A 30yrs female was referred to us for the favor of EUS sos ERCP for elevated Sr. Alkaline Phosphatase with normal Sr. Bili rubinad normal US Gabdomen, CT Scan and MRCP with an episode of acute pancreatitis in the recent past. At the time of EUS exam, patient’s Sr.Amylase was normal and patient did not have any pancreatic pain. Throughout the clinical course patient did not have any cholangitis like symptoms. EUS examination revealed a normal CBD which was traced from CHD to papilla.The rewash no evidence of ductal dilatation of any extra hepaticbiliary obstruction seen. Pancreas appeared slightly odematous but essentially normal. Classical stack sign could be seen which Ruled out Pancreas Divisum. Gallbladder appeared distended with multiple imaging micro liths measuring around 2-3 mm with mild cholecystitis. In view of these findings, ERCP was not considered necessary and therefore not performed.

Expert Comments: As we have seen in this case that a young patient with mild episode of acute pancreatitis and mildly elevated Sr. Alkaline Phosphatase conventional imaging modalities such as USG Abdomen, CT scan and MRCP could not detect the etiology of pancreatitis and some LFT abnormality. However, EUS was able to detect multiple small 2-3 mm imaging microliths in the Gall bladder, which can explain patient’s symptoms and biochemical abnormalities.

EUS allows us to detect several etiological factors which can lead to pancreatitis such as imaging microlithsin the Gall bladder, small stones in the CBD or MPD, small tumors in ampulla of vater, periampullary region or pancreatic head and even small Intraductal tumors of pancreatic duct. Studies have shown that the sensitivity of fluorescent microscopy to look for cholesterol crystals in bile aspirated from the gall bladder is very sensitive and this should be reserved for those patients in who even EUS cannot identify imaging microliths to definitively rule out biliary pancreatitis.

Take home message: Therefore it is evident that, patients with an episode of acute pancreatitis or recurrent acute pancreatitis should undergoan EUS evaluation to look for etiology of pancreatitis. Imaging microliths can be missed on conventional imaging in best of centres and machines and hence EUS should be an integral part of imaging work up of patients with unknown etiology of pancreatitis or LFT abnormality where extra hepatic biliary obstruction is suspected.

Normal CBD seen Gall bladder seen with multiple imagine microliths

Normal CBD seen Gall bladder seen with multiple imagine microliths

Ciassical stack sign seen, lower CBD & MPD upto the ampullla of vater

Ciassical stack sign seen, lower CBD & MPD upto the ampullla of vater

 

 

 

 

 

 

 

Gallbladder seen distended with multiple imaging microliths measuring2-3mm missed on USG abdomen, CT Scan and MRCP

Gallbladder seen distended with multiple imaging microliths measuring2-3mm missed on USG abdomen, CT Scan and MRCP

MPD appeared normal in the genu and body of pancreas

MPD appeared normal in the genu and body of pancreas

A 35 yrs/female was sent to us for the favor of EUS evaluation of diagnosed chronic pancreatitis. Patient has been suffering from upper abdominal pain for the last 5 years and she was treated conservatively and then was taken up for surgery for idiopathic chronic pancreatitis elsewhere. However, due to anesthesia related complications at that time, patient ended up in ICU for a period of few months and therefore, referred to us for non surgical management of chronic pancreatitis.

EUS revealed multiple large 1.5 cms stones in the pancreatic duct which also measured around 16 mm in the head. Multiple stones were seen in the head and genu region of the main pancreatic duct (MPD). There was no evidence of any parenchymal calcification and parenchyma appeared atrophied. Fluoroscopy showed multiple large radio-opaque stones in the head and genu region. In view of predominantly ductal disease and severe symptoms, endotherapy was considered.

ERCP confirmed the EUS findings and after pancreatic sphincterotomy, balloon sphincteroplasty a 5 fr naso-pancreatic catheter was placed. Patient was then subjected to ESWL (3 sessions , spaced over a week, 5000 shocks / sitting under propofol sedation). Post ESWL, patient was again taken up for endotherapy and at that time complete ductal clearance was achieved after removal of naso-pancreatic catheter. After ductal clearance a 10 fr stent was placed into the MPD to ensure effective ductal decompression. Patient became asymptomatic immediately and was sent back. Now we have called the patient after 3 months for a stent removal and reassessment if any further endotherapy is necessary.

