GuidelineAdverse events associated with EUS and EUS with FNA
Section snippets
Mechanical and optical properties of echoendoscopes
The 2 main types of echoendoscopes are radial scanning and curvilinear-array (CLA) devices. Radial scanning devices contain either a rotating mechanical US transducer or a wraparound, nonrotating electronic US transducer that generates a 360-degree radial US image perpendicular to the long axis of the endoscope. CLA (sometimes referred to as linear array) echoendoscopes produce a US image in a single plane parallel to the long axis of the endoscope via an electronic US transducer. EUS-FNA is
Perforation
Upper GI endoscopy with a standard upper endoscope carries a risk of perforation of 0.03%.1, 5 Cervical intubation with EUS endoscopes is performed blindly, and the longer, more rigid tip has raised concern of cervical esophageal perforation, particularly in patients with Zenker's diverticulum. A prospective study of 4894 patients undergoing upper EUS found a cervical esophageal perforation rate of 0.06% (3 patients, CLA instrument used in all).6 All patients were treated surgically and
EUS with FNA
FNA is commonly performed to obtain tissue from masses or lymph nodes, as well as to aspirate the contents of cystic structures (eg, pancreatic cysts) for analysis. In addition, the same needles used to perform FNA can also be used to inject alcohol, corticosteroids, or anesthetic agents to achieve celiac plexus blockade (CPB) or celiac plexus neurolysis (CPN). EUS-FNA needles are available in 19-, 22-, and 25-gauge sizes. Core biopsy needles are available to obtain biopsy specimens for
Infectious adverse events
Bacteremia is a rare occurrence after diagnostic endoscopy. Several early studies showed an incidence rate of approximately 0% to 8% (excluding patients with biliary obstruction at ERCP).27, 28, 29 The frequency of bacteremia as an adverse event of EUS and EUS-FNA has been prospectively studied in 4 separate trials, 1 of which included only rectal EUS.30, 31, 32, 33
These studies, which collectively include more than 350 patients, did not find a statistically significant increase in the rate of
Pancreatitis
The risk of iatrogenic pancreatitis as a result of EUS-FNA arises in patients undergoing FNA of pancreatic masses, cysts, or the pancreatic duct. All of these procedures involve direct passage of the needle through pancreatic tissue. Reported rates of pancreatitis associated with pancreatic EUS-FNA range from 0% to 2%.34, 47, 48, 49, 50 The risk of pancreatitis does not appear to be influenced by cystic versus solid masses or by the needle gauge used. One study evaluated pancreatitis
Hemorrhage
Hemorrhage as an adverse event of EUS-FNA has been described in only a limited fashion. One study reported 2 episodes of clinically significant bleeding after EUS-FNA of pancreatic lesions, one of which resulted in death.48 Mild intraluminal bleeding has been reported to occur in as many as 4% of cases.35 One study specifically evaluated extraluminal hemorrhage in patients undergoing EUS-FNA over a 13-month period.52 Three cases of extraluminal hemorrhage occurred among 227 patients for an
Bile peritonitis
Bile peritonitis is a rare adverse event of EUS-FNA. There is one report of bile peritonitis after EUS-FNA of a pancreatic-head mass requiring laparotomy.54 During a study of the use of EUS-FNA to obtain bile directly from the gallbladder in an attempt to identify patients with microlithiasis, bile peritonitis developed in 2 of the first 3 patients, resulting in termination of the study.55 EUS-FNA of solid gallbladder masses was shown to be safe in 2 small case series.56, 57
Malignant seeding
EUS-FNA frequently involves a needle advanced from the lumen across the GI tract into adjacent malignant tissue. There are 3 case reports of tumor seeding along an FNA needle path; 1 each of pancreatic cancer, melanoma (both transgastric), and malignant mediastinal lymphadenopathy (transesophageal).
EUS with CPB/CPN
EUS can be used to perform CPB or CPN as a means of achieving analgesia. The technique involves the delivery of corticosteroids (in blockade) or absolute alcohol (in neurolysis) plus a local anesthetic into the celiac plexus via EUS-guided injection with an FNA needle. Adverse events associated with this procedure include transient diarrhea (4%-15%), transient orthostasis (1%), transient increases in pain (9%), and abscess formation.39, 40 Patients should receive adequate intravenous hydration
EUS-guided biliary and pancreatic access
EUS-guided pancreaticobiliary access is a relatively new technique to access biliary and pancreatic ducts via EUS-guided needle puncture through the gastric or duodenal wall. The technique was developed as a salvage therapy when conventional ERCP fails to achieve pancreaticobiliary access, often because of altered anatomy. Small published series report success rates of 50% to 85%, with adverse event rates ranging from 10% to 16%.62, 63
Conclusions
Adverse events are inherent in the performance of EUS and EUS-FNA. As these procedures assume larger roles in the management of GI and non-GI disorders, the potential for adverse events will likely increase. Knowledge of potential adverse events secondary to EUS and EUS-FNA, their expected frequency, and their associated risk factors may help to minimize their occurrence. Endoscopists are expected to carefully select patients for the appropriate intervention, be familiar with the planned
Disclosure
The following author disclosed a financial relationship relevant to this publication: Dr Fisher, consultant to Epigenomics, Inc; Dr Hwang, consultant to U.S. Endoscopy and speaker for Novartis; Dr Pasha, research support from Capervision. The other authors disclosed no financial relationships relevant to this publication.
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This document is a product of the Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.