[Fat Bear Popular Science] A "precision weapon" for diagnosing hidden lesions. This article will show you how powerful "ultrasound endoscopy" is?

Recently, the Department of Gastroenterology of the Affiliated Cancer Hospital of Chongqing University successfully performed a lung tissue puncture biopsy under the guidance of ultrasound endoscopy. This diagnostic technology not only clarified the nature of the patient's lung lesions, but also provided a clear idea for the patient's next clinical diagnosis and treatment plan.

Uncle Xu, 57 years old this year, was diagnosed with nasopharyngeal carcinoma 2 years ago, and has been undergoing chemotherapy and radical radiotherapy during this period. A small nodule was found on the right lung during an examination 1 year ago, and no obvious changes were found during subsequent regular checkups. But 1 month ago, when Uncle Xu underwent a chest CT scan, it was shown that the nodule had enlarged, and the possibility of metastasis could not be ruled out. However, due to the special location of the lesion and the proximity of the lesion to important organs such as the heart and thoracic aorta, traditional bronchoscopy and percutaneous lung puncture biopsy could not be completed and were more risky, so the cause of Uncle Xu's disease could not be determined because a puncture biopsy could not be performed.

"Although the doctors said it was secondary lung cancer, we can't be 100% sure without a puncture biopsy. Our family also wants to know whether his disease is primary or secondary, so that we can better treat it according to the cause. How can we treat it without finding out the cause?" said Ms. Wang, Uncle Xu's wife. "In order to find out the cause, we went to many hospitals, even hospitals outside the province, but every time the doctor said that the location was too special and the traditional puncture biopsy was too risky and it would not work!"

Later, after being introduced by fellow patients, Uncle Xu and his family came to the Affiliated Cancer Hospital of Chongqing University with a try-it attitude. The person they consulted was Chen Weiqing, the director of the Department of Gastroenterology. Faced with the lesion in this special location, how to perform a puncture biopsy to make a clear diagnosis became a difficult problem for Director Chen Weiqing. Finally, after consulting with experts in the department, Director Chen Weiqing thought of a "magic weapon" that might be able to perfectly solve this problem, and that "magic weapon" was "ultrasound endoscopy."

"Ultrasound gastroscopy can not only play a role in gastrointestinal diagnosis and treatment, but also in the diagnosis and treatment of lesions of organs adjacent to the digestive tract, such as bile duct cancer, pancreatic cancer, mediastinum, pelvis, retroperitoneum and other organ lesions. When faced with lesions in this special location, it may also be possible to use 'ultrasound endoscopy' to solve it." Director Chen Weiqing introduced.

After finding a solution to the problem, Director Chen Weiqing immediately arranged for the endoscopy center to prepare for Uncle Xu to undergo a lung tissue puncture biopsy under the guidance of an ultrasound gastroscope. During the operation, Director Chen Weiqing first performed an ultrasound endoscopy on Uncle Xu. The ultrasound examination results showed irregular low-echo shadows in the right lower lung between the right lobe of the liver and the pericardium and thoracic aorta. After the examination, Director Chen Weiqing used a puncture needle under ultrasound guidance to puncture the lesion once, and ended the operation after obtaining sufficient tissue strips. The operation went very smoothly, and no bleeding was observed during and after the operation.

The lung tissue puncture biopsy under the guidance of ultrasound gastroscopy not only clarified the nature of the lesion, but also provided a clear idea for Uncle Xu's next diagnosis and treatment plan.

"Ultrasound endoscopy and puncture biopsy can serve as a supplement for clear diagnosis when other traditional puncture methods are not possible in organs adjacent to the digestive tract." Director Chen Weiqing introduced that the successful implementation of this operation once again demonstrated the important role of ultrasound endoscopy and ultrasound puncture biopsy in assessing lesions and clarifying the nature of lesions.

So what is the magic weapon that helped us succeed in this operation - "endoscopy"? Let's take a look at it with the expert team of the Department of Gastroenterology of the Affiliated Cancer Hospital of Chongqing University.

Expert Profile

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Chen Weiqing

Director of the Department of Gastroenterology, Affiliated Cancer Hospital of Chongqing University, chief physician, doctor of medicine, and doctoral supervisor.

He has been engaged in the diagnosis and treatment of gastrointestinal, hepatopancreatic and other diseases for more than 30 years, and has conducted in-depth research on the clinical diagnosis and treatment of gastrointestinal bleeding, severe pancreatitis, cirrhosis and its complications, inflammatory bowel disease, etc. He is particularly good at endoscopic diagnosis and interventional treatment of gastrointestinal, hepatopancreatic and other diseases, such as clinical evaluation/diagnosis and treatment of cirrhosis and its complications, EMRL, EMR, ESD, endoscopic ultrasound diagnosis, and endoscopic ultrasound-guided puncture biopsy/injection/drainage.

Clinic hours: Monday morning

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Jiang Juan

Head nurse of the Department of Gastroenterology, Affiliated Cancer Hospital of Chongqing University, head nurse, diabetes specialist nurse, and one of the top ten science popularization ambassadors in Chongqing.

He is mainly engaged in research on gastroenterology disease nursing and tumor nursing, and is good at chronic disease management nursing education.

What is endoscopic ultrasound?

Ultrasound endoscopy is the "perspective eye" of gastroenterologists and the "third eye" of gastroenterologists. Simply put, it is "endoscopy + ultrasound", that is, ultrasound performed in the gastrointestinal tract. Different from the traditional method of placing the ultrasound probe on the surface of the skin, this ultrasound probe is placed in the gastrointestinal tract. So how do you put the probe in? That requires the use of an endoscope, which mainly places the ultrasound probe at the front end of an endoscope (gastroscope, colonoscope) or introduces a miniature ultrasound probe through the endoscope, and performs ultrasound scanning of the wall of the digestive tract (esophagus, stomach, colon) or adjacent organs (pancreas, bile duct, gallbladder, liver, etc.) under direct vision of the endoscope through the digestive tract.

Advantages of endoscopic ultrasound

What are the advantages of ultrasound endoscopy? First, we need to understand the layers of the digestive tract. The digestive tract can generally be divided into four layers, from the inside to the outside: the mucosal layer, the submucosal layer, the muscular layer, and the serosa layer.

Although traditional gastroscopy and colonoscopy can directly diagnose most gastrointestinal diseases, because they use visible light imaging, they can only see the outermost layer of the digestive tract, that is, the mucosal layer.

So, how do we determine the nature and type of lesions that grow under the mucosa of the digestive tract and lesions in organs outside the gastrointestinal cavity (such as the bile duct, pancreas, etc.)?

At this time, endoscopic ultrasound can fully demonstrate its value. If endoscopy and surface ultrasound cannot make a clear diagnosis, endoscopic ultrasound examination can be performed. Endoscopic ultrasound can give full play to the dual advantages of "endoscopy" and "ultrasound". It can see lesions from the inside to the outside, which can be said to be a "strong combination" to obtain a clearer and more comprehensive diagnosis.

Ultrasound probes can observe the submucosal conditions and use the characteristics of ultrasound echoes to perform differential diagnosis of lesions. It helps to determine the origin and nature of submucosal tumors of the digestive tract, determine whether mucosal tumors can be removed endoscopically, and is used to determine the depth of invasion of digestive system tumors and the possibility of surgical resection. It can also diagnose pancreatic and biliary system tumors, especially for smaller tumors with high accuracy. It is a good auxiliary diagnosis and differential diagnosis method for the diagnosis of chronic pancreatitis. In general, ultrasound endoscopy can not only play a role in gastrointestinal diagnosis and treatment, but also has great potential in the diagnosis and treatment of lesions of organs adjacent to the digestive tract, such as bile duct cancer, pancreatic cancer, mediastinum, pelvic cavity, retroperitoneum and other organ lesions.

The distance of ultrasound diagnosis is key. The closer the distance, the fewer interfaces the ultrasound passes through, and the clearer the image. For lesions of the digestive tract itself, such as submucosal tumors, the endoscope can be used to get close to the lesion under direct vision, and eliminate gas interference through methods such as suction, water injection, and installation of water bags to obtain clear ultrasound images.

In short, the advantages of ultrasound endoscopy over ordinary endoscopy are:

● It can understand the depth of the lesion

● It is possible to understand the origin of the disease

● Visible understanding of the situation outside the cavity

Who needs endoscopic ultrasound?

What are the indications for endoscopic ultrasound?

Ultrasonic endoscopy is the doctor's third eye. As one of the advanced endoscopic techniques, it plays an extremely important role. It is not only of great value in diagnosing diseases, but is also indispensable in puncture and treatment, greatly expanding the scope of endoscopic treatment.

The following are the indications for endoscopic ultrasound.

#01

Diagnosis of suspected digestive tract cancer and determination of the depth of invasion;

The tumor can be seen under the endoscope, but we still need to understand to which layer the tumor has grown, whether there is metastasis to the surrounding lymph nodes, and whether there is metastasis to adjacent organs. Ultrasound endoscopy can stage the tumor and guide subsequent treatment.

#02

The depth of invasion and metastasis of digestive tract malignant tumors are classified into TN stages;

#03

Diagnosis of submucosal lesions of the digestive tract (esophageal cancer, gastric cancer, duodenal lesions, colon cancer, rectal cancer, leiomyoma, lateral developmental tumors, etc.)

Ultrasound endoscopy can easily distinguish the growth layer of intramural tumors, and the interruption and abnormal changes in any layer of the structure can determine the depth of tumor infiltration. For submucosal tumors growing in the esophagus, stomach, duodenum and colorectum, the nature of the tumor can be preliminarily determined by the tumor's origin layer, size, echo characteristics, etc. It can be distinguished whether the bulge in the digestive tract is caused by compression of submucosal tumors or extramural lesions. Adequate tissue specimens can be obtained through puncture biopsy to determine the nature of the lesion, evaluate surgical resectability, prognosis and guide the selection of treatment plans.

#04

Pancreatic and biliary system diseases (pancreatic cancer, bile duct stones, bile duct cancer, pancreatitis, pancreatic cysts)

Endoscopic ultrasound can be scanned closely against the stomach wall or duodenal wall, and is separated from the pancreas and bile duct by only one wall, so it can clearly display the entire pancreatic tissue, the entire length of the bile duct, and the gallbladder. It plays an irreplaceable role in the diagnosis of small pancreatic tumors, tumors at the end of the bile duct, or tumors in the duodenal papilla. Endoscopic ultrasound is highly reliable in diagnosing pancreatic and bile duct tumors and tumors infiltrating large blood vessels or surrounding important organs, and can avoid unnecessary laparotomy exploration.

At present, all laboratory tests or imaging tests for diagnosing chronic pancreatitis are difficult to judge early pancreatitis, and there is no gold standard for diagnosing chronic pancreatitis. Endoscopic ultrasound can clearly show the parenchymal structure of the pancreas and subtle changes in the pancreatic duct, such as high echoes in the pancreatic parenchyma, lobular structure of the gland, cystic changes, calcification, pancreatic duct dilatation, pancreatic duct stones and other signs. Endoscopic ultrasound is a sensitive tool for diagnosing chronic pancreatitis. For small pancreatic cancers, endoscopic ultrasound (EUS) has the highest sensitivity compared to CT and MRI.

#05

Differential diagnosis of ulcerative lesions;

#06

Some mediastinal lesions;

#07

Determine the degree of esophageal varices and the effect of embolization therapy.

important!

Endoscopic ultrasound and guided puncture biopsy (EUS-FNA) can accurately evaluate the nature, size, morphology, and infiltration depth of gastrointestinal tumors, which has guiding significance for later treatment methods, especially for guiding the treatment plan of biliary and pancreatic system diseases.

The following are some things to note before endoscopic ultrasound examination.

#01

The preoperative preparation for endoscopic ultrasound examination is basically the same as that for endoscopic examination, and relevant preoperative examinations such as electrocardiogram should be completed.

#02

Ultrasonic gastroscopy (lesions of the esophagus, stomach, gallbladder, and pancreas): The same precautions as endoscopic examination, the most important point is not to drink water.

#03

Do not eat or drink for 6 to 8 hours before the examination. The examination should be performed on an empty stomach. If there is food in the stomach, it will affect the observation. Patients with pyloric obstruction should fast for 2 to 3 days. If necessary, gastric lavage should be performed before the operation to remove the food accumulated in the stomach.

#04

Take defoaming agents orally to eliminate the foam stuck on the mucous membrane and provide a clearer field of vision.

#05

Be careful to remove removable dentures.

Ultrasonic endoscopic examination requires the following points.

#01

The patient needs to fast for more than 4 to 6 hours. For upper gastrointestinal examination, the patient needs to take lidocaine jelly for local anesthesia and lubrication. For lower gastrointestinal examination, the patient needs to prepare the intestine.

#02

The usual body position is the same as that for ordinary endoscopic examination. Before the examination, the nurse will assist in taking the side-lying position with the knees bent in front of the chest.

#03

If it is a painless ultrasonic endoscopy, after anesthesia, it will be like sleeping, and the examination will be completed when you wake up. Of course, during the anesthesia process, the anesthesiologist, endoscopist, and endoscopic nurse will pay attention to your condition at any time, so there is no need to worry.

#04

If it is a common ultrasound endoscope, the front end of the ultrasound endoscope is harder, the outer diameter is thicker than that of a common endoscope, and the curvature is smaller, so it is more painful for the patient when inserted. Therefore, you need to take a deep breath and bite the mouth pad tightly, keep your head down and tilt it back slightly, increase the gap in the throat to facilitate the insertion of the ultrasound endoscope and the flow of saliva. The most important thing is to relax and cooperate with the doctor and nurse who are examining you, and avoid excessive tension.

Things to note after the inspection

There are no special precautions after ordinary endoscopic ultrasound examination. Generally, you are only required to fast for 2 hours after the operation. If EUS-FNA or other endoscopic ultrasound treatment is performed, you need to be observed and treated according to the doctor's postoperative instructions.

Text/Fat Bear

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Audit/Gastroenterology

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