Endoscopic ultrasound

Endoscopic ultrasound is usually used to diagnose nature of disease related symptoms, which are causing abdominal or chest pain. It is also helpful in identifying the extent of various diseases present in the lungs or gastrointestinal tract or sometimes, to confirm the findings from some previous tests such as CT-scan or MRI scan. The Endoscopic ultrasound scan helps in the diagnosis of the following:

• Lymphomas
• Bile duct stones or gallstones
• Sarcoidosis
• The cancerous growth of the lungs, colon, stomach, pancreas, esophagus along with rectal and ampullary cancers.
• Barrett’s esophagus
• Pancreatitis and cysts in the pancreas.
• Neuroendocrine tumors
• Fistulas in the rectum
• Fecal incontinence

The Endoscopic ultrasound scan is very effective in the following:

• Determining the stage of the tumor, if any.
• Assessing the penetration of the tumor into the abdominal wall in lung, esophageal, pancreatic and rectal cancers.
• To examine the spread of cancer or metastasis to the lymph nodes and other nearby organs.
• To examine carefully some of the abnormal findings from the other imaging tests e.g. pancreatic cyst.
• To provide exact information and confirmation about the non-small cell cancer, in order to guide treatment.
• Helping to drain the pseudocyst and other abnormal fluid collection in the patient’s abdomen.
• To allow precise targeting for medication delivery directly into the lungs, pancreas and other organs.

An endoscopic ultrasound scan is easily tolerated by the patient and does not need any hospitalization. It is considered safe and performed in the out-patient department.

Endoscopic ultrasound is not advised by the doctor if the patient has had an abdominal surgery that changed the anatomy inside the patient’s body or abdomen such as Roux-en-Y gastric bypass.

Endoscopic ultrasound imaging is a very effective and safe procedure if performed with expertise. There are some risks associated with the procedure, which the doctor explains before the procedure. Some of these risks are highlighted below.

• Infection
• Bleeding especially in cases where the patient undergoes a fine needle aspiration test also.
• Perforations or tearing off in the throat or intestinal wall.
• Inflammation of the pancreas or pancreatitis, especially if the fine needle aspiration of the pancreas is combined with Endoscopic ultrasound.

These risks associated with Endoscopic ultrasound can be prevented by following the instructions of the doctor carefully during the preparation process of Endoscopic ultrasound.

There might be some signs and symptoms observed after the Endoscopic ultrasound scan, which are to be taken care off. Some of these symptoms are as mentioned.

• Difficulty in breathing
• Fever
• Pain in the chest
• Difficulty in swallowing
• Vomiting
• Dark or black colored stool
• Persistent or severe pain in the abdomen

The doctor will discuss the endoscopic ultrasound procedure with the patient in detail, along with its benefits and risks.

Before the procedure:

Some points to be taken into consideration are as mentioned.

• The doctor takes a complete medical history and physical examination test before performing the endoscopic ultrasound procedure. The patient may be asked about the age of the patient, any past surgeries, allergies to any medicines, previous personal history and family history of abdominal or gastrointestinal problems. In the physical examination, the doctor examines the patient very carefully for any other concerning signs and symptoms.
• The doctor also advises to bring along the previous test reports, related to any blood investigations, X-ray, CT-scan or MRI scan, before the surgery.
• The patient is advised to avoid the blood-thinning medications before the endoscopy ultrasound scan such as ecospirin, aspirin and so on. The use of such medicines may lead to excessive and uncontrolled bleeding, especially if the procedure is combined with the fine needle aspiration cytology. Hence, it is important to take the medicines as and when prescribed by the doctor.
• If a patient is diabetic, it is important to ask the doctor to take insulin before the procedure or not.
• Inform the doctor about any past allergies or surgeries, if any.
• Avoid drinking or eating anything for at least 3-4 hours before the endoscopy ultrasound procedure.
• The patient is advised to empty the urinary bladder and bowel, before the procedure. If the endoscopy is of the rectum area, the patient is advised some laxatives or an enema, or sometimes to follow a liquid diet before the endoscopy procedure.
• Remove or avoid any jewelry, eyeglasses, hairpins, electronic gadgets or any metal objects.
• Change into a hospital gown.
• This procedure does not need any hospitalization and the patient can go back home after the procedure.
• The doctor advises the patient to bring a companion along to drive back home safely.

