I believe care must be customized
to each patient because the practice
of medicine is not a “one size fits all”.

William B. Evans, M.D.

Therapeutic EUS Procedures

Serving Patients in Louisville, Kentucky

Therapeutic endoscopic ultrasound (EUS) is a type of procedure used to visualize and produce images of the digestive system by inserting an endoscope (a long, flexible tube with a camera on the tip) through the mouth or rectum. It was initially developed as a diagnostic procedure, but with the development of fine-needle aspiration (FNA) to obtain tissue, EUS is advancing in its role to provide therapeutic applications to treat different gastrointestinal (GI) disorders, instead of using more invasive approaches like surgery.

Therapeutic EUS procedures should only be performed by a highly specialized therapeutic endoscopist like Dr. Evans who has training and extensive experience in EUS and ERCP, both of which are high-risk and technically demanding procedures that are sometimes used together in the treatment of certain disorders of the digestive system.

The four types of therapeutic EUS procedures used by Louisville Gastroenterologist Dr. Evans are EUS celiac plexus neurolysis (EUS-CPN), EUS-guided pseudocyst drainage, EUS-guided biliary drainage (EUS-BD) and EUS-guided liver biopsy. Details on each type of procedure, including pre- and post-operative instructions, will be discussed further in the following sections.

EUS Celiac Plexus Neurolysis (EUS-CPN)

Pain in the upper abdomen and mid-back may be caused by a tumor invading the nerves and adjacent organs. Most commonly these tumors are pancreatic or stomach cancers. The tumors can invade the local bundles of nerves called the celiac plexus, which transmits pain signals to the brain. Strong pain medications called opiates are used to help control this type of pain. However, opiates can have unpleasant side effects like constipation and drowsiness.

The EUC-CPN procedure is used to provide pain relief through the injection of medication into the celiac plexus (nerve bundle). There are different surgical approaches to accomplish this, including percutaneous (through the skin) and surgical. The safest approach is with EUS guidance since it provides a visualization of the celiac plexus, which is located between the top of the stomach and the spine, close to the aorta.

Approximately 75 percent of patients who undergo the EUC-CPN procedure get some degree of pain relief; most patients are able to decrease their need for pain medications, and a few are able to stop them completely.

How Do You Prepare for EUS Procedure?

Prior to the procedure, Dr. Evans will go over some pre-operative instructions that you will need to follow in the days before your procedure. Following these instructions is essential to limit surgery risks and provide the best results.

  • Stop certain medications. Dr. Evans and his staff will need to be made aware of all medications that you are taking, especially blood-thinning medications. These may include Coumadin (warfarin), Plavix (clopidogrel), Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban) and Lovenox (enoxaparin). Since the use of these medications increases the risk of excessive bleeding, they should be stopped prior to your procedure. If you are using insulin, the dosage or timing will also need to be adjusted the day of the procedure. Doctor-prescribed aspirin may be continued before your procedure. In addition, Dr. Evans asks that you provide him or his staff with a list of medications to which you are allergic.
  • Stop eating hours beforehand. Refrain from eating anything starting the midnight before your procedure is scheduled.

What Happens During EUS-CPN?

During the procedure, a needle is directed under visualization into the area of the celiac plexus and then a combination of a local anesthetic and a sclerosing agent are injected.

What Should You Expect after the Procedure?

After the procedure, you will be returned to the “post-op” area to recover from sedation. You will also be monitored for any potential complications from the procedure and/or sedation. Once you are fully recovered, Dr. Evans will provide you with an explanation of the findings from your procedure, along with a copy of the procedure report, patient information handouts and follow-up instructions. He will also give you a full preliminary report at this time.

Due to the effects of sedation, patients are instructed not to drive, operate machinery or make important decisions for the first 24 hours. You will need to arrange for someone to drive you home after surgery. The nursing staff will review all of the instructions prior to discharge.

You will be able to eat after you leave the hospital, unless instructed otherwise. Dr. Evans and his staff will give you a diet to follow.

Possible Complications and Risks

The most common complication is abdominal pain for a few hours after the procedure. Patients are monitored for two to three hours after the EUS-CPN due to a high chance of temporary low blood pressure; extra intravenous fluids are given before and during the procedure to help prevent this. The majority of patients have a few days of diarrhea. Over-the-counter antidiarrheal medications work well to alleviate these symptoms.

