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Normal linear echoanatomy
Normal Linear Echoanatomy Marc Giovannini, MD
rate for the diagnosis of malignancy, but normal echoanatomy findings are needed before beginning such interventional procedures. The aim of this article is to describe the normal upper gastrointestinal (GI) endoscopic ultrasound anatomy. The procedure is performed with the patient in left lateral decubitus position. The introduction of the instrument to the third part of the duodenum is performed under endoscopic guidance, and then the EUS examination can begin. The examination of the pancreas, the sus mesocolic area, and the mediastinum is performed using the 5-MHz frequency, but examination of the digestive wall requires the 7.5-MHz frequency. We describe biliopancreatic EUS, gastric EUS, and the mediastinal and cervical EUS examinations.
probe maintained in this position, it is withdrawn, under countertraction from the water-filled balloon, up to the superior genu and allows the visualization of a part of the head of the pancreas and the intrapancreatic part of the common bile duct (Fig 7). The probe is now positioned in the superior genu (Figs 8 and 9) and allows the visualization of the isthmus of the pancreas (Fig 10), the splenomesenteric confluence, the gastroduodenal artery, and the common bile duct (Fig 11). While the probe is still positioned in the superior genu, a clockwise rotation of 180 ~ is performed (Fig 12). It is possible to visualize the portal vein and the common bile duct from its pedicular part (Fig 13). The color Doppler allows visualization of the common bile duct. The clockwise rotation of 180 ~ allows visualization of the hilum of the liver (Fig 14). This cross section allows the visualization of the portal vein bifurcation (Fig 15). It is very important to perform this cross section in suspected portal vein thrombosis or in a case of hepatic lymph node staging. The probe is again withdrawn, still under tension, and positioned in the first part of the duodenum, where it is pointed toward the upper side (Fig 16). This cross section allows visualization of the gallbladder (Fig 17). The probe is withdrawn in the same position, and it is possible to examine the cystic duct.
Biliopancreatic Examination
Endoscopic Ultrasonography of the Stomach
The examination begins after positioning the EUS probe in the third part of the duodenum below the major papilla (Fig 1). It is recommended to pass the pylorus under endoscopic guidance similar to the technique used for endoscopic retrograde cholangiopancreatography (ERCP). The examination of this area allows visualization of the uncinate process and the head of the pancreas, the common bile duct, the superior mesenteric vein and the portal vein, the gallbladder, and the cystic duct. The probe is positioned on the postero-internal side of the duodenum and allows examination of the inferior vena cava (Fig 2), the uncinate process of the pancreas, and the superior mesenteric vein (Fig 3). The probe is then withdrawn following the internal side of the duodenum and positioned at the level of the major papilla (Figs 4 and 5). The probe is then withdrawn, still following the internal side of the second duodenum, and a clockwise rotation is performed. It is possible to visualize the common bile duct, the portal vein, and the head of the pancreas (Fig 6). With the
The transducer placed on the posterior side of the antrum of the stomach allows visualization of the body of the pancreas with the main pancreatic duct (Fig 18), the splenoportal confluence, and the pancreatic part of the common bile duct (Fig 19). In this position, it is possible to examine the splenomesentericoportal confluence (Fig 20). The probe is withdrawn and positioned in the body of the stomach on the posterior side and allows one to visualize the tail of the pancreas, the splenic artery, the splenic vein, and the left renal vein (Fig 21). In this position, it is possible to examine the .left kidney (Fig 22). The probe is now. positioned in the fundus to visualize the spleen (Figs 23 and 24). The probe is positioned on the right and posterior side of the lesser curvature to visualize the celiac area (Fig 25) and the left part of the liver (Fig 26). It is possible to examine a part of the body of the pancreas, the celiac trunk with the splenic artery, the superior mesemeric artery, and the abdominal aorta (Fig 27). The probe is then positioned in the vertical part of the lesser curvature to visualize the left lobe of the liver and the hepatic hilum (Fig 28).
