Interventional EUS for Pancreatobiliary Disorders
Cyrus Piraka MDAssistant Professor Gastroenterology
Director of EndoscopyUniversity of Miami Hospital
Miami FL
Objectives
bull Understand and identify the role of Endoscopic Ultrasound (EUS) in diagnosis of pancreatobiliarydisorders ndash Where is EUS helpfulndash EUS pancreatobiliary anatomyndash Types of EUS scopes
bull Understand where EUS is used for therapy in pancreatobiliary disordersndash EUS‐directed therapyndash EUS complementing ERCPndash As an alternative to surgery and IR
Intro to EUS ndash Anatomy
bull What can we see and accessndash Entire pancreas
ndash Entire extrahepatic bile duct and bifurcation
ndash Left liver and much of the right liver
ndash Ampulla
ndash Adrenals bull Left is easier than right to access
NodesbullCeliacbullPeripancreaticbullPerigastricgastrohepaticbullHilum of liverbullMediastinal
Associated vesselsbullAorta and celiac trunkbullSuperior mesenteric artery and veinbullSplenic artery and veinbullHepatic artery left gastric artery and gastroduodenal arterybullPortal vein and confluencebullRenal arteries and veins
From Feldman Sleisenger amp Fordtrans Gastrointestinal and Liver Disease 8th edCopyright copy 2006 Saunders An Imprint of Elsevier
EUS ndash Scope types
bull Radial ndash more intuitive better for lumpsbumps and for esophagusrectum but cannot FNA
bull Linear ndash better for pancreatobiliary tree can perform FNA and injectionwire passage
bull Probe ndash through a therapeutic scope can access small spaces and evaluate biliary or pancreatic duct but limited depth of penetration and cannot FNA
Equipment ndash Radial EUS
Pros
bull 360 degree image
bull Cross‐sectional imaging
bull Better for mucosalsubmucosalimaging
Consbull Cannot as easily do therapy
bull Image quality not as good as linear
Source Olympus
Equipment ndash Linear EUS
Pros
bull High quality image
bull Can do directed therapybiopsies
bull Has elevator (like ERCP)
Cons bull Not cross‐sectionalbull Not 360 degreesbull Harder to completely
visualize mucosasubmucosa
Source Olympus
Equipment ndash AccessoriesToys
bull Mini‐probendash Intraductal ultrasound
ndash Evaluate stricture
Source Olympus
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Objectives
bull Understand and identify the role of Endoscopic Ultrasound (EUS) in diagnosis of pancreatobiliarydisorders ndash Where is EUS helpfulndash EUS pancreatobiliary anatomyndash Types of EUS scopes
bull Understand where EUS is used for therapy in pancreatobiliary disordersndash EUS‐directed therapyndash EUS complementing ERCPndash As an alternative to surgery and IR
Intro to EUS ndash Anatomy
bull What can we see and accessndash Entire pancreas
ndash Entire extrahepatic bile duct and bifurcation
ndash Left liver and much of the right liver
ndash Ampulla
ndash Adrenals bull Left is easier than right to access
NodesbullCeliacbullPeripancreaticbullPerigastricgastrohepaticbullHilum of liverbullMediastinal
Associated vesselsbullAorta and celiac trunkbullSuperior mesenteric artery and veinbullSplenic artery and veinbullHepatic artery left gastric artery and gastroduodenal arterybullPortal vein and confluencebullRenal arteries and veins
From Feldman Sleisenger amp Fordtrans Gastrointestinal and Liver Disease 8th edCopyright copy 2006 Saunders An Imprint of Elsevier
EUS ndash Scope types
bull Radial ndash more intuitive better for lumpsbumps and for esophagusrectum but cannot FNA
bull Linear ndash better for pancreatobiliary tree can perform FNA and injectionwire passage
bull Probe ndash through a therapeutic scope can access small spaces and evaluate biliary or pancreatic duct but limited depth of penetration and cannot FNA
Equipment ndash Radial EUS
Pros
bull 360 degree image
bull Cross‐sectional imaging
bull Better for mucosalsubmucosalimaging
Consbull Cannot as easily do therapy
bull Image quality not as good as linear
Source Olympus
Equipment ndash Linear EUS
Pros
bull High quality image
bull Can do directed therapybiopsies
bull Has elevator (like ERCP)
Cons bull Not cross‐sectionalbull Not 360 degreesbull Harder to completely
visualize mucosasubmucosa
Source Olympus
Equipment ndash AccessoriesToys
bull Mini‐probendash Intraductal ultrasound
ndash Evaluate stricture
Source Olympus
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Intro to EUS ndash Anatomy
bull What can we see and accessndash Entire pancreas
ndash Entire extrahepatic bile duct and bifurcation
ndash Left liver and much of the right liver
