends and outstanding issues
Morbid anatomy
  Portal vein
  Common bile duct
Endosonographic anatomy
Performing EUS of the pancreas and biliary tree
  Body and tail of pancreas
   Radial EUS
   Linear EUS
  Head and uncinate process of pancreas
   Radial EUS
Benign biliary disease
  Choledochal cysts
  Primary sclerosing cholangitis (PSC)
Malignant biliary disease
  Ampullary carcinoma
  Carcinoma of the gallbladder
Benign pancreatic disease
   Acute pancreatitis
   Chronic pancreatitis
   Autoimmune pancreatitis
Cystic lesions of the pancreas
   Serous cystadenoma
   Mucinous cystadenoma
   Solid-cystic pseudopapillary tumor
   Intraductal mucin-producing tumor/neoplasm (IPMT/N)
   Mucinous cyst adenocarcinoma
Solid tumors of the pancreas
   Screening for adenocarcinoma
  Neuroendocrine tumors
Training in pancreatico-biliary EUS
Outstanding issues and future trends
Non-invasive imaging modalities
  Chest CT
  Positron emission tomography
Invasive staging
Endoscopic ultrasound-guided fine-needle aspiration
  Accuracy for diagnosing malignancy
  EUS and identification of metastatic disease
  EUS technique
  Limitations of EUS-FNA
Combined minimally invasive staging with endoscopic ultrasound and endobronchial ultrasound
Outstanding issues and future trends
  EUS-FNA and molecular markers in lung cancer

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