Endoscopic Ultrasound Scan (EUS)

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You have been advised by your consultant to have an investigation known as Endoscopic Ultrasound (EUS). This procedure requires your formal consent. This booklet has been written to enable you to make an informed decision in relation to agreeing to the investigation. You will be required to sign a consent form on the day of the procedure, which is a legal document, therefore please read this booklet carefully. If you are unable to keep your appointment, please notify the endoscopy unit as soon as possible. This will enable staff to give your appointment to someone else and to re-arrange another date and time for you.

You need to understand all the information, including the possibility of complications. There will be the opportunity to speak to a health care professional about anything that you do not understand on the day of the procedure before you sign the consent form.

What is an endoscopic ultrasound?

An Endoscopic Ultrasound (EUS) is a procedure that enables the doctor to examine the lining and layers of the upper gastrointestinal tract, which includes the oesophagus (gullet), stomach, duodenum (first part of the small intestine that is connected to the stomach) and the surrounding areas and organs such as the pancreas and gallbladder, the tubes connecting them and lymph nodes. It involves passing a flexible slender tube with a camera and an ultrasound probe attached to the tip, down your gullet, into the stomach and duodenum.

Why is a EUS done?

EUS is usually performed for the following reasons:

To identify and evaluate the size / nature of abnormal areas/lesions. These may be suspected lesions or those that have been found on other forms of scans like an abdominal ultrasound, CT, or MRI.
To identify lesions or abnormalities within the walls of and immediately beyond the areas mentioned above.
To identify gallstones and to confirm their presence or other abnormalities within the bile duct.
To examine the pancreas gland.
To obtain a specimen of tissue or fluid from an area of interest, termed EUS-FNA/FNB (Fine Needle Aspiration/ Biopsy)
To help drain pancreatic cysts and palliative drainage of Gallbladder and, rarely, obstructed bile ducts by using specially designed stents.
To provide further staging information about further treatment decisions including surgery.

What are the benefits of an EUS?

This type of examination is more detailed than others as it allows the deeper structures to be seen closer and better.
Smaller lesions affecting deeper and harder to reach organs are better identified.
Aspiration or biopsies (samples) can be obtained to ascertain their nature.
Can be done as an outpatient procedure.
Can sometimes reduce the need for open exploratory surgery to a minimally invasive outpatient procedure.

What are the risks/consequences of not having the procedure?

Your doctors may not be able to identify certain illnesses to an agreeable degree of accuracy.
We may not be able to obtain a biopsy required to plan further treatment.
Other alternatives will have to be discussed.

What are the alternatives to this procedure?

Abdominal Ultrasound and/ or guided biopsies.
CT scan and or guided biopsies
Open surgical exploration

However, your doctor will choose to recommend EUS as an option for you if he/she feels that it would be of more benefit compared to the above options.

How do I prepare?

To allow a thorough and safe examination, it is essential that the stomach is empty.

Do not have anything to eat or drink for at least six hours (preferably overnight) before the procedure. If the procedure is planned in the afternoon, have an early, light breakfast before fasting for the required six hours. EUS is best carried out under sedation. Therefore, you will need to arrange for someone to accompany you to the appointment and to take you home afterwards.

You will need to remove any loose teeth or dentures for the duration of the procedure.

Some parts of the procedure may necessitate an antibiotic dose prior to commencement. You will need to report any drug allergies to the doctor or nurse.

What about my medication?

If you are on any medication, especially blood pressure tablets, you should take these with a sip of water at the usual time. DO NOT skip your blood pressure medication unless specifically asked to do so. If you are unsure whether you are on blood pressure lowering medication, do not hesitate to ask your doctor/nurse or pharmacist for advice.

Diabetes: If you are diabetic, it is important that you contact your diabetic specialist nurse or assessment nurse prior to any of these preparations so that they can instruct you on changes that need to be made for the procedure.

Anticoagulants/ Antiplatelets: If you are taking blood-thinning medicines, such as Warfarin, Dabigatran, Dalteparin, Heparin, Apixaban, Aspirin etc. the dose of these may need to be altered or stopped before your procedure. You may also need to have blood tests before your procedure. If the referring doctor did not give you instructions, you may be referred to the bridging clinic for advice on stopping your medication. If you are unsure about which medicines you are on, please ask your doctor, nurse or pharmacist.

What to bring with you

Along with your appointment letter you will have received a health questionnaire. Please complete it and bring it with you. You will also find enclosed a copy of your consent form; please read this carefully but do not sign it. This is just an example for you to read carefully prior to your appointment. The endoscopist will meet with you prior to your endoscopy to discuss what is going to happen, any risks and any serious or common side effects. At this point you will be given the opportunity to ask any questions and then you will sign the ‘actual’ consent form.

After your procedure you will be offered a choice of hot drink and biscuits. If you have any allergies/ intolerance, you might want to bring a snack as we are unable to cater for all dietary requirements.

How long will I be in the Endoscopy unit?

You should expect to be in the unit for approximately 3-4 hours. Please note that the time of your appointment is not the time that the procedure will be performed. How long you will be in the unit will depend on how quickly you recover from the procedure, the sedation you may have had and on how busy the unit is. The unit also looks after emergencies, and these can sometimes take priority over outpatient procedures. You should be kept informed of any delays but if you have any questions or concerns, please ask a member of the staff. If you feel unwell during your wait, please let the staff know as soon as possible.

What happens when I arrive?

After checking in at reception, a qualified nurse will welcome you and take you to the admissions area where you will have a brief medical assessment. Please note that the endoscopy unit operates a same sex environment and your relative may not be able to accompany you past the waiting area unless there are exceptional circumstances.