Though rare, there also have been reports of bleeding, infection, and paralysis.

Uncommon risks from sedation used for the EUS-CPN procedure are: reactions to sedation medications, possible aspiration of stomach contents into the lungs and complications from heart and lung diseases.

All of these risks must be balanced against the potential benefits of the procedure and the risks of alternative approaches to the condition.

EUS-Guided Pseudocyst Drainage

Anatomy of pancreas from Dr. William Evans LouisvilleThe pancreas is a 6-inch long gland located in the upper abdomen between the stomach and the spine. One of its jobs is to produce a juice made up of enzymes (chemicals) that help digest proteins and fats in food that has been consumed. The pancreas makes about one-half liter of fluid per day, which travels down a small tube (or duct) that drains into the upper small intestine.

Inflammation of the pancreas is called pancreatitis and it can take on two forms: acute and chronic. Acute pancreatitis is most commonly due to gallstones or heavy alcohol use. Chronic pancreatitis, due to long-standing alcohol use and smoking, occurs when healthy pancreas tissue is replaced by scar tissue. In either condition, there can be a blockage in the flow of juice through the pancreatic duct, which can cause the fluid made by the pancreas to leak out into the abdomen and become surrounded by fibrous (scar) tissue. This is called a pseudocyst.

If large enough, a pseudocyst can lead to considerable pain as well as nausea and vomiting. Rarely, pseudocysts can become infected, bleed, or burst open. They are usually found by CT (computed tomography) scans or MRI (magnetic resonance imaging). Once found, drainage may be indicated.

There are three methods used to drain pseudocysts: percutaneous catheter (an X-ray placed tube to drain the fluid outside the body), surgery or endoscopic drainage. Endoscopic drainage is preferred because it is less invasive and has fewer complications than surgery, doesn’t require a drain coming from the body and has great long-term success rates. Endoscopic-ultrasound (EUS) guided drainage is preferred for the majority of pseudocysts that are close to the stomach and first part of the small intestine (duodenum).

How Do You Prepare for the Procedure?

Prior to the procedure, Dr. Evans will go over some pre-operative instructions that you will need to follow in the days before your procedure. Following these instructions is essential to limit surgery risks and provide the best results.

  • Stop certain medications. Dr. Evans and his staff will need to be made aware of all medications that you are taking, especially blood-thinning medications. These may include Coumadin (warfarin), Plavix (clopidogrel), Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban) and Lovenox (enoxaparin). Since the use of these medications increases the risk of excessive bleeding, they should be stopped prior to your procedure. If you are using insulin, the dosage or timing will also need to be adjusted the day of the procedure. Doctor-prescribed aspirin may be continued before your procedure. In addition, Dr. Evans asks that you provide him or his staff with a list of medications to which you are allergic.
  • Stop eating hours beforehand. Refrain from eating anything starting the midnight before your procedure is scheduled.

What Happens During EUS-Guided Pseudocyst Drainage?

For EUS-guided pseudocyst drainage, fluoroscopy (X-ray) is used. With the patient sedated, the pseudocyst is located, an area is chosen next to the stomach or duodenum, and a needle is then advanced into the pseudocyst, followed by a guidewire. Over the wire, a “tract” is made between the cyst and the stomach/duodenum with a special balloon. Then the tract is kept open by placement of a stent (a special hollow tube similar to a drinking straw), which allows the pseudocyst to drain internally.

What Should You Expect after the Procedure?

After the procedure, you will be returned to the “post-op” area to recover from sedation. You will also be monitored for any potential complications from the procedure and/or sedation. Once you are fully recovered, Dr. Evans will provide you with an explanation of the findings from your procedure, along with a copy of the procedure report, patient information handouts and follow-up instructions. He will also give you a full preliminary report at this time.

Due to the effects of sedation, patients are instructed not to drive, operate machinery or make important decisions for the first 24 hours. You will need to arrange for someone to drive you home after surgery. The nursing staff will review all of the instructions prior to discharge.

You will be able to eat after you leave the hospital, unless instructed otherwise. Dr. Evans and his staff will give you a diet to follow.