ndash Ampulla
ndash Adrenals bull Left is easier than right to access
NodesbullCeliacbullPeripancreaticbullPerigastricgastrohepaticbullHilum of liverbullMediastinal
Associated vesselsbullAorta and celiac trunkbullSuperior mesenteric artery and veinbullSplenic artery and veinbullHepatic artery left gastric artery and gastroduodenal arterybullPortal vein and confluencebullRenal arteries and veins
From Feldman Sleisenger amp Fordtrans Gastrointestinal and Liver Disease 8th edCopyright copy 2006 Saunders An Imprint of Elsevier
EUS ndash Scope types
bull Radial ndash more intuitive better for lumpsbumps and for esophagusrectum but cannot FNA
bull Linear ndash better for pancreatobiliary tree can perform FNA and injectionwire passage
bull Probe ndash through a therapeutic scope can access small spaces and evaluate biliary or pancreatic duct but limited depth of penetration and cannot FNA
Equipment ndash Radial EUS
Pros
bull 360 degree image
bull Cross‐sectional imaging
bull Better for mucosalsubmucosalimaging
Consbull Cannot as easily do therapy
bull Image quality not as good as linear
Source Olympus
Equipment ndash Linear EUS
Pros
bull High quality image
bull Can do directed therapybiopsies
bull Has elevator (like ERCP)
Cons bull Not cross‐sectionalbull Not 360 degreesbull Harder to completely
visualize mucosasubmucosa
Source Olympus
Equipment ndash AccessoriesToys
bull Mini‐probendash Intraductal ultrasound
ndash Evaluate stricture
Source Olympus
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
NodesbullCeliacbullPeripancreaticbullPerigastricgastrohepaticbullHilum of liverbullMediastinal
Associated vesselsbullAorta and celiac trunkbullSuperior mesenteric artery and veinbullSplenic artery and veinbullHepatic artery left gastric artery and gastroduodenal arterybullPortal vein and confluencebullRenal arteries and veins
From Feldman Sleisenger amp Fordtrans Gastrointestinal and Liver Disease 8th edCopyright copy 2006 Saunders An Imprint of Elsevier
EUS ndash Scope types
bull Radial ndash more intuitive better for lumpsbumps and for esophagusrectum but cannot FNA
bull Linear ndash better for pancreatobiliary tree can perform FNA and injectionwire passage
bull Probe ndash through a therapeutic scope can access small spaces and evaluate biliary or pancreatic duct but limited depth of penetration and cannot FNA
Equipment ndash Radial EUS
Pros
bull 360 degree image
bull Cross‐sectional imaging
bull Better for mucosalsubmucosalimaging
Consbull Cannot as easily do therapy
bull Image quality not as good as linear
Source Olympus
Equipment ndash Linear EUS
Pros
bull High quality image
bull Can do directed therapybiopsies
bull Has elevator (like ERCP)
Cons bull Not cross‐sectionalbull Not 360 degreesbull Harder to completely
visualize mucosasubmucosa
Source Olympus
Equipment ndash AccessoriesToys
bull Mini‐probendash Intraductal ultrasound
ndash Evaluate stricture
Source Olympus
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS ndash Scope types
bull Radial ndash more intuitive better for lumpsbumps and for esophagusrectum but cannot FNA
bull Linear ndash better for pancreatobiliary tree can perform FNA and injectionwire passage
bull Probe ndash through a therapeutic scope can access small spaces and evaluate biliary or pancreatic duct but limited depth of penetration and cannot FNA
Equipment ndash Radial EUS
Pros
bull 360 degree image
bull Cross‐sectional imaging
bull Better for mucosalsubmucosalimaging
Consbull Cannot as easily do therapy
bull Image quality not as good as linear
Source Olympus
Equipment ndash Linear EUS
Pros
bull High quality image
bull Can do directed therapybiopsies
bull Has elevator (like ERCP)
Cons bull Not cross‐sectionalbull Not 360 degreesbull Harder to completely
visualize mucosasubmucosa
Source Olympus
Equipment ndash AccessoriesToys
bull Mini‐probendash Intraductal ultrasound
ndash Evaluate stricture
Source Olympus
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Equipment ndash Radial EUS
Pros
bull 360 degree image
bull Cross‐sectional imaging
bull Better for mucosalsubmucosalimaging
Consbull Cannot as easily do therapy
bull Image quality not as good as linear
Source Olympus
Equipment ndash Linear EUS
Pros
bull High quality image
bull Can do directed therapybiopsies
bull Has elevator (like ERCP)
Cons bull Not cross‐sectionalbull Not 360 degreesbull Harder to completely
visualize mucosasubmucosa
Source Olympus
Equipment ndash AccessoriesToys
bull Mini‐probendash Intraductal ultrasound