Expert Comments

In this case due to severe anesthesia related complications during a planned surgery for chronic pancreatitis elsewhere, the relatives of the patient and the patient herself insisted for endoscopic treatment. As we have seen that complex calculuos chronic pancreatitis with radio-opaque stones can be successfully managed endoscopically, provided that the disease is predominantly ductal without any parenchymal calcification. Proper case selection and aggressive endotherapy protocol can give us predictable outcomes. Since the pilot endotherapy, patient has gained 5kg wt and she has been asymptomatic. For proper assessment of the extent of chronic pancreatitis we can rely on CT Scan, MRCP and EUS and then decide which treatment is ideal for the patient. Hence the role of EUS cannot be overemphasized in evaluation of chronic pancreatitis.

Take home message

Endotherapy of Chronic Pancreatitis is an evolving science, however, careful case selection and aggressive endotherapy in calculuos chronic pancreatitis with mainly ductal disease (stones and strictures) may obviate the need for surgery in small subset of patients.

Fluoroscopy showing large radio-opaque stones in the pancreatic duct in the head and genu region

Fluoroscopy showing large radio-opaque stones in the pancreatic duct in the head and genu region

Large multiple stones seen on EUS with smooth tapering of the lower CBD

Large multiple stones seen on EUS with smooth tapering of the lower CBD

 

 

 

 

 

 

 

Dilated MPD ( 14 mm) seen with parenchymal atrophy in the body of pancreas

Dilated MPD ( 14 mm) seen with parenchymal atrophy in the body of pancreas

Selective cannulation of MPD was achieved

Selective cannulation of MPD was achieved

 

 

 

 

 

 

 

 

Pancreatogram revealed massively dilated MPD with stones

Pancreatogram revealed massively dilated MPD with stones

Pancreatic sphincterotomy & balloon sphincteroplasty was then performed

Pancreatic sphincterotomy & balloon sphincteroplasty was then performed

 

 

 

 

 

 

 

 

Naso-pancreatic drainage catheter was placed to facilitate ESWL and simultaneous flushing and post ESWL pancreatogram

Naso-pancreatic drainage catheter was placed to facilitate ESWL and simultaneous flushing and post ESWL pancreatogram

Stone extraction was carried out with balloon catheter and dormia basket

Stone extraction was carried out with balloon catheter and dormia basket

 

 

 

 

 

 

 

 

A 10 fr stent was then placed after ductal clearance in the MPD

A 10 fr stent was then placed after ductal clearance in the MPD

Fluoroscopy showed completely cleared radio-opaque stones and placed 10 fr stent in the MPD

Fluoroscopy showed completely cleared radio-opaque stones and placed 10 fr stent in the MPD

 

 

 

 

 

A 74 yrs male was referred to us for the favor EUS to evaluate a suspicious lesion in the duodenal bulb on previous endoscopy performed elsewhere by a Gastroenterologist. Patient had dyspeptic symptoms and diarrhea off and on for which he underwent some investigations where this duodenal small submucosal lesion was seen on endoscopy. Patient’s 24 hrs 5HIAA was marginally elevated and therefore further investigations were considered. EUS showed a small hypoechoic lesion in the duodenal bulb which appeared localized in the Submucosal layer of the duodenum suggestive of a strong possibility of carcinoid. In view of these findings patient requested us to remove this lesion if possible endoscopically as he was extremely anxious with endoscopic findings. Hence, after due consent, patient was taken up for EMR and the lesion was carefully removed. The lesion was sent for histopathological examination which turned out to be a duodenal carcinoid. Immunohistochemical study was also carried out to characterize the lesion and patient was referred to the primary gastroenterologist for further management.

Expert Comments:

As we have seen in this case, presence of small Submucosal lesion can be accurately evaluated on EUS and subsequently successfully removed with EMR technique. Japanese colleagues have mastered these techniques and have shown it to be very effective in mucosal and Submucosal (SM1) lesions where they have advocated Endoscopic Submucosal Dissection (ESD). For these advanced techniques, early detection of small mucosal and submucosal lesion is vital. Now that routine endoscopy is available widely, we have seen more such patients with indications of EMR and ESD at Endoscopy Asia.

Take home message:

Careful evaluation with high definition / magnification endoscopes with features of NBI (narrow band imaging) and combined with EUS will allow us to treat a small subset of such patient with such early mucosal / submucosal SM1 lesions.

Small lesion seen in the duodenal bulb, seen through EMR cap

Small lesion seen in the duodenal bulb, seen through EMR cap

Duodenal wall layers seen with a small 7.0 mm x 4.0 mm

Duodenal wall layers seen with a small 7.0 mm x 4.0 mm

Cap and snare technique was used to resect the lesion

Cap and snare technique was used to resect the lesion

Resected lesion was retrieved and sent for histopathological and immunohistochemical examination

Resected lesion was retrieved and sent for histopathological and immunohistochemical examination

A 64 yrs/ Female was referred to us for the favor of Ileo-Colonoscopy to evaluate the exact etiology of frank bleeding per rectum. Patient had two episodes in last 2 days and hence we considered her for the procedure after a thorough preparation.

