This is the current release of the guideline.

This guideline updates a previous version: American Society for Gastrointestinal Endoscopy. Role of endoscopic ultrasonography. Gastrointest Endosc 2000;52:852-9.

• Luminal gastrointestinal (GI) malignancies
• Barrett's esophagus and esophageal cancer
• Gastric cancer and gastric lymphoma
• Rectal cancer
• Subepithelial (submucosal) lesions
• Pancreaticobiliary malignancies
• Benign pancreaticobiliary diseases including chronic and acute pancreatitis, autoimmune pancreatitis, cystic lesions of the pancreas, and choledocholithiasis
• Fecal incontinence and perianal disease

Assessment of Therapeutic Effectiveness
Diagnosis
Evaluation
Management
Treatment

Colon and Rectal Surgery
Family Practice
Gastroenterology
Internal Medicine
Oncology

Physicians

To discuss the use of endoscopic ultrasonography (EUS) for the diagnosis and management of gastrointestinal abnormalities

Patients with gastrointestinal abnormalities

1. Endoscopic ultrasonography (EUS)
2. EUS-guided fine-needle aspiration (EUS-FNA) or core biopsy

Note: The routine application of EUS in Barrett's esophagus (BE) with low-grade dysplasia or without dysplasia is not recommended.

• Accuracy, reliability, and sensitivity of endoscopic ultrasonography (EUS)
• Cost-effectiveness of EUS

Searches of Electronic Databases

In preparing this guideline, MEDLINE and PubMed databases were used to search publications through 2006 related to the role of endoscopic ultrasonography (EUS) by using the keyword(s) "Endoscopic ultrasound" and each of the following: Barrett's esophagus, esophageal cancer, gastric cancer, gastric lymphoma, rectal cancer, submucosal lesions, pancreaticobiliary disease, lymph nodes, mediastinal adenopathy, fecal incontinence and perianal disease, and therapeutic EUS. The search was supplemented by accessing the "related articles" feature of PubMed with articles identified on MEDLINE and PubMed as the references. Pertinent studies published in English were reviewed. Studies or reports that described less than 10 patients were excluded from analysis if multiple series with greater than 10 patients addressing the same issue were available.

Not stated

Expert Consensus (Committee)

Not applicable

Systematic Review

Not stated

Expert Consensus

Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus.

Grades of Recommendation*

*Adapted from Guyatt G, Sinclair J, Cook D, Jaeschke R, Schunemann H, Pauker S. Moving from evidence to action: grading recommendations—a qualitative approach. In: Guyatt G, Rennie D, eds. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.

The guideline developers reviewed published cost analyses.

Internal Peer Review

This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

Recommendations were graded on the strength of the supporting evidence (Grades 1A-3). Definitions of the recommendation grades are presented at the end of the "Major Recommendations" field.

Summary

Barrett's Esophagus (BE)

• The role of endoscopic ultrasonography (EUS) in evaluating patients with BE and high-grade dysplasia (HGD) is to exclude the presence of occult cancer, submucosal invasion, and malignant lymphadenopathy (1C).
• The routine application of EUS in BE with low-grade dysplasia or without dysplasia is not recommended (3).

Esophageal Cancer

• In esophageal cancer, EUS provides accurate locoregional staging that is superior to computerized tomography (CT) scanning (1C+).
• Preoperative EUS staging of esophageal cancer is cost effective and can guide preoperative management (1C+).

Gastric Cancer and Lymphoma

• EUS is useful in the locoregional staging of gastric carcinoma and lymphomas (1C+).
• EUS may be used to monitor response to therapy with disease regression in gastric lymphoma (1C).

Rectal Cancer

• EUS is accurate in the preoperative locoregional staging of rectal cancer (1C+).
• Preoperative EUS staging of rectal cancer is cost effective and can guide preoperative management (1C+).

Submucosal Lesions

• When a submucosal lesion is identified, EUS should be considered to further characterize the lesion (1C).
• EUS-fine-needle aspiration (FNA) or core biopsy can help establish a tissue diagnosis and potentially characterize malignant risk (1C+).
• EUS should be performed before consideration of endoscopic removal of SML (3).

