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■ CLINICAL PRACTICE Clinical Medicine 2009, Vol 9, No 6: 539–43

Endoscopic ultrasound: what is it and when should it be used?

Yogananda Reddy and Robert P Willert

ABSTRACT – Endoscopic ultrasound (EUS) is an increasingly There are two types of commonly used echoendoscopes each
available diagnostic and therapeutic tool used within the UK. with differing characteristics. Radial EUS was the first to be
It has wide applications both in the gastrointestinal tract and developed and provides a 360-degree view in a plane perpendic-
mediastinum with its current main uses being in the staging ular to that of the scope, similar to a computed tomography (CT)
of luminal malignancies and assessment of pancreatic and image (Fig 2). Linear EUS provides a localised oblique image
subepithelial lesions. The emergence of linear EUS has parallel to the scope and enables therapeutic intervention under
opened up new therapeutic avenues with fine needle aspira- ultrasound (Fig 3). High frequency EUS mini-probes are also
tion, trucut biopsies, coeliac plexus blocks and transmural available which can be passed down a standard biopsy channel of
pseudocyst drainage all now possible. Future developments an endoscope in cases where strictures cannot be passed using a
include localised brachytherapy/chemotherapy and alcohol standard EUS scope.
ablation of unresectable pancreatic malignancies and EUS-
guided endoscopic surgery. Indications for endoscopic ultrasound

KEY WORDS: cancer staging, endoscopic ultrasound, fine The indications for EUS can be divided into several categories:
needle aspiration
• staging of GI malignancies
• evaluating pancreaticobiliary disease
Introduction • evaluating subepithelial abnormalities
• evaluating extraluminal abnormalities
Endoscopic ultrasound (EUS) was developed in the 1980s • staging of lung cancer
but was rarely used within most of the UK. The advent of
therapeutic EUS using linear echoendoscopes a decade later, in
• therapeutic EUS.

particular the ability to sample lymph nodes and suspected Staging of gastrointestinal cancers
malignancies by fine needle aspiration (FNA), led to its wider
uptake although service provision still remains centralised in Accurate staging of upper GI malignancy is vital for appro-
most areas. Currently the staging of oesophageal and oesopha- priate treatment selection for the patient. Because of its ability
gogastric junctional cancers in patients potentially fit for cura- to delineate the different layers of the GI tract wall, EUS has
tive surgery remains the most common indication for EUS, now become an integral component in classifying GI cancers by
although the increasing use of cross-sectional imaging is the widely accepted TNM classification.
resulting in incidental pancreatic lesions often requiring EUS
assessment. This paper aims to detail the widening applications Oesophageal cancer
of EUS both as a diagnostic modality and increasing therapeutic In oesophageal cancer, EUS has been proven to be superior to CT
intervention so those without current access are aware of the scanning for accurate local staging.1 EUS is more accurate at
relevant referral indications and its increasing contribution to
patient care.

What is endoscopic ultrasound?

Endoscopic ultrasound combines the two modalities of endo-
scopic visualisation with high frequency ultrasound to enable
imaging of the wall of the gastrointestinal (GI) tract and
beyond into the organs and vessels in proximity. The ability to
define each of the five wall layers of the GI tract corresponding
with its histological counterpart and also detect localised lymph
nodes forms the basis for most EUS procedures (Fig 1).

Yogananda Reddy, specialist registrar; Robert P Willert, consultant

gastroenterologist Fig 1. Wall layers at endoscopic ultrasound and corresponding
Department of Gastroenterology, Manchester Royal Infirmary histology.

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Yogananda Reddy and Robert P Willert

Fig 3. Linear endoscopic ultrasound scope with fine needle

aspiration (FNA) and pancreatic mass FNA.

scanning in staging accuracy, ranging from 71% to 88%

Fig 2. Radial endoscopic ultrasound (EUS) scope with EUS of
(T stage) and 77% to 80% (N stage).4,5 Both imaging modalities
bile duct stone. are complimentary in the staging process with EUS being partic-
ularly useful in staging localised early gastric cancer to assess for
endoscopic resectability.
evaluating the coeliac axis lymph nodes and is usually performed
when the CT staging has not shown distant metastasis. This helps Pancreatic cancer
in appropriate patient selection for neoadjuvant chemoradiation
therapy. Patients with very early oesophageal cancer may also The high resolution images of EUS in visualising the pancreatic
benefit from less invasive procedures such as endoscopic mucosal duct and parenchyma make it highly sensitive in the detection of
resection. Meta-analysis comparing CT and EUS in oesophageal small tumours, cysts and vascular invasion.6 EUS is superior to
cancer have shown T staging accuracy of 50–80% and 85–90% spiral CT, magnetic resonance imaging (MRI), or positron emis-
respectively.2 The NHS health technology assessment systematic sion tomography (PET) in the detection of small pancreatic
review of endoscopic ultrasound in gastro-oesophageal cancer tumours with a staging sensitivity greater than 90%.6,7 It is also the
confirms the high accuracy of EUS for T and N staging of most sensitive modality for detecting pancreatic neuroendocrine
oesophageal cancer.3 tumours and can distinguish structures as small as 2–3 mm.8

Gastric cancer Pancreaticobiliary disease

The accuracy of EUS in staging gastric cancer is not comparable Cystic lesions of the pancreas
to oesophageal cancer because of difficulty in differentiating
between the subserosa and serosal layers. However, many studies With the increasing availability of CT scans there has been a
have demonstrated superiority of EUS over conventional CT steady rise in the number of incidental cystic lesions of the

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Endoscopic ultrasound: what is it and when should it be used?

pancreas and although the majority of these lesions are small Mediastinal lymphadenopathy
and benign up to 10% may represent malignant or pre-
malignant neoplasms.9 Despite advances in CT and MRI, the Endoscopic ultrasound can readily identify lymph nodes in the
ability to differentiate between benign and malignant cysts aortopulmonary, subcarinal, paratracheal and para-oesophageal
remains limited. EUS not only provides high resolution images regions. EUS-FNA of mediastinal nodes improves the diagnostic
but also has the added advantage of sampling the cyst content accuracy in determining the malignant feature and hence
and any local lymph nodes. EUS-FNA with cytology in such avoiding mediastinoscopy or thoracotomy. EUS-FNA has been
cystic lesions can improve the diagnostic accuracy.10 shown to yield diagnosis when CT, PET, bronchoscopy and
pleurocenteses have been negative or inconclusive. The sensi-
tivity of EUS-FNA for detecting malignancy in mediastinal
Chronic pancreatitis lymph nodes is in the region of 88–96%15 and it is also possible
Endoscopic ultrasound is a very sensitive imaging modality for to differentiate tuberculosis, sarcoidosis and lymphoma
the detection of structural changes of chronic pancreatitis following EUS-FNA and trucut biopsy without the need for
which may be absent on transabdominal ultrasound, CT, MRI invasive mediastinoscopy. The recent development of tissue
or endoscopic retrograde cholangiopancreatography (ERCP).11 elastography to determine malignant lymph node potential by
Care must be taken, however, not to over diagnose normal age- analysing lymph node tissue density is also possible using EUS
related pancreatic changes as early chronic pancreatitis. Often which may help refine future EUS-FNA to the most suspicious
the most difficult diagnostic interpretation is distinguishing node.16
chronic focal pancreatitis from a hypoechoic pancreatic mass in
patients with chronic pancreatitis. In this situation a positive Endoscopic ultrasound in lung cancer staging
EUS-FNA is very helpful but the low sensitivity means that
surgery is often required when EUS-FNA is negative for The staging of lung cancer is dependent on transbronchial
malignancy. biopsy, CT-guided FNA, mediastinoscopy with biopsy or thora-
coscopy. EUS-FNA has been proven to be an accurate and safe
procedure for lymph node staging in patients with documented
Choledocholithiasis lung cancer.17 EUS also has the ability to identify mediastinal
In patients with suspected biliary stone disease, EUS has a nodes missed on staging CT and in non-small cell lung cancer
sensitivity of greater than 90% in detecting common bile duct EUS-FNA has been shown to be accurate and cost effective for
stones. It is comparable to ERCP in diagnosing biliary stone nodal staging in patients with documented posterior
disease, without the inherent risks of pancreatitis, but it lacks mediastinal lymphadenopathy, with a sensitivity of 83% and
the therapeutic ability for stone removal. It is far superior to the specificity of 97%.18,19 Recently the development of endo-
transabdominal ultrasound and controlled studies have bronchial ultrasound (EBUS) has been shown to be compli-
shown EUS is comparable or superior to magnetic resonance mentary to EUS allowing near-complete minimally invasive
choiangiopancreatography in the detection of biliary stone mediastinal staging in patients with suspected lung cancer with
disease.12 a diagnostic accuracy of 90–100%.20

Subepithelial lesions of the gastrointestinal tract Therapeutic endoscopic ultrasound

Endoscopic ultrasound has an important role in the evalua- The initial development of EUS-FNA has progressed to provide
tion of subepithelial lesions in the GI tract. It can characterise new and novel therapeutic indications for EUS. Coeliac plexus
lesions by determining their size, margins, layer of origin and blocks and neurolysis using EUS-guided injection of steroids or
echo texture and can differentiate between extramural or alcohol into the coeliac plexus, and more recently directly into
intramural lesions. The most common upper GI subepithelial the celiac ganglia, is a safe and effective method for pain control
lesions are normal wall indentations caused by extramural in pancreatic cancer and to a lesser extent in chronic pancreatitis
organs such as the liver, spleen, gall bladder or splenic vein.13 (Fig 4).21,22
Benign subepithelial lesions identified by EUS include Drainage of symptomatic pseudocysts previously has been
lipomas, simple cysts, congenital duplication cysts, ectopic done blind via a direct endoscopic approach or required
pancreatic tissue and varices. Malignant subepithelial lesions surgery. EUS cystogastrostomy allows characterisation of the
diagnosed by EUS include metastases, lymphoma and carci- pseudocyst, direct puncture into the cyst under EUS visualisa-
noid tumours. Gastrointestinal stromal tumours (GISTS) are tion (thereby avoiding any vessels) and stent placement in one
increasingly recognised with the majority of these lesions procedure while having a shorter patient stay than surgery.
being benign but some have malignant potential depending This should be the treatment of choice for symptomatic
on size, mitotic index and location. EUS trucut biopsy can uncomplicated pseudocysts where available.24 EUS can also be
enable differentiation between malignant and benign utilised to access the biliary system when ERCP has failed by
GISTs.14 puncture of the common bile duct with a wire under EUS

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Yogananda Reddy and Robert P Willert

Summary
Although initially slow to be accepted within the UK, EUS has
now an established role in many arenas. It is a safe and cost
effective procedure which has a significant impact on the man-
agement of patients with oesophageal and oesophagogastric
junctional cancer in accurately staging the disease. It is also the
most sensitive method of detecting pancreatic malignancies,
for determining the nature of subepithelial lesions and has a
complimentary role in the staging of non-small cell lung
cancer. Its therapeutic potential continues to increase as new
indications are found and the procedure gradually becomes
more available across the UK.

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