During the procedure:

• The doctor gives sedative medicines to make the patient relax and calm down.
• Then the doctor passes an endoscope (a small tube-like structure, flexible in nature with a light fitted in it) through the patient’s mouth and through the digestive tract.
• There is a small ultrasound device attached to the head of the endoscope, which produces sound waves that hit the patient's internal structures and emit reflections. These reflections are collected, which form an image on the monitor.
• These images, which are captured, are very enhanced and clear in nature, for the doctor to monitor and examine the abnormalities very easily.
• If the endoscopy ultrasound is combined with fine needle aspiration, then the doctor passes another device that is curved in nature into the patient’s digestive tract. This device guides the fine (thin) needle into the lymph nodes, any other abnormalities or tumor cells. The needle helps to remove some fluid and tissues for detailed analysis.
• If the endoscopy ultrasound is combined with fine needle aspiration, then the entire procedure takes around 1 hour to finish.
• The endoscope is then carefully removed from the patient’s digestive tract and mouth.

After the procedure:

• The tissue and fluid sample is labeled properly and sent to the lab for further analysis.
• The results and endoscopy ultrasound images are handed over to the doctor to further discuss with the patient in detail.
• After the test, the patient is allowed to go home and resume normal routine activities.
• The patient is allowed to eat and drink normally.

The gastroenterologist (a specialized doctor in diseases related to the digestive tract) and pulmonologist (a specialized doctor in diseases related to the lungs and also special training in endoscopic ultrasound) are the ones who interpret the images of the scan carefully.  If the scan was combined with the fine needle aspiration, then the lab report is sent by the pathologist and the doctor discusses the finding with the patient and plan for the treatment if any abnormality is detected.

Q1. What are the sign and symptoms for which endoscopic ultrasound is necessary to be done?

A1. The doctor advises an endoscopic ultrasound if any of the following signs and symptoms are observed in a patient:

• The chronic problem of constipation
• Any of the inflammatory bowel disease e.g. Crohn’s disease or ulcerative colitis.
• The repetitive occurrence of stomach ulcers
• Blockage or obstruction of the esophagus.
• Gallstones
• Bleeding in the digestive tract of an unknown origin.
• Hiatal hernia
• Abnormal vaginal bleeding
• Blood observed in the urine.
• GERD or gastroesophageal reflux disease
• Tumors
• Chronic pancreatitis

Q2. What are the types of endoscopies?

A2. The various types of endoscopies are as follows:

• Arthroscopy – To examine the joints
• Bronchoscopy – To examine the lungs
• Cystoscopy – To carefully study the urinary bladder
• Colonoscopy – To detect various problems in the colon.
• Enteroscopy – Done for the small intestines
• Laparoscopy – Monitor the pelvic or abdominal area
• Hysteroscopy – To diagnose for any problems inside the uterus
• Laryngoscopy – To examine the larynx
• Mediastinoscopy – Examination of the mediastinum or the part between the lungs.
• Sigmoidoscopy – To detect for abnormalities in the rectum or the sigmoid colon (lower portion of the large intestine)
• Thoracoscopy – This is also known as pleuroscopy and is done to examine the portion between the chest wall or the lungs
• Upper gastrointestinal endoscopy – To monitor the upper intestinal tract and the esophagus
• Ureteroscopy – To examine the ureter for any abnormalities. This procedure is done through the urethra.

Q3. Are there any other better techniques that have come up in the procedure of endoscopy?

A3. With the advancement in technology, there are some other techniques in the endoscopy, as mentioned below.

• Capsule endoscopy – In this technique, the patient is asked to swallow a small capsule, which consists of a tiny camera in it. It passes down the digestive tract of the patient without causing any problem to the patient and takes numerous images of the tract as it moves.
• Endoscopic retrograde cholangiopancreatography (ERCP) – This method combines with the X-ray with the endoscopy of the upper gastrointestinal tract. This is done to treat various problems related to the pancreas and bile ducts.
• Chromoendoscopy – In this procedure, a special contrast or a dye is to be consumed by patients. It forms lining in the intestine during the procedure. This assists the doctor to diagnose any signs of abnormality on the lining of the intestine.
• Narrow band imaging (NBI) – This procedure uses a special type of filter which creates more contrast media between the mucosa and the vessels.
• Endoscopic mucosal resection (EMR) – This method assists the doctors to remove the cancerous growth in the digestive tract. In this procedure, a needle is inserted through the endoscope in order to inject a liquid below the abnormal tissue area. This technique differentiates the cancerous cells from the other normal layers so the doctor can easily remove the cancerous cells.