Pancreatic Cancer

• Pancreatic adenocarcinoma can be accurately identified, staged, and diagnosed by EUS and EUS-FNA (1C+).
• Neuroendocrine tumors can be localized and sampled by EUS (3).

Chronic and Acute Pancreatitis

• EUS is the most sensitive imaging study for the detection of structural changes of chronic pancreatitis (1C).
• EUS has been shown to be useful for identifying the presence of bile duct stones in cases of acute gallstone pancreatitis and in selecting patients for endoscopic retrograde cholangiopancreatography (ERCP) at intermediate risk for choledocholithiasis (1C).

Autoimmune Pancreatitis

• EUS, EUS–FNA, and EUS core biopsy can help establish the diagnosis of autoimmune pancreatitis (3).

Pancreatic Cystic Lesions

• EUS is useful for the characterization of the morphology of pancreatic cystic lesions (1C).
• EUS can be used to guide drainage of benign inflammatory lesions (3).

Fecal Incontinence and Perianal Disease

• Internal and external anal sphincter defects can be accurately identified by EUS in the evaluation of fecal incontinence (1C).
• EUS may be used for the identification and characterization of abscesses and perianal fistulae (3).

Choledocolithiasis

• EUS is highly accurate in the detection of choledocolithiasis and has fewer complications than ERCP (1C).

Mediastinal Lymphadenopathy

• EUS-FNA is a safe and accurate method for obtaining a tissue diagnosis in patients with mediastinal adenopathy (1C+).

Lymph Nodes

• Use of EUS and EUS-FNA to differentiate benign from malignant lymph nodes should be considered in patients when results would alter treatment (1C+).

Therapeutic EUS

• EUS-guided celiac neurolysis can provide significant reduction of pancreatic cancer pain (1C).

Definitions:

Grades of Recommendation*

*Adapted from Guyatt G, Sinclair J, Cook D, Jaeschke R, Schunemann H, Pauker S. Moving from evidence to action: grading recommendations—a qualitative approach. In: Guyatt G, Rennie D, eds. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.

None provided

The type of supporting evidence is identified for each recommendation (see "Major Recommendations").

Appropriate utilization of endoscopic ultrasonography in the evaluation, diagnosis, and treatment of patients with gastrointestinal abnormalities

• The accuracy of endoscopic ultrasonography (EUS) in staging gastric cancer does not approach that of esophageal cancer. Understaging, due to microscopic deposits, and overstaging, particularly of T2 tumors, due to tumor-associated fibrosis or inflammation, can occur.
• EUS can render false-negative results in the setting of chronic pancreatitis, diffusely infiltrating carcinoma, prominent ventral/dorsal anlage, and recent acute pancreatitis.

Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness

Not applicable: The guideline was not adapted from another source.

2000 (revised 2007 Sep)

American Society for Gastrointestinal Endoscopy - Medical Specialty Society

American Society for Gastrointestinal Endoscopy

Standards of Practice Committee

Committee Members: S. Ian Gan, MD; Elizabeth Rajan, MD; Douglas G. Adler, MD; Todd H. Baron, MD, Chair; Michelle A. Anderson, MD; Brooks D. Cash, MD; Raquel E. Davila, MD; Jason A. Dominitz, MD, MHS; M. Edwyn Harrison III, MD; Steven O. Ikenberry, MD; David Lichtenstein, MD; Waqar Qureshi, MD; Bo Shen, MD; Mark Zuckerman, MD; Robert D. Fanelli, MD, SAGES Representative; Kenneth K. Lee, MD, NAPSGHAN Representative; Trina Van Guilder, RN, SGNA Representative

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American Society for Gastrointestinal Endoscopy. Role of endoscopic ultrasonography. Gastrointest Endosc 2000;52:852-9.

None available

None available

This NGC summary was completed by ECRI Institute on March 3, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.