Radial endosonography atlas endoscopic and ultrasound interpretation. Vladimir Romanov

Introduction

More than 30 years have passed since the first introduction(creation) of ultrasonic endoscope and its integration in clinical practice. The Japanese inspired by the success of endoscopy in early stomach cancer diagnostics, have created the endoscope with the ultrasonic sensor especially for diagnostics of early pancreas cancer. However, it appeared so that the capabilities of endosonography are much bigger. Resolution less than one mm. allows to define structure of the hollow organ’s walls of the gastrointestinal tract layer by layer, which is impossible with CT and MRI. Determination of tumor invasion depth into stomach wall became possible in preoperative period. So tumor staging and metastasis determination are important advantages of this method. Diagnostics of GIT mesenchymal formations and determination of their tissue origin became possible. And such terrible disease as gastrointestinal stromal tumor, is detected on an early stage only by endosonography.

A real "boom" occurred in the 90s, when a new type of the ultrasonic endoscope with a longitudinally scanning probe was offered, it allowed to produce an ultrasound controlled fine-needle puncture (FNA) of lymph nodes, gastrointestinal tumors, and pancreas. From that moment began the development of interventional endosonography, which includes a number of new medical techniques: abscess sanitization, post necrotic pancreas cysts drainage, creation of biliodigestive anastomosis, neyrolisis, hardening of benign tumors of the pancreas, locally advanced unresectable pancreatic cancer treatment realizing PDT, injection of stem cells and dendritic cells, local chemotherapy, radioactive iodine 121 brachytherapy. According to Japanese authors, recent techniques can significantly reduce the amount of pancreas tissue tumors, and bring it to operable stage, and in some cases cure completely. Currently endosonography is recognized worldwide and has become an integral part of gastrointestinal endoscopy. It is noted that endosonography should be conducted by a competent specialist in fluent endoscopic examination. Precise knowledge of anatomy is very important. Specialist must have a strong spatial imagination and stereo topographical knowledge. Because the study aims are to identify the tumor process and staging,doctor requires a deep knowledge in oncology.

The author, based on 10 years of experience in clinical endosonography method is convinced in the need of publication in the form of atlas, which would combine endoscopic and ultrasound images. According to the author, it should significantly accelerate the development of this method and help to correctly interpret a found pathology. The book consists of 550 illustrations and 6 chapters dedicated to endosonography of esophagus, stomach, duodenum, gallbladder, bile ducts, and also hard to diagnostic pancreas.

There is still a lot of subjectivism in the interpretation of ultrasound images, and if endosonography specialists will find discrepancies in interpretation and will offer their own more accurate version, author will assume that his purpose is achieved.

V.A. Romanov

Methods of inspection and technical aspects of endosonography of esophagus, stomach and duodenum.

The esophagus is a tubular structure and is convenient for endosonography, as practically it has no bends. Research is conducted with a water-filled balloon covering the sensor. With various kinds of structures mini sensors are used. To inspect the stomach walls, endoscopes with radial sensors (mechanical or electronic) and the ultrasonic probe are mainly used, initiated through the channel of endoscope. Location at 3600 provides a complete visualization of the walls of the gastrointestinal tract and its adjacent structures. For a detailed study of the stomach wall high-frequency sensors of 12 to 30 MHz are used. The use of these sensors provides a high quality ultrasonic image with a resolution less than 1mm. Such definition is virtually unavailable to other diagnostic methods such as CT and ultrasound with extracorporeal sensor. Our experience shows that for more detailed layered structure of the stomach wall, mechanical sensor is preferred to electronic, especially with minimal pathology.

The study is conducted as a standard procedure of esophagogastroduodenoscopy on the left side. To create acoustic conducting environment stomach filled with deaerated water from 200 ml to 500 ml. Saline can be also used. For higher quality scanning is preferred to preliminarily wash stomach through the endoscope channel with a defoamer and subsequent aspiration of water, containing frothy secretion and food masses remnants.

The amount of added water foe examination depends on the location of pathology. Scanning in the antral section requires more water, especially if the stomach is "hook" shaped. Remains of air from the stomach must be removed by aspiration. The patient must be in the "light" Trendelenburg position, right side position of patient is also often used.

Scanning of the middle and the upper thirds of stomach are carried out in the horizontal position of the patient. Fitting lumen with water should be dosed, depending on the size of the stomach. In the absence of axial hernia and cardiac sphincter deficiency, scanning of the upper third of the stomach arch is possible in the "light" anti-Trendelenburg. There is no to fully fill the lumen of stomach with water, because it can lead to regurgitation. It is necessary to control water coverage of scanning object.

On the screen the stomach wall is a circular structure that consists of alternating rings of increased and decreased echogenicity. Most authors describe a 5-layered structure of the stomach wall. Authors usually describe the stomach wall structure as a 5-layered structure. The first 2 layers correspond to the mucosa, the third - submucosal layer, the fourth - the actual muscle layer, and the fifth is serosa. But at the frequency of 12 MHz 7 and 9 layers are distinguished in the stomach wall.

Histological and ultrasonic layers are correlated.

There are 4 methods of scanning:

The use of a latex balloon for the miniprobe as for the endoscope.

When the stomach is filled with water, the endoscope and the probe are used without latex balloons.

combined method, which uses latex balloons in water.

Scanning without water and without latex balloon, with miniprobe with severe pyloric structure or cardiac. Contact scanning.

