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## Complete Summary

#### GUIDELINE TITLE

Role of EUS.

#### BIBLIOGRAPHIC SOURCE(S)

ASGE Standards of Practice Committee, Gan SI, Rajan E, Adler DG, Baron
TH, Anderson MA, Cash BD, Davila RE, Dominitz JA, Harrison ME 3rd,
Ikenberry SO, Lichtenstein D, Qureshi W, Shen B, Zuckerman M, Fanelli
RD, Lee KK, Van Guilder T. Role of EUS. Gastrointest Endosc 2007
Sep;66(3):425-34. \[142 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17643438)

#### GUIDELINE STATUS

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.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   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

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Colon and Rectal Surgery\
Family Practice\
Gastroenterology\
Internal Medicine\
Oncology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

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

#### TARGET POPULATION

Patients with gastrointestinal abnormalities

#### INTERVENTIONS AND PRACTICES CONSIDERED

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.

#### MAJOR OUTCOMES CONSIDERED

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

-   Cost-effectiveness of EUS

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

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.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

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

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendation\***

  ----------------------------------------------------------------------------
  **Grade of             **Clarity   **Methodologic    **Implications**
  Recommendation**       of          Strength/\        
                         Benefit**   Supporting        
                                     Evidence**        
  ---------------------- ----------- ----------------- -----------------------
  1A                     Clear       Randomized trials Strong recommendation;
                                     without important can be applied to most
                                     limitations       clinical settings

  1B                     Clear       Randomized trials Strong recommendation;
                                     with important    likely to apply to most
                                     limitations       practice settings
                                     (inconsistent     
                                     results, nonfatal 
                                     methodologic      
                                     flaws)            

  1C+                    Clear       Overwhelming      Strong recommendation;
                                     evidence from     can apply to most
                                     observational     practice settings in
                                     studies           most situations

  1C                     Clear       Observational     Intermediate-strength
                                     studies           recommendation; may
                                                       change when stronger
                                                       evidence is available

  2A                     Unclear     Randomized trials Intermediate-strength
                                     without important recommendation; best
                                     limitations       action may differ
                                                       depending on
                                                       circumstances or
                                                       patients\' or societal
                                                       values

  2B                     Unclear     Randomized trials Weak recommendation;
                                     with important    alternative approaches
                                     limitations       may be better under
                                     (inconsistent     some circumstances
                                     results, nonfatal 
                                     methodologic      
                                     flaws)            

  2C                     Unclear     Observational     Very weak
                                     studies           recommendation;
                                                       alternative approaches
                                                       likely to be better
                                                       under some
                                                       circumstances

  3                      Unclear     Expert opinion    Weak recommendation;
                                     only              likely to change as
                                                       data become available
  ----------------------------------------------------------------------------

\*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.

#### COST ANALYSIS

The guideline developers reviewed published cost analyses.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

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

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

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]{.underline}**

**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]{.underline}**:

**Grades of Recommendation\***

  ----------------------------------------------------------------------------
  **Grade of             **Clarity   **Methodologic    **Implications**
  Recommendation**       of          Strength/\        
                         Benefit**   Supporting        
                                     Evidence**        
  ---------------------- ----------- ----------------- -----------------------
  1A                     Clear       Randomized trials Strong recommendation;
                                     without important can be applied to most
                                     limitations       clinical settings

  1B                     Clear       Randomized trials Strong recommendation;
                                     with important    likely to apply to most
                                     limitations       practice settings
                                     (inconsistent     
                                     results, nonfatal 
                                     methodologic      
                                     flaws)            

  1C+                    Clear       Overwhelming      Strong recommendation;
                                     evidence from     can apply to most
                                     observational     practice settings in
                                     studies           most situations

  1C                     Clear       Observational     Intermediate-strength
                                     studies           recommendation; may
                                                       change when stronger
                                                       evidence is available

  2A                     Unclear     Randomized trials Intermediate-strength
                                     without important recommendation; best
                                     limitations       action may differ
                                                       depending on
                                                       circumstances or
                                                       patients\' or societal
                                                       values

  2B                     Unclear     Randomized trials Weak recommendation;
                                     with important    alternative approaches
                                     limitations       may be better under
                                     (inconsistent     some circumstances
                                     results, nonfatal 
                                     methodologic      
                                     flaws)            

  2C                     Unclear     Observational     Very weak
                                     studies           recommendation;
                                                       alternative approaches
                                                       likely to be better
                                                       under some
                                                       circumstances

  3                      Unclear     Expert opinion    Weak recommendation;
                                     only              likely to change as
                                                       data become available
  ----------------------------------------------------------------------------

\*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.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

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

#### POTENTIAL HARMS

-   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.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

ASGE Standards of Practice Committee, Gan SI, Rajan E, Adler DG, Baron
TH, Anderson MA, Cash BD, Davila RE, Dominitz JA, Harrison ME 3rd,
Ikenberry SO, Lichtenstein D, Qureshi W, Shen B, Zuckerman M, Fanelli
RD, Lee KK, Van Guilder T. Role of EUS. Gastrointest Endosc 2007
Sep;66(3):425-34. \[142 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17643438)

#### ADAPTATION

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

#### DATE RELEASED

2000 (revised 2007 Sep)

#### GUIDELINE DEVELOPER(S)

American Society for Gastrointestinal Endoscopy - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society for Gastrointestinal Endoscopy

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*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

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

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.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Society for
Gastrointestinal Endoscopy Web
site](http://www.asge.org/PublicationsProductsIndex.aspx?id=352).

Print copies: Available from the American Society for Gastrointestinal
Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

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

#### COPYRIGHT STATEMENT

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

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008