Advances in endoscopic ultrasound imaging of colorectal diseases

Abstract

The development of endoscopic ultrasound (EUS) has had a significant impact for patients with digestive diseases, enabling enhanced diagnostic and therapeutic procedures, with most of the available evidence focusing on upper gastrointestinal (GI) and pancreatico-biliary diseases. For the lower GI tract the main application of EUS has been in staging rectal cancer, as a complementary technique to other cross-sectional imaging methods. EUS can provide highly accurate in-depth assessments of tumour infiltration, performing best in the diagnosis of early rectal tumours. In the light of recent developments other EUS applications for colorectal diseases have been also envisaged and are currently under investigation, including beyond-rectum tumour staging by means of the newly developed forward-viewing radial array echoendoscope. Due to its high resolution, EUS might be also regarded as an ideal method for the evaluation of subepithelial lesions. Their differential diagnosis is possible by imaging the originating wall layer and the associated echostructure, and cytological and histological confirmation can be obtained through EUS-guided fine needle aspiration or trucut biopsy. However, reports on the use of EUS in colorectal subepithelial lesions are currently limited. EUS allows detailed examination of perirectal and perianal complications in Crohn's disease and, as a safe and less expensive investigation, can be used to monitor therapeutic response of fistulae, which seems to improve outcomes and reduce the need for additional surgery. Furthermore, EUS image enhancement techniques, such as the use of contrast agents or elastography, have recently been evaluated for colorectal indications as well. Possible applications of contrast enhancement include the assessment of tumour angiogenesis in colorectal cancer, the monitoring of disease activity in inflammatory bowel disease based on quantification of bowel wall vascularization, and differentiating between benign and malignant subepithelial tumours. Recent reports suggest that EUS elastography enables highly accurate discrimination of colorectal adenocarcinomas from adenomas, while inflammatory bowel disease phenotypes can be distinguished based on the strain ratio calculation. Among EUS-guided therapies, the drainage of abdominal and pelvic collections has been regarded as a safe and effective procedure to be used as an alternative for the transcutaneous route, while the placing of fiducial markers under EUS guidance for targeted radiotherapy in rectal cancer or the use of contrast microbubbles as drug-delivery vehicles represent experimental therapeutic applications that could greatly impact the forthcoming management of patients with colorectal diseases, pending on further investigations.

Keywords: Colorectal cancer; Colorectal submucosal tumours; Contrast-enhanced endoscopic ultrasound; Elastography; Endoscopic ultrasound; Endoscopic ultrasound-guided therapy; Inflammatory bowel disease.

Figure 1

Endoscopic ultrasonography image in a T3 sigmoid cancer showing hypoechoic infiltration beyond the muscularis propria (arrows).

Figure 2

Contrast-enhanced endoscopic ultrasonography in a T3 tumour of the recto-sigmoid junction. A: Before contrast arrival (left side contrast harmonic imaging mode, right side B mode); B: Maximal enhancement of the tumour 15 s after contrast injection with hyperenhanced areas alternating with avascular (necrotic) areas.

Figure 3

Endoscopic ultrasonography elastography image of a rectal adenocarcinoma with a predominantly blue pattern indicating a low strain mass (left side real-time sono-elastography mode, right side B mode).

Figure 4

Three-dimensional endoscopic ultrasonography in a T3 rectal cancer with peritumoral lymph nodes (red arrows).

Figure 5

Contrast-enhanced endoscopic ultrasonography in a large rectal gastrointestinal stromal tumour. A: Before contrast uptake; B: Heterogeneous enhancement after contrast injection.