When scanning with endoscope it is necessary for the ultrasonic waves to be perpendicular to the stomach wall, with 20-30mm focal length of the transducer. In this case it is possible to get clear and qualitative endosonography. When scanning is made at an angle to the stomach wall, the image becomes blurred, blurry, lose lamellar structure, image resolution and original dimensions. For a short focused mini probe scanning distance to the object is about 3 to 10 mm.

While duodenum scanning it is useful to fill it with water. This allows you to get high-quality ultrasound images of the lumen and the walls up to the underside of the horizontal branch.

In the process of work we used a radial ultrasonic fibroscope – Olympus GF-UM20 with a mechanical sensor and ultrasonic probes with mini sensors UM-2R and UM-3R. In addition, for a short period of time Pentax company has provided us the opportunity to work with the radial and convex ultrasound endoscopes EG-3670URK and EG-3870UTK in combination with ultrasound scanner Hitachi EUB 7000 HV elastography function.

Elastography method is very promising and holds great diagnostic capabilities. Ever since the days of Hippocrates, it is known that a high density of tumors is seen as an indicator of malignancy. This principle is the basis of a new method of ultrasonic elastography. Blue color indicates the solid tissue, red and green soft. Information obtained with elastography helps in differential diagnosis of tumors.

Esophagus
Varicose veins. Leiomyoma. ………………………………              ...........9
Leiomyoma. Fibrovascular polyp………………………………………   …………11
Reflux esophagitis. Scleroderma…………………………………………….……13
Lichen Planus. Early esophageal cancer……………………………         ….14
Early esophageal cancer ………………………………………………………….….15
Esophageal cancer ………………………………………………….……………….….16

Stomach
Acoustic layers. Varicose veins of stomach vault……………                ..21
Varicose veins. Adenomatous polyps………………………………………   ……22
Hyperplastic polyps…………..………………………………………               ……23
Peutz-Jeghers polyp….…………..…………………………………         …………24
Ménétrier's disease. Stomachal wall cyst …………………………  ……………26
Lipoma …………………………………………………………………………           .…28
Leiomioma ……………………………..……………………………………         ….…30
Gastrointestinal stromal tumor…...…………………………….                  …33
Fibrolipoma, choristoma……………………………………………………       ….…38
Neurioma ………………………………………………………………          ………….40
Carcinoid.……………………………………………………………………           ….…41
Carcinoid. Polypoid cancer ……………………………………………          ….…42
Early cancer …………………………………………………………………         ….…43
Early cancer. Photodynamic threpy……………………………………      ….…54
Stomach cancer ………………………………………………..……………    ……….73

Duodenum
Normal. Fibrolipoma………………………………………………………         ………75
Lipoma. Carcinoid………………..………………………………………         …….…76
Carcinoid. Gastrointestinal stromal tumor …………………                ….…77
Metastases of melanoma……………..……………………………… …………….…78
Doudenum cancer. ……………………………………………………           .. ….79
Cancer of the major duodenal papilla ……………………………………………. 80
Adenoma of the major duodenal papilla……………………                  … 84
Adenoma of the major duodenal papilla. Stenting ……    ………………… 85
Villous adenoma of the major duodenal papilla. Removal …………………. 86

Bile ducts
Choledochal cyst. ………………………………………………………………. ........ 91
Expansion, choledochal scar structure. …………………………………   ……. 92
Choledocholithiasis. ……………………………………………………………   ……… 93
Choledocholithiasis. Incarcerater stone in MPD ampoule…… …………….. 95
Surgery. Removal of incarcerated stone. ………………………………… ……. 96
Removal of incarcerated stone.Choledocholithiasis. ………………….  ……. 97
Removal of gallstone in the lumen of the intestine…………………  .....… 98
Cancer of the common bile duct. Stenting.. ………………………………..…. 99

Gallbladder.
Gallbladder. Dyskinesia. Courvoisier symptom. ……………………………….. 101
Cholestasis. Microlithiasis. Sludge. …………………………………………… …… 102
Polyp, stem adenoma. Cholecysitis. Stone.………………………………… … 103

Stone in the cervical area. Multiple stones. Sludge ……………………...   104
Micropolyposis. Gallbladder cancer. Cancer of the common bile duct... 105

Pancreas.
A panoramic image of the pancreas. Acute pancreatitis.. ………     .… 107
Chronic pancreatitis. Alcoholic pancreatitis.……………………….……      .. 108
Micronodular cirrhosis. Alcoholic pancreatitis. …………………           .…. 110
Chronic autoimmune pancreatitis.. …………………………………… ……...… 111
Autoimmune pancreatitis. Postnecrotic cyst.. ………………………………. 112
Drainage of the cyst. ………………………………………………………………….. 113
Pseudocyst of the pancreatic head. Serous cystadenoma. …………  .. 114
Posttraumatic cyst. Drainage of the cyst. …………………………………  … 115
Cystadenocarcinoma. ………………………………………………………………….. 116
Pancreatic abscess. Insuloma.…………………………………………………      . 117
Insuloma.……………………………………………………………………………     ….. 118
Intraductal cancer. Cancer of the pancreas head. ……………….…    ….. 119
Hooklike appendix cancer.

Cancer of the head and body of the pancreas.. …..…                    … 120
Lymphadenopathy. Cancer of the pancreas body. …………………………. 121

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