Antibiotics will be given during the procedure and a short course will be prescribed upon release. A repeat imaging test (CT scan or MRI) will be ordered to assess for drainage.

Possible Complications and Risks

Although complications are rare when EUS procedures are performed by specially trained and experienced doctors like Dr. Evans, they do occur. Possible complications include a small risk of bleeding, inflammation of the pancreas (pancreatitis) and infection.

A rare, but major, complication is a perforation, a tear, through the lining of the intestine that may require surgery to repair. The risk is about 1 percent for pseudocyst drainage. In some cases, the pseudocyst may not be amenable to drainage, and another alternative will be required.

All of these risks must be balanced against the potential benefits of the procedure and the risks of alternative approaches to the condition.

EUS-Guided Biliary Drainage (EUS-BD)

The liver produces a green liquid called bile, which is stored in the gallbladder. The drainage routes, or ducts, of the liver and gallbladder drain into the proximal small intestine (duodenum), just beyond the stomach. As food enters the duodenum, bile is released through a small muscular tissue valve called the papilla, where it mixes with food to help digest fats.

Blockage of the biliary ductal system occurs in the setting of pancreatic, liver, gallbladder and biliary duct cancers. Jaundice, which can lead to potential liver failure, occurs when tumors block the bile ducts.

ERCP is commonly used to drain bile ducts in these situations. However, gaining access to the bile duct is unsuccessful in about 5-15 percent of patients, due to tumor blockage or previous surgery. To gain access after an unsuccessful ERCP, a percutaneous (across the skin) route or surgery has been done in the past. Both are more invasive and are associated with complications.

Over the last decade, EUS-guided biliary drainage has emerged as an effective alternative to these treatments. When compared to the percutaneous route, there was lower risk for adverse events to occur with EUS-guided biliary drainage. Overall, success rates for this procedure are around 85 percent, with 10-20 percent risk of complications (most of which are mild).

How Do You Prepare for the Procedure?

Prior to the procedure, Dr. Evans will go over some pre-operative instructions that you will need to follow in the days before your procedure. Following these instructions is essential to limit surgery risks and provide the best results.

  • Stop certain medications. Dr. Evans and his staff will need to be made aware of all medications that you are taking, especially blood-thinning medications. These may include Coumadin (warfarin), Plavix (clopidogrel), Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban) and Lovenox (enoxaparin). Since the use of these medications increases the risk of excessive bleeding, they should be stopped prior to your procedure. If you are using insulin, the dosage or timing will also need to be adjusted the day of the procedure. Doctor-prescribed aspirin may be continued before your procedure. In addition, Dr. Evans asks that you provide him or his staff with a list of medications to which you are allergic.
  • Stop eating hours beforehand. Refrain from eating anything starting the midnight before your procedure is scheduled.

What Happens During EUS-BD?

For EUS-BD, fluoroscopy (X-ray) is used. Depending on the situation, one of three approaches is chosen to drain the bile ducts using X-ray and EUS-guidance. A needle is used to access the bile duct and a guidewire is placed. Over the guidewire, either a stent (a special hollow tube like a drinking straw) is placed to drain bile into the stomach or small intestine.

What Should You Expect after the Procedure?

After surgery, you will be returned to the “post-op” area to recover from sedation. You will also be monitored for any potential complications from the procedure and/or sedation. You may also be admitted to the hospital as a precaution.

Due to the effects of sedation, patients are instructed not to drive, operate machinery or make important decisions for the first 24 hours. You will need to arrange for someone to drive you home after surgery. The nursing staff will review all of the instructions prior to discharge.

You will be able to eat after you leave the hospital, unless instructed otherwise. Dr. Evans and his staff will give you a diet to follow.

Possible Complications and Risks

As stated earlier, complication rates can be as high as 20 percent, and are usually associated with the route of bile duct drainage. The most common complications are infection, leaking of bile into the abdominal cavity and bleeding.

All of these risks must be balanced against the potential benefits of the procedure and the risks of alternative approaches to the condition.

EUS-Guided Liver Biopsy

The liver, located in the upper right abdomen, is an important organ that is essential for life. There are multiple diseases and/or conditions that can lead to damage of the liver. A liver biopsy is an outpatient procedure that is used to obtain a piece of liver tissue for analysis.