Ileo-colonoscopy revealed a small 3-4 mm classical angiodysplastic lesion in the caecum close to the appendicular opening. The lesion was very well appreciated on NBI ( narrow band imaging). Terminal ileum (15 cms) and rest of the colon appeared absolutely normal. In view of these findings bipolar heater probe coagulation was performed and the lesion was completely fulgurated. Complete haemostasis was ensured and patient was sent home on OPD basis.

Expert Comments & Take home message

It is our protocol at Endoscopy Asia that whenever a patient is subjected for colonoscopy, we always make an attempt to have inspection of terminal ileum in all patients, more so if we are suspecting any bleeding lesions. It is important to have all therapeutic options available as we know there are mechanical and thermal methods of haemostasis. Here we felt that bipolar heater probe coagulation was effective and it provides complete fulguration of the lesion, however, one has be cautious as the wall of caecum is thinnest compared to other parts of the colon. Optimal bowel preparation is the key.

Classical angiodysplasia seen in caecum

Classical angiodysplasia seen in caecum

Angiodysplasia seen on NBI in caecum

Angiodysplasia seen on NBI in caecum

 

 

 

 

 

 

 

The lesion was fulgurated with bipolar heater probe

The lesion was fulgurated with bipolar heater probe

Post fulguration complete haemostasis achieved

Post fulguration complete haemostasis achieved

A 73 yrs female patient presented to us with severe epigastric pain with mild LFt abnormality and dilated CBD seen on USG abdomen. In view of these findings EUS was considered and EUS revealed a dilated CBD with two large 12-15mm stones in the prepapillary portion of the lower CBD. Gall bladder appeared contracted. Pancreas and MPD appeared normal. In view of these findings ERCP was then considered and performed. After biliary sphincterotomy, balloon sphincteroplasty of the prepapillary portion of CBD was achieved with a 15 mm balloon and both the stones were removed intact without crushing. Complete ductal clearance was achieved and 7 fr stent was placed to ensure effective ductal decompression.

Expert Comments:

As we can see in this case of a 73 yrs female patient with dilated CBD and mild LFT abnormality when the diagnosis is not certain on USG abdomen, then it our standard protocol to perform EUS prior to a definitive intervention for the bile duct as it is imperative to rule out neoplastic process in elderly patients. Fortunately for her large stones were detected just above the ampulla which are sometimes difficult to see on USG abdomen due to bowel gas. Hence, a certain diagnosis is desired before a definitive ERCP and ductal clearance.

Take home message: Whenever a patient has unexplained pain with dilated CBD and mild LFT abnormality, especially in an elderly patient, a definitive diagnosis with the help of EUS would guide us regarding optimal therapy for such patients. Large CBD stones can now be managed without special techniques of Mechanical lithotripsy, ESWL or even Laser lithotripsy. These specialized techniques can be offered only when the above mentioned technique is not successful.

Large impacted stone seen in the lower CBD with upper dilated bile duct above

Large impacted stone seen in the lower CBD with upper dilated bile duct above

Two large stones were seen in the lower CBD on cholangiogram ( ERCP)

Two large stones were seen in the lower CBD
on cholangiogram ( ERCP)

 

 

 

 

 

 

 

Biliary sphincterotomy was performed

Biliary sphincterotomy was performed

Balloon sphincteroplasty was performed with a 15 mm CRE balloon

Balloon sphincteroplasty was performed with a 15 mm CRE balloon

 

 

 

 

 

 

 

A large 15 mm stone extracted after balloon Sphiincteroplasty

A large 15 mm stone extracted after balloon
Sphiincteroplasty

A 7 fr stent was placed in the CBD for effective ductal decompression

A 7 fr stent was placed in the CBD for effective ductal decompression

A 59 yrs male was referred to us for the favor of EUS sos EUS guided FNA of a suspicious mass lesion in the uncinate process of pancreas seen on CT scan performed recently. Patient did not have any symptoms except for one episode of nausea and small vomitus two weeks prior to a CT scan and therefore as a precaution he underwent a routine executive health check up where this lesion was suspected. The biochemical profile was normal and there was no LFT abnormality.

On EUS we saw a small irregular hypoechoic mass measuring 3.0 cms x 2.0cms in the uncinate process of pancreas. Fortunately the mass appeared locally respectable as it was not invading the SMV or SMA. There were no hypoechoic nodes seen or free fluids. In view of these findings EUS guided FNA was then performed under Color Doppler control from the uncinate process mass. The cytology report confirmed it to be malignant lesion. Patient was then immediately subjected to surgical resection after PET CT and other preop investigations,  which was successfully carried out and patient recovered uneventfully.

