Endoscopic Ultrasound: An Overview
Guest: Dr. Joseph Romagnuolo – Gastroenterology & Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Joe Romagnuolo who is Associate Professor of Medicine at the Digestive Disease Center here at the Medical University of South Carolina. Dr. Romagnuolo, I know one of your areas of real expertise is in the use of endoscopic ultrasound. Can you explain just what that technology is?
Dr. Joe Romagnuolo: Endoscopic ultrasound is a type of endoscopy where a flexible tube with a camera gets passed through the mouth into the stomach, or into the rectum, to be able to take ultrasound images of the inside of the GI tract, to either image those structures better or to image structures that are very nearby, better.
Dr. Linda Austin: Under what clinical circumstances would you perform that? Who gets that procedure?
Dr. Joe Ramagnuolo: We do it often for cancer staging. Because CT scans and MRIs, really, are not able to see the gut wall with any kind of high resolution, it is very difficult for them to tell how deep into the wall the tumor is penetrating. Whereas, with ultrasound, because we are able to put that ultrasound probe right against the wall of the esophagus, or the stomach. We can see exactly how many wall layers the tumor has gone through and give you an accurate staging of that tumor.
Dr. Linda Austin: And, why is staging so important?
Dr. Joe Romagnuolo: Staging has two important uses. One is to prognosticate. One is to be able to tell you the prognosis of your tumor, how likely you are to recur, etc. The other is to determine what kind of treatment would be best suited for that tumor.
Dr. Linda Austin: So, that, is very important?
Dr. Joe Romagnuolo: In some cases, it makes the difference between whether someone gets chemotherapy before an operation, whether they get an operation at all, etc. So, it is very important.
Dr. Linda Austin: So, typically, then, most of the patients that you would use this on have already been diagnosed as having cancer of, what, of the esophagus, the stomach, of the, how about, intestine?
Dr. Joe Romagnuolo: Right. The esophagus and stomach are tumors that we are often asked to stage. The rectum is the other area that we can stage very accurately. Lesions that are higher up in the colon, than the rectum, are generally not staged with endoscopic ultrasound. But, those three tumors are staged very frequently with EUS and, almost all the time, those patients already have a diagnosis of cancer before they come to us for staging. For pancreatic cancer, which can be diagnosed and staged with EUS, often times, there is not a diagnosis of cancer, just a suspicion.
Dr. Linda Austin: I see. I am sure that somebody listening to this will be going through this procedure, or somebody that they love will be going through the procedure. Can you walk us through what happens to the patient on the day of the procedure?
Dr. Joe Romagnuolo: With what we call the upper EUS procedures, we are examining either the esophagus, the stomach, or the pancreas, and passing a scope through the mouth, then the only preparation is generally that patients are fasting overnight and will get an intravenous when they register and the procedure is done under sedation, whereas the rectal ultrasounds are done with a colon prep, to clean out the bowel, as well as an enema, prior to the procedure.
Dr. Linda Austin: So, the dreaded prep with go lightly that people have when they have a colonoscopy.
Dr. Joe Romagnuolo: Yes. Generally, it is not quite as vigorous as a colonoscopy prep, but at least the rectum has to be reasonably clean for us to see what we are doing with ultrasound and to make it safe for us to be able to perform any needle biopsies. With this technology, we have the ability to pass a needle through the stomach wall, or the rectal wall, to be able to get out lymph nodes or other structures that are outside of the GI tract, and we can do those under ultrasound vision.
Dr. Linda Austin: Now, is this ever done as part of follow-up treatment, post chemotherapy, or in later stages?
Dr. Joe Romagnuolo: Occasionally, patients who are borderline, in terms of resectability, meaning, it is borderline whether or not the tumor will be able to be removed with surgery, they will undergo some type of therapy, chemotherapy, perhaps, and/or radiation, patients will be restaged to see if downstaging has occurred so that, perhaps, the tumor has shrunken enough, it can be removed surgically.
Dr. Linda Austin: Now, you mentioned that, most of the time, endoscopic ultrasound is used for staging of cancer. What are some of the other reasons a patient might have this procedure?
Dr. Joe Romagnuolo: The other reason that you might have the procedure is to diagnose or get better images of the pancreas or biliary tree. Because the gall bladder and the bile duct are very close to the small intestine, the first part of the small intestine, the duodenum, because both of those structures are within millimeters of the intestine wall, they are seen in very high detail with ultrasound, in high resolution. So, you can diagnose bile duct stones, or gall bladder stones that have been missed with other imaging modalities, even MRI, because of that high resolution imaging.
Dr. Linda Austin: Anything new on the horizon in diagnostic imaging, any new techniques that we are exploring here at Medical University or elsewhere?
Dr. Joe Romagnuolo: One of the techniques that we will be exploring shortly is something called contrast EUS. EUS is the acronym for endoscopic ultrasound. Contrast EUS involves putting a micro bubble solution into a vein, very tiny bubbles that are the size of blood cells, which can flow through the lung vessels with ease, and they will help us to differentiate inflamed lymph nodes versus malignant lymph nodes, or an inflammatory lump in the pancreas versus a tumor. The aim is to have that ultrasound contrast agent help us to better decide whether something is malignant or benign.
Dr. Linda Austin: Dr. Romagnuolo, thank you so much for talking to us today.
Dr. Joe Romagnuolo: Thank you.
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