A liver biopsy is recommended in the following instances:

  • to diagnose or determine the severity of certain liver diseases (hepatitis B or C, autoimmune hepatitis or non-alcoholic fatty liver disease)
  • to determine the amount of scar tissue present in the liver (cirrhosis)
  • to evaluate a mass seen on a previous X-ray test like an ultrasound, CT scan or MRI
  • to monitor the liver following liver transplantation

Traditionally, liver biopsy has been done in the X-ray department with a percutaneous (across the skin) approach. With the patient awake, anti-anxiety medications and a local anesthetic are used to ensure that they are comfortable. After the procedure, the patient has to remain on their right side for hours, and no activity is recommended for a few days after the biopsy.

With the development of better equipment and needles, EUS can be done to obtain a liver biopsy. Endoscopic ultrasound (EUS) is used to obtain tissue samples from lesions found in the GI tract. It can be used to sample masses from the liver as well. In fact, studies have proven that liver specimens obtained by EUS are just as good as traditional techniques. In fact, the advanced EUS-guided liver biopsy procedure has two major advantages over conventional liver biopsies:

  1. Provides an improved patient experience, since the patient is asleep for the procedure.
  2. Simultaneously evaluates the upper GI tract with an upper endoscopy while also examining the pancreas, gallbladder and bile ducts.

How Do You Prepare for the Procedure?

Prior to the procedure, Dr. Evans will go over some pre-operative instructions that you will need to follow in the days before your procedure. Following these instructions is essential to limit surgery risks and provide the best results.

  • Stop certain medications. Dr. Evans and his staff will need to be made aware of all medications that you are taking, especially blood-thinning medications. These may include Coumadin (warfarin), Plavix (clopidogrel), Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban) and Lovenox (enoxaparin). Since the use of these medications increases the risk of excessive bleeding, they should be stopped prior to your procedure. If you are using insulin, the dosage or timing will also need to be adjusted the day of the procedure. Doctor-prescribed aspirin may be continued before your procedure. In addition, Dr. Evans asks that you provide him or his staff with a list of medications to which you are allergic.
  • Stop eating hours beforehand. Refrain from eating anything starting the midnight before your procedure is scheduled.

What Happens During EUS-Guided Liver Biopsy?

EUS is usually performed as an outpatient procedure at Jewish Hospital. After you check in, you will be escorted to the “pre-op” area where an IV will be placed and nurses will take your medical information. You will then meet with an anesthesiologist to discuss the sedation for the procedure.

You will then be taken to a procedure room and connected to monitors to monitor your blood pressure, heart rate and blood oxygen levels throughout the course of the procedure. The procedure takes on average 20-40 minutes to complete.

An EGD and endoscopic ultrasound examination will be performed. During the procedure, a needle is guided across the wall of the stomach into the liver to gain tissue for analysis by a pathologist under a microscope.

What Should You Expect after the Procedure?

After the procedure, you will return to the “post-op” area to recover from sedation. During this time, you will be monitored for any potential complications from the procedure and/or sedation. Once you are fully recovered, Dr. Evans will provide you with an explanation of the findings from your procedure, along with a copy of the procedure report, patient information handouts and follow-up instructions. He will give you a full preliminary report at this time; however, it may take several days for the final results of biopsies to return.

Due to the effects of sedation, patients are instructed not to drive, operate machinery or make important decisions for the 24 hours following EUS. You will need to arrange for someone to drive you home after surgery. You will be able to eat after you leave the hospital, unless instructed otherwise. Some patients may have a temporary sore throat after the procedure, and over-the-counter anesthetic lozenges help soothe symptoms. The nursing staff will review these and other important post-op instructions with you prior to discharge.

Possible Complications and Risks

Although complications are rare when EUS procedures are performed by specially trained and experienced doctors like Dr. Evans, they do occur. Possible complications include a small risk of bleeding and infection.

These risks must be balanced against the potential benefits of the procedure and the risks of alternative approaches to the condition.

Disclaimer: This information is intended to provide general guidance and does not provide definitive medical advice. It is not a definitive basis for diagnosis or treatment in any particular case. This material does not cover all information and is not intended as a substitute for professional medical care. It is important that you consult your doctor regarding your specific condition, contraindications and potential complications.