Linear endoscopic ultrasound (EUS) is a new EUS technique that uses a curved array transducer. This type of EUS endoscope provides EUS fine-needle biopsy, but it is necessary to know the normal echoanatomy, which is totally different than radial EUS. I have performed this small atlas to allow the normal echoanatomy with the use of linear EUS. Copyright 9 2000 by W.B. Saunders Company
'ndoscopic ultrasound (EUS) using a curved array trans-
E ,ducer allows EUS-guided biopsy with a high sensitivity
From the Endoscopic Unit, Paoli-CalmettesInstitute,Marseilles,France. Address reprint requeststo Marc Giovannini, Chief of Endoscopic Unit, Paoli-CalmettesInstitute,232 Bd St-Marguerite, 13273 Marseilles, Cedex 9, France. Copyright 9 2000 by W.B. Saunders Company 1096-2883/00/0203-0002510.00/0 doi: 10.1053/tgie.2000.7726
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Endoscopic Ultrasonography of the Mediastinum The transducer is positioned in the short length of the esophagus to examine the posterior mediastinum (Fig 29). The
Techniques in Gastrointestinal Endoscopy, Vol 2, No 3 (July), 2000: pp 124-135
Fig 1. Probe in the 3rd part of duodenum. Fig 4. Papilla area examination.
examination of the posterior mediastinum must be methodical and systematic and must be performed in 3 parts: 9 1st part: Examination of the mediastinum area under the arch of the aorta and the arch of the azygos vein. 9 2nd part: Examination of the area of the arches. 9 3rd part: Examination of the cervical esophagus.
Fig 2. IVC, inferior vena cava; AO, abdominal aorta.
When the probe is positioned on the posterior and left side of the esophagus (Fig 30), it is possible to examine the thoracic aorta,the left pleura, and the left lung (Fig 31). The transducer is positioned on the right side of the esophagus (Fig 32) in the posterior mediastinum and allows one to visualize the azygos vein (Fig 33) as far as its arch, situated between 24 and 25 cm from the teeth. The color Doppler examination of the azygos vein allows one to visualize collateral veins, which are not visible with a conventional gray scale EUS (Fig 34). The probe
Fig 3. IVC, inferior vena cava.
Fig 5. VBP, common bile duct; W, pancreatic duct (wirsung duct).
NORMAL LINEAR ECHOANATOMY
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j/ Fig 6. Bile duct examination. Fig 8. Pancreatic head examination.
Fig 9. Neck of the pancreas examination. Fig 7. CBD, common bile duct; PV, portal vein.
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MARC GIOVANNINI
Fig 10. Head and body of the pancreas.
Fig 13. CBD, common bile duct; PV, portal vein.
Fig 11. VBP, common bile duct; AGD, gastroduodenal artery; TP, portal vein.
Fig 12. Hepatic bilium examination. NORMAL LINEAR ECHOANATOMY
Fig 14. Portal vein bifurcation area.
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Fig 16. Gallbladder area.
Fig 15. TP, portal vein.
Fig 17. Gallbladder.
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Fig 18. Body of the pancreas.
MARC GIOVANNINI
Fig 19. Body of the pancreas examination with splenomesenteric conference.
Fig 21. Tail of the pancreas examination.
Fig 20. SMV, superior mesenteric vein; PV, portal vein; SV, splenic vein.
Fig 22. SA, splenic artery.
NORMAL LINEAR ECHOANATOMY
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Fig 23. Spleen area examination. Fig 25. Celiac area examination.
Fig 24. Rate, spleen; V. Splenique, splenic vein.
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Fig 26. Left hepatic lobe area. MARC GIOVANNINI
Fig 27. P, pancreas; SA, splenic artery; SMA superior mesenteric artery; CT, celiac trunk; CSA, superior coronary artery.
Fig 28. PV, portal vein.
NORMAL LINEAR ECHOANATOMY
Fig 29. Saggital mediastinal view.
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Fig 30. Thoracic aorta examination.
Fig 32, Azygos vein area examination.
Fig 33. Azygos vein.
Fig 31. Thoracic aorta.
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Fig 34. Azygos vein and collaterals veins. MARC GIOVANNINI
Fig 35. Left atrium, pulmonary artery, and veins examination.
Fig 37. Arches of aorta and azygos vein.
Fig 36. PV, pulmonary vein; LA, left atrium; PA, pulmonary artery; LV, left ventricle. NORMAL LINEAR ECHOANATOMY
Fig 38. PA, pulmonary artery. 133
Fig 39. Subclavian artery origin.