Expert Comments

This patient had an incidental detection of neoplasm in pancreas on a routine executive health check up and this is really an anecdotal case, as we know that most patients with pancreatic tumors are detected and diagnosed in late stages when they present in form of gross wt loss, pain or obstructive jaundice. This patient did not have jaundice as the lesion was not very large and it was located in the uncinate process of pancreas still away from the CBD. There could be a potential argument by surgeons that when we see a neoplasm in pancreas which is resectable then there is not need for biopsy, I too endorse this and I am sure published literature supports it too, however, it has been our consistent experience that whenever a patient who is suspected to have a cancer and if there is tissue diagnosis, the acceptance of a supramajor surgical intervention becomes easier.

These are classical cases of pancreatic neoplasms that can be detected on EUS accurately when LFT is normal and ERCP is not indicated. It is our policy at Endoscopy Asia to carry out detailed staging and tissue diagnosis of primary tumor in pancreas as well as if there are distant nodes if the nodal staging by performing EUS-FNA of the nodes is going to influence the treatment strategy we will perform that too. We feel that though there few case reports of tumor cell seeding of the EUS-FNA tract, the incidence is very small, keeping this information in mind we have to certainly be very careful when a percutaneous approach for FNA is used such as Ultrasound / Fluoros or CT guided FNA is contemplated. In most cases when we perform EUS guided FNA the needle tract usually becomes part of the surgical specimen when a standard Whipple operation is performed.

Take home message

Whenever there is a suspicion of any mass or pathology in pancreas, EUS would provide accurate diagnosis in most cases. A word of caution though is that there are very few incidences when there is an isoechoic mass, even EUS may not be able to detect.However, in most cases when pancreas appears normal on a careful EUS then it is very unlikely that we are dealing with any pathology in pancreas, in other words the negative predictive value of EUS for pancreatic disease is very high. In this case timely diagnosis and resection has given a hope for cure even in pancreatic cancer.

Irregular hypoechoic lesion seen in the uncinate  process of pancreas close to SMA but no invasion

Irregular hypoechoic lesion seen in the uncinate process of pancreas close to SMA but no invasion

The hypoechoic lesion in the uncinate process and the vascular interface seen intact

The hypoechoic lesion in the uncinate process and the vascular interface seen intact

 

 

 

 

 

 

 

 

The mass has not invaded the SMV / SV / Portal Vein confluence confirmed on color Doppler

The mass has not invaded the SMV / SV / Portal Vein confluence confirmed on color Doppler

EUS-FNA was performed, needle seen in the hypoechoic mass in the uncinate process of pancreas

EUS-FNA was performed, needle seen in the hypoechoic mass in the uncinate process of pancreas

A 53 yrs Male was referred to us for the favor of diagnosis and management of occult G.I. bleed leading to drop in Hb. Patient has undergone several OGD scopy and Colonoscopy elsewhere over a period of 11 months and was hospitalized few times for blood transfusions. Finally when he was referred to us, during careful clinical history, patient did mention that he had passed frank blood in stools once and therefore we considered him for an Ileo-colonoscopy. On Ileo-colonoscopy we found a small visible superficial ulcer with active oozing in the terminal ileum about 10 cms from the ileo-caecal junction (most likely Dieulafoy lesion). The lesion could be well appreciated on NBI (Narrow Band Imaging) and then in view of the type of pathology we decided to apply haemoclips rather than coagulation with heater probe or other thermal methods. Complete haemostasis was achieved. Patient was admitted for few days and observed. Now after 1 year of follow up patient has maintained Hb and does not have any episode of malena or frank bleeding per rectum and FOBT is negative.

Expert comments

As we can see that this patient has undergone several endoscopic procedures at different places and terminal ileum was not evaluated in previous colonoscopies done elsewhere. Therefore it is imperative to evaluate terminal ileum. It is a standard protocol at Endoscopy Asia that whenever a patient is referred to us for the favor of Colonoscopy intubation of terminal ileum is attempted in all cases and achieved in most. Hence it is our policy that if a patient is sent to us for diagnosis of occult G.I. bleed, even if patient has undergone OGD scopy and Colonoscopy elsewhere we feel that it is useful to repeat these procedures again carefully before performing more cost intensive procedures such as Capsule endoscopy or Single/ Double balloon Enteroscopy to look for any bleeding lesion in the small bowel. We preferred hemoclips to thermal coagulation mainly due to technical considerations and usually thin wall of terminal ileum.

Take home message: A careful and detailed high resolution ileo-colonoscopy allowed us accurate detection of bleeding site and effective endoscopic treatment. Terminal ileal intubation is mandatory in patients with suspected Occult G.I. bleed.

Oozing seen from a lesion? Dