Endoscopic Ultrasound Guidelines

Introduction

Endoscopic Ultrasound (EUS) has evolved into an essential tool for diagnosis and therapy in gastroenterology. These guidelines provide recommendations for the application of EUS in Kenya, with consideration for the unique healthcare environment and available resources.

Diagnostic EUS Applications

Pancreatobiliary Evaluation

Evaluation of suspected pancreatic tumors
Evaluation of pancreatic cystic lesions
Diagnosis and staging of pancreatic cancer
Evaluation of idiopathic acute pancreatitis
Evaluation of suspected chronic pancreatitis
Evaluation of bile duct abnormalities when ERCP is contraindicated
Evaluation of suspected choledocholithiasis when other imaging is inconclusive
Evaluation of suspected gallbladder lesions

Gastrointestinal Wall and Adjacent Structure Evaluation

T staging of esophageal, gastric, rectal, and duodenal cancers
Evaluation of subepithelial lesions of the GI tract
Evaluation of thickened gastric folds
Assessment of perianal and perirectal inflammatory conditions
Evaluation of mediastinal lymphadenopathy
Evaluation of posterior mediastinal masses

EUS-Guided Fine Needle Aspiration (FNA) and Biopsy (FNB)

EUS-guided tissue acquisition is indicated for:

Solid pancreatic masses
Pancreatic cystic lesions when analysis of cyst fluid will impact management
Lymph nodes when a diagnosis would change management
Subepithelial lesions ≥2cm or with suspicious features
Unexplained gastrointestinal wall thickening
Mediastinal masses or lymphadenopathy of unknown etiology
Liver lesions that are inaccessible by percutaneous approach
Left adrenal masses when clinically indicated

Technical Considerations for EUS-FNA/FNB

22G or 25G needles are recommended for routine sampling of pancreatic lesions
19G needles may be preferable for specific indications (e.g., cystic lesions or core tissue needed)
At least 3-4 passes are recommended for solid pancreatic lesions without rapid on-site evaluation
Fewer passes (1-2) may be adequate for lymph nodes
Use of stylet is optional and based on endoscopist preference
Consider EUS-FNB over EUS-FNA when histology is required for diagnosis

Contraindications

Absolute contraindications to EUS include:

Hemodynamic instability
Severe coagulopathy that cannot be corrected
Perforated viscus
Severe respiratory distress

Relative contraindications include:

Large hiatal hernia (for transesophageal approaches)
Severe esophageal or gastric varices (for FNA/FNB)
Altered upper GI anatomy that prevents endoscope passage
Pregnancy (especially first trimester)
Recent myocardial infarction (<3 months)

Complications

Potential complications of EUS procedures include:

Diagnostic EUS: Similar to upper endoscopy (perforation, bleeding, adverse reaction to sedation)
EUS-FNA/FNB: Bleeding (1-2%), infection (<1%), pancreatitis (1-2% for pancreatic FNA), perforation (rare)
Therapeutic EUS: Bleeding (5-10%), infection (5-15%), perforation (3-5%), stent migration (5-10%)

Risk of complications is higher for therapeutic compared to diagnostic procedures.

Training and Competency

Recommendations for EUS training and competency in Kenya:

Endoscopists should be proficient in standard endoscopic procedures before undertaking EUS training
Minimum of 225 supervised EUS procedures (including 50 EUS-FNA) during training
Minimum annual volume of 50 EUS cases to maintain competency
Progression from diagnostic to therapeutic EUS only after achieving competency in diagnostic procedures
Participation in continuous medical education specific to EUS
Development of regional centers of excellence for EUS in Kenya to maximize effective use of resources

Resource Considerations

Adaptations for implementation of EUS in Kenya:

Concentration of EUS services in regional referral centers to ensure adequate procedure volumes
Development of telemedicine networks for consultation with international experts when needed
Collaborative training programs with international partners
Prioritization of cases where EUS will have highest clinical impact
Consideration of refurbished equipment to reduce costs where appropriate
Development of maintenance programs with manufacturer support

Citation

Gastroenterology Society of Kenya. (2023). Clinical Practice Guideline for Endoscopic Ultrasound. GSK Guidelines 2023. Nairobi, Kenya.

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