ndash Evaluate stricture
Source Olympus
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Equipment ndash Linear EUS
Pros
bull High quality image
bull Can do directed therapybiopsies
bull Has elevator (like ERCP)
Cons bull Not cross‐sectionalbull Not 360 degreesbull Harder to completely
visualize mucosasubmucosa
Source Olympus
Equipment ndash AccessoriesToys
bull Mini‐probendash Intraductal ultrasound
ndash Evaluate stricture
Source Olympus
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Equipment ndash AccessoriesToys
bull Mini‐probendash Intraductal ultrasound
ndash Evaluate stricture
Source Olympus
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS ndash Basic Diagnostics
bull Cancer diagnosis and stagingndash Pancreaticndash Bile ductampullaryndash Liverndash Esophagusndash Mediastinallungndash GastricMALT lymphomandash Rectalndash Neuroendocrine tumorsInsulinoma
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS ndash Basic Diagnostics
bull Chronic pancreatitisbull Bile duct stonesGallbladder stonesbull Pancreatic cystsbull Autoimmune Pancreatitisbull Intramuralsubmucosal lesionsmassesbull Extrinsic compressionbull IBDfistula assessmentbull Mediastinal lesionsadenopathybull MaleFemale GU organsbull Anal canalfecal incontinence
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Unexplained abdominal painsuspected sphincter of Oddi dysfunction (SOD)ndash Look for chronic pancreatitis
ndash Look for biliary sludgestone and biliary dilation
ndash Identifying dilated bile duct may move someone from a type III to type II SOD or type II to type I SOD
ndash Look for ampullary polypcancer
bull Unexplained weight lossndash Rule out pancreatic cancer in select circumstances
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Abnormal imaging (CT MRI ERCP)ndash Biliary dilation
bull Look for ampullary massbull Look for pancreatic massbull Look for hilar massnode
ndash Unexplained bile duct stricturebull Look for pancreatic cancerbull Look for cholangiocarcinomabull Look for hilar node
ndash Pancreatic cystbull Differentiate type and need for surgery vs surveillance
ndash Massbull Pancreatic cancer vs focal chronic pancreatitis vs autoimmune pancreatitisbull Cholangiocarcinoma or metastasis
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS in pancreatitis ‐ Diagnostic
bull Immediatendash Identification of bile duct stone in GS pancreatitis
bull Delayedndash Identify cause (especially in recurrent AP)
bull Yield 32‐88bull Further evaluation of gallbladderCBDbull Chronic pancreatitisbull Pancreas divisumbull Cancerbull Autoimmune pancreatitisbull Ampullary lesion
ndash Identify complications (pseudocyst)
Wilcox et al GIE 2006
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Necrotic Pseudocyst ‐ EUS
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS in pancreatitis ‐ Diagnostic
bull FNAndash 19 gauge or 22 gauge needlendash Tissue diagnosis of cancerndash Aspirate cyst to differentiate pseudocyst vs cystic neoplasm
bull Trucut biopsyndash 19 gauge corendash Increase yieldndash Autoimmune pancreatitis
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS in pancreatobiliary disorders ndashdiagnostic uses
bull Planning ERCP or surgical treatment for chronic pancreatitisndash Look for stones
ndash Look for strictures
ndash Look for dilated duct
bull Surveillance in family history of pancreatic cancer
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Cancer
bull Diagnosis ndash FNAbull Staging
ndash Tbull 1 ndash lt2 cm and within pancreasbull 2 ndash gt 2 cm and within pancreasbull 3 ndash hits adjacent organsvessels except superior mesenteric artery or celiac
arterybull 4 ndash hits superior mesenteric artery or celiac artery
ndash Nbull 0 ndash no involvement of lymph nodesbull 1 ndash affected lymph nodes
ndash Mbull 0 ndash no metastasesbull 1 ndash distant metastasesbull x ndash cannot define metastatic involvement with the study
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Cysts
bull May be pre‐malignantndash Mucinous cysts
bull IPMN
bull Mucinous cystadenoma
bull Cystadenocarcinoma
bull No significant malignant potentialndash Serous (ldquomicrocysticrdquo) cystadenoma
ndash Pseudocyst
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Cysts
bull Determine need for surgery vs surveillance vs neitherndash Likely cyst typendash Size greater than 3 cmndash Family historyndash Growth over timendash Main duct involvement in IPMNndash Mural nodularityndash Associated massndash Symptoms
bull Weight lossbull Abdominal painbull Recurrent pancreatitis
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS ndash Interventional
bull Celiac plexus block and neurolysisndash Pancreatic cancer
ndash Other intra‐abdominal cancer
ndash Chronic pancreatitis
ndash Chronic abdominal pain
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Source top5pluscom
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS ‐ Therapeutic
bull Pseudocyst drainagendash Cyst gastrostomy duodenostomy esophagostomy
bull Abscess drainage
bull Pancreatic Necrosectomyndash Progressive dilation of enterostomy
ndash Irrigation with nasocystic drain or via scope
ndash Debridement with Dormia basketother tools
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
EUS single step pseudocyst drainage
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Other ‐ Therapeutic
bull EUS Rendezvous for ERCPndash Transmural ante‐ or retrograde ductal accessndash Biliary accessndash Pancreatic duct accessndash Altered anatomy cases (ie post‐Whipple access of pancreatic duct)
bull Choledochoduodenostomybull Gastropancreatic stenting
ndash Creation of pancreaticogastric fistulabull Injection of anti‐tumor agentsbull Fiducial placement for targeted radiation therapy
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Case
bull 54 yo man ho alcohol abuse
bull Admitted with one week of epigastric pain radiating to the back
bull EUS reveals 2 pseudocysts (larger 16 x 9cm) ascites and no region of apposition of pseudocyst to stomach so drainage deferred
bull Jejunal feeds continues sxs improved
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
ERCP ndash biliary stricture chronic pancreatitis no leak
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
bull CT repeated showing 20x17 cm pseudocyst (grew) and 2nd pseudocyst shrank to 5x2cm
bull CT angio excluded pseudoaneurysm
bull EUS pseudocyst gastrostomy performed
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Pseudocyst
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Pseudocyst ‐ EUS
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Needle and wire ‐ fluoro
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Balloon dilation of tract
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Pseudocyst gastrostomy
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
4 weeks post‐procedure
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
bull 5 weeks later readmitted for abdominal pain and nv
bull ERCP ndash PD leak stented
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
PD leak
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Follow‐up ndash leak resolved ongoing CBD stricture tx
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Case
bull 60 yo man non‐alcoholic with single episode of pancreatitis
bull Weight loss
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Cancer ‐ EUS
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Pancreatic cancer nodes
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Conclusions
bull EUS plays a critical role in the evaluation of causes of pancreatitis and pancreatobiliarydisorders
bull In select circumstances EUS is a helpful tool in treatment of the causes and complications of pancreatitis and other pancreatobiliarydisorders
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45
Bibliography
bull Antillon MR Shah RJ Stiegmann G Chen YK Single‐step endoscopic ultrasound guided drainage of simple and complicated pancreatic pseudocysts Gastrointestinal Endoscopy 200663(6)797
bull Bhutani MS ldquoEndoscopic ultrasound guided antitumor therapyrdquo Endoscopy200335(8)S54‐6
bull Gress F Schmitt C Sherman S Ikenberry S Lehman G ldquoA prospective randomized comparison of endoscopic ultrasound‐ and computed tomography‐guided celiac plexus block for managing chronic pancreatitis painrdquo American Journal of Gastroenterology 199994(4)900‐5
bull Piraka C Shah RJ Fukami N Chathadi KV Chen YK ldquoEUS‐guided transesophageal transgastric and transcolonic drainage of intra‐abdominal fluid collections and abscessesrdquo Gastrointestinal Endoscopy 2009 Oct70(4)786‐92
bull Piraka C Chen Y ldquoPseudocyst Drainage ERCP and EUS ApproachesrdquoTechniques in Gastrointestinal Endoscopy Volume 9 Issue 3 Pages 169‐175
bull Wilcox CM Varadarajulu S Eloubeidi M ldquoRole of endoscopic evaluation in idiopathic pancreatitis a systematic reviewrdquo Gastrointestinal Endoscopy 2006 Jun63(7)1037‐45