Fig 41. Trachea area.
Fig 40. SCA, subclaviar artery.
Fig 42. (A) BSG, left bronchus. (B) Trachee, trachea. 134
MARC GIOVANNINI
Fig 45. CIG, left internal carotid; thyroide, thyroid gland.
Fig 43. Carotid arteries and jugular veins examination. is pointed toward the anterior side of the esophagus in the middle part of the posterior mediastinum to examine the cardiac area (Fig 35). It is possible to visualize the left atrium, the left ventricle, the pulmonary artery, and the aortic opening
(Fig 36). The transducer is again positioned between 24 and 25 cm from the teeth (zone of the arches: arch of the aorta, arch of the azygos vein) (Fig 37). It is very important to visualize the aortopulmonary window area situated between the arch of the aorta and the pulmonary artery (Fig 38). The probe is withdrawn a few centimeters, and this allows examination of the vessels of the neck at the level of the arch of the aorta (Fig 39), the left internal carotid artery, and the left internal jugular vein. It is possible also to visualize the left subclavian artery (Fig 40) related to the superior part of the left lung. The transducer is now positioned between 22 and 24 cm from the teeth (Fig 41). This cross section allows visualization of the tracheal bifurcation (Fig 42A), as this area is very important to examine in the case of esophageal carcinoma when looking for tracheal involvement. The probe is withdrawn after this to the cervical part of the esophagus to visualize the trachea (Fig 42B) and the cricoid bone. However, with clockwise and anticlockwise rotation of the probe, it is possible to visualize the vessels of the neck (Fig 43) (Fig 44). The probe is now positioned between 17 and 18 cm from the teeth to examine the thyroid gland (Fig 45).
Conclusion
Fig 44. CI, internal carotid; dl, internal jugular vein; thyroide, thyroid gland.
NORMAL LINEAR ECHOANATOMY
EUS examination of the upper GI using a curved array transducer with sufficient experience allows as good a visualization of the mediastinum, the pancreas, and the perigastric area as a radial EUS machine. Linear device is required for interventional procedures, and a good knowledge of the linear EUS anatomy is a prerequisite for interventional EUS.
135
rate for the diagnosis of malignancy, but normal echoanatomy findings are needed before beginning such interventional procedures. The aim of this article is to describe the normal upper gastrointestinal (GI) endoscopic ultrasound anatomy. The procedure is performed with the patient in left lateral decubitus position. The introduction of the instrument to the third part of the duodenum is performed under endoscopic guidance, and then the EUS examination can begin. The examination of the pancreas, the sus mesocolic area, and the mediastinum is performed using the 5-MHz frequency, but examination of the digestive wall requires the 7.5-MHz frequency. We describe biliopancreatic EUS, gastric EUS, and the mediastinal and cervical EUS examinations.
probe maintained in this position, it is withdrawn, under countertraction from the water-filled balloon, up to the superior genu and allows the visualization of a part of the head of the pancreas and the intrapancreatic part of the common bile duct (Fig 7). The probe is now positioned in the superior genu (Figs 8 and 9) and allows the visualization of the isthmus of the pancreas (Fig 10), the splenomesenteric confluence, the gastroduodenal artery, and the common bile duct (Fig 11). While the probe is still positioned in the superior genu, a clockwise rotation of 180 ~ is performed (Fig 12). It is possible to visualize the portal vein and the common bile duct from its pedicular part (Fig 13). The color Doppler allows visualization of the common bile duct. The clockwise rotation of 180 ~ allows visualization of the hilum of the liver (Fig 14). This cross section allows the visualization of the portal vein bifurcation (Fig 15). It is very important to perform this cross section in suspected portal vein thrombosis or in a case of hepatic lymph node staging. The probe is again withdrawn, still under tension, and positioned in the first part of the duodenum, where it is pointed toward the upper side (Fig 16). This cross section allows visualization of the gallbladder (Fig 17). The probe is withdrawn in the same position, and it is possible to examine the cystic duct.
Biliopancreatic Examination
Endoscopic Ultrasonography of the Stomach
The examination begins after positioning the EUS probe in the third part of the duodenum below the major papilla (Fig 1). It is recommended to pass the pylorus under endoscopic guidance similar to the technique used for endoscopic retrograde cholangiopancreatography (ERCP). The examination of this area allows visualization of the uncinate process and the head of the pancreas, the common bile duct, the superior mesenteric vein and the portal vein, the gallbladder, and the cystic duct. The probe is positioned on the postero-internal side of the duodenum and allows examination of the inferior vena cava (Fig 2), the uncinate process of the pancreas, and the superior mesenteric vein (Fig 3). The probe is then withdrawn following the internal side of the duodenum and positioned at the level of the major papilla (Figs 4 and 5). The probe is then withdrawn, still following the internal side of the second duodenum, and a clockwise rotation is performed. It is possible to visualize the common bile duct, the portal vein, and the head of the pancreas (Fig 6). With the
The transducer placed on the posterior side of the antrum of the stomach allows visualization of the body of the pancreas with the main pancreatic duct (Fig 18), the splenoportal confluence, and the pancreatic part of the common bile duct (Fig 19). In this position, it is possible to examine the splenomesentericoportal confluence (Fig 20). The probe is withdrawn and positioned in the body of the stomach on the posterior side and allows one to visualize the tail of the pancreas, the splenic artery, the splenic vein, and the left renal vein (Fig 21). In this position, it is possible to examine the .left kidney (Fig 22). The probe is now. positioned in the fundus to visualize the spleen (Figs 23 and 24). The probe is positioned on the right and posterior side of the lesser curvature to visualize the celiac area (Fig 25) and the left part of the liver (Fig 26). It is possible to examine a part of the body of the pancreas, the celiac trunk with the splenic artery, the superior mesemeric artery, and the abdominal aorta (Fig 27). The probe is then positioned in the vertical part of the lesser curvature to visualize the left lobe of the liver and the hepatic hilum (Fig 28).
Linear endoscopic ultrasound (EUS) is a new EUS technique that uses a curved array transducer. This type of EUS endoscope provides EUS fine-needle biopsy, but it is necessary to know the normal echoanatomy, which is totally different than radial EUS. I have performed this small atlas to allow the normal echoanatomy with the use of linear EUS. Copyright 9 2000 by W.B. Saunders Company
'ndoscopic ultrasound (EUS) using a curved array trans-
E ,ducer allows EUS-guided biopsy with a high sensitivity
From the Endoscopic Unit, Paoli-CalmettesInstitute,Marseilles,France. Address reprint requeststo Marc Giovannini, Chief of Endoscopic Unit, Paoli-CalmettesInstitute,232 Bd St-Marguerite, 13273 Marseilles, Cedex 9, France. Copyright 9 2000 by W.B. Saunders Company 1096-2883/00/0203-0002510.00/0 doi: 10.1053/tgie.2000.7726
124
Endoscopic Ultrasonography of the Mediastinum The transducer is positioned in the short length of the esophagus to examine the posterior mediastinum (Fig 29). The
Techniques in Gastrointestinal Endoscopy, Vol 2, No 3 (July), 2000: pp 124-135
Fig 1. Probe in the 3rd part of duodenum. Fig 4. Papilla area examination.
examination of the posterior mediastinum must be methodical and systematic and must be performed in 3 parts: 9 1st part: Examination of the mediastinum area under the arch of the aorta and the arch of the azygos vein. 9 2nd part: Examination of the area of the arches. 9 3rd part: Examination of the cervical esophagus.
Fig 2. IVC, inferior vena cava; AO, abdominal aorta.
When the probe is positioned on the posterior and left side of the esophagus (Fig 30), it is possible to examine the thoracic aorta,the left pleura, and the left lung (Fig 31). The transducer is positioned on the right side of the esophagus (Fig 32) in the posterior mediastinum and allows one to visualize the azygos vein (Fig 33) as far as its arch, situated between 24 and 25 cm from the teeth. The color Doppler examination of the azygos vein allows one to visualize collateral veins, which are not visible with a conventional gray scale EUS (Fig 34). The probe
Fig 3. IVC, inferior vena cava.
Fig 5. VBP, common bile duct; W, pancreatic duct (wirsung duct).
NORMAL LINEAR ECHOANATOMY
125
j/ Fig 6. Bile duct examination. Fig 8. Pancreatic head examination.
Fig 9. Neck of the pancreas examination. Fig 7. CBD, common bile duct; PV, portal vein.
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MARC GIOVANNINI
Fig 10. Head and body of the pancreas.
Fig 13. CBD, common bile duct; PV, portal vein.
Fig 11. VBP, common bile duct; AGD, gastroduodenal artery; TP, portal vein.
Fig 12. Hepatic bilium examination. NORMAL LINEAR ECHOANATOMY
Fig 14. Portal vein bifurcation area.
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Fig 16. Gallbladder area.
Fig 15. TP, portal vein.
Fig 17. Gallbladder.
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Fig 18. Body of the pancreas.
MARC GIOVANNINI
Fig 19. Body of the pancreas examination with splenomesenteric conference.
Fig 21. Tail of the pancreas examination.
Fig 20. SMV, superior mesenteric vein; PV, portal vein; SV, splenic vein.
Fig 22. SA, splenic artery.
NORMAL LINEAR ECHOANATOMY
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Fig 23. Spleen area examination. Fig 25. Celiac area examination.
Fig 24. Rate, spleen; V. Splenique, splenic vein.
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Fig 26. Left hepatic lobe area. MARC GIOVANNINI
Fig 27. P, pancreas; SA, splenic artery; SMA superior mesenteric artery; CT, celiac trunk; CSA, superior coronary artery.
Fig 28. PV, portal vein.
NORMAL LINEAR ECHOANATOMY
Fig 29. Saggital mediastinal view.
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Fig 30. Thoracic aorta examination.
Fig 32, Azygos vein area examination.
Fig 33. Azygos vein.
Fig 31. Thoracic aorta.
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Fig 34. Azygos vein and collaterals veins. MARC GIOVANNINI
Fig 35. Left atrium, pulmonary artery, and veins examination.
Fig 37. Arches of aorta and azygos vein.
Fig 36. PV, pulmonary vein; LA, left atrium; PA, pulmonary artery; LV, left ventricle. NORMAL LINEAR ECHOANATOMY
Fig 38. PA, pulmonary artery. 133
Fig 39. Subclavian artery origin.
Fig 41. Trachea area.
Fig 40. SCA, subclaviar artery.
Fig 42. (A) BSG, left bronchus. (B) Trachee, trachea. 134
MARC GIOVANNINI
Fig 45. CIG, left internal carotid; thyroide, thyroid gland.
Fig 43. Carotid arteries and jugular veins examination. is pointed toward the anterior side of the esophagus in the middle part of the posterior mediastinum to examine the cardiac area (Fig 35). It is possible to visualize the left atrium, the left ventricle, the pulmonary artery, and the aortic opening
(Fig 36). The transducer is again positioned between 24 and 25 cm from the teeth (zone of the arches: arch of the aorta, arch of the azygos vein) (Fig 37). It is very important to visualize the aortopulmonary window area situated between the arch of the aorta and the pulmonary artery (Fig 38). The probe is withdrawn a few centimeters, and this allows examination of the vessels of the neck at the level of the arch of the aorta (Fig 39), the left internal carotid artery, and the left internal jugular vein. It is possible also to visualize the left subclavian artery (Fig 40) related to the superior part of the left lung. The transducer is now positioned between 22 and 24 cm from the teeth (Fig 41). This cross section allows visualization of the tracheal bifurcation (Fig 42A), as this area is very important to examine in the case of esophageal carcinoma when looking for tracheal involvement. The probe is withdrawn after this to the cervical part of the esophagus to visualize the trachea (Fig 42B) and the cricoid bone. However, with clockwise and anticlockwise rotation of the probe, it is possible to visualize the vessels of the neck (Fig 43) (Fig 44). The probe is now positioned between 17 and 18 cm from the teeth to examine the thyroid gland (Fig 45).
Conclusion
Fig 44. CI, internal carotid; dl, internal jugular vein; thyroide, thyroid gland.
NORMAL LINEAR ECHOANATOMY
EUS examination of the upper GI using a curved array transducer with sufficient experience allows as good a visualization of the mediastinum, the pancreas, and the perigastric area as a radial EUS machine. Linear device is required for interventional procedures, and a good knowledge of the linear EUS anatomy is a prerequisite for interventional EUS.
135