In the admission room, you will be asked some questions regarding your medical and surgical history to confirm that you are fit to undergo the procedure and about your arrangements for getting home. The nurse will make sure that you understand the procedure and discuss any questions you may have. Your blood pressure, heart rate, respiration and oxygen levels will be recorded. If you have diabetes, your blood sugar level will also be checked and recorded. In preparation for sedation, which will be given later, the nurse may insert a cannula (a small plastic tube) into a vein in your hand or arm.

A doctor will come and discuss the procedure and any risks or side effects. You will be given the opportunity to ask any questions and you will be asked to sign a consent form.

You will be asked to put on a hospital gown. If you wear spectacles or dentures you will be asked to remove them. All your belongings will be kept within the same room throughout your procedure to prevent anything being lost. It is advisable to leave any valuables at home as we do not accept responsibility for them.

After signing your consent form in the admission area, you will be escorted to the procedure room, you will be introduced to the team and a verbal safety checklist (called World Health Organisation “WHO” checklist) will be done.

Your throat will be made numb by using the local anaesthetic spray. Oxygen will be given, usually via a sponge tipped tube which is placed into one of your nostrils. A mouth guard is placed lightly between your teeth to protect them.

Intravenous sedation

You can choose to have an intravenous sedative (usually Midazolam) and a painkiller (usually Pethidine or Fentanyl) which will be administered through an IV cannula (a plastic tube) inserted in a vein in your arm/hand. This will make you lightly drowsy and relaxed, but not make you go to sleep like a general anaesthetic. You will still hear what is said to you and therefore, will be able to carry out simple instructions during the procedure. Some people do not remember anything about the procedure once the effects have worn off.

Whilst you are sedated, we will monitor your breathing, respiration, and pulse rate via a finger probe, so that any changes can be recorded and dealt with accordingly. You will also be given some oxygen via a nasal sponge into your nostril. Your blood pressure may also be checked and recorded.

If you are having sedation, you must arrange for a responsible adult to collect you and stay with you overnight. If you have not been able to make these arrangements, you will not be able to have the procedure with sedation. You should not drive, return to work, operate machinery, or drink alcohol for 24 hours after the procedure, nor should you make any important decisions. The reason for this is that the sedation may, even though you may feel perfectly normal, still be in the body and may impair your judgement.

The EUS Procedure

The procedure usually will take between 30 and 60 minutes. Occasionally the procedure can be longer. If an Upper Endoscopy (Usual camera test examining your gullet, stomach, and duodenum) test has not been done recently, one will be done prior to EUS. This is to ensure that we do not miss any obvious lesions or cause inadvertent complications due to already present abnormalities, as the camera attached to the EUS endoscope is not meant for direct visual assessment.

Milton Keynes University Hospital is a teaching hospital and there may be a student and/or a trainee present in the room or a supervised trainee may be doing your procedure. If you have any concerns or objections, please contact the Endoscopy Unit prior to your test or make the nurse admitting you aware of this.

Aftercare

After the procedure, you will remain in the Endoscopy Unit for about 2-4 hours. You may have some abdominal bloating due to the air which has been pumped into your stomach during the procedure. The nurses will advise you when you can eat and drink.

When do I know the result?

Usually, the doctor or nurse will be able to tell you the results straight after the test, or if you have been sedated, when you are discharged. However, if a sample (biopsy) has been taken for examination, the results may take up to two weeks. Details of results and any necessary treatment should be discussed with your consultant. A nurse will discharge you, discuss any aftercare and follow up needed and answer any questions you may have. Before leaving you should receive written information on your procedure and a copy of the consent form.

If you are having sedation, the person collecting you must come to the unit to collect you. We advise that they park in the nearest car park to the Unit.

Are there any risks or complications?

The doctor or specialist nurse who has requested the test will have considered this already. The risks must be compared with the benefit of having the procedure carried out. The possible complications of gastroscopy are listed below. Any numbers which relate to risk are from studies of patients who have had this procedure. Your doctor will tell you if the risk of complications is higher or lower for you.

You may experience bloating, abdominal (tummy) discomfort and a sore throat for a few hours afterwards, which is normal.
There is a slight risk of damage to your teeth, crowns or bridgework so please tell the nurse if you have crowns or have had any bridgework.
There is a risk of making a small hole or tear (perforation) in the wall of your gullet, stomach, or duodenum. This happens in about 1 in 5,000 patients. In this unlikely event, you may be required to stay within the hospital for an extended period of time and may necessitate further corrective endoscopic or surgical procedures.
There is a small risk of causing bleeding (1 in 10,000 cases), which may be serious enough for you to be admitted to hospital and need treatment with a blood transfusion and/or other remedial procedures.
A small risk (1 in 1000) of pancreatitis (inflammation of the pancreas) exists if it is targeted for sampling. This is usually mild with an abdominal pain that is self-limiting. However, very rarely severe pancreatitis, requiring prolonged hospitalization may occur.
There is a small (<1%) risk of introducing an infection when a needle sampling is performed.
A rare complication is a reaction to the sedative or numbing throat spray. Sedation can also alter your breathing rate, heart rate and blood pressure so you will be monitored for any changes during the procedure.
Complications can happen. Some of these can be serious and can even cause death (risk: 1 in 25,000).

What to do if you feel unwell once at home

After the procedure, if you feel ill, if you have any severe pain, fever, chills, feel faint or if you notice any blood in your faeces or have any black stools, you must then seek urgent advice from the Endoscopy Department between 09:00 and 17:30 (01908 996 460) Monday to Saturday.

Outside these hours, please call a nurse on Ward 22 (01908 996 455) for advice or go to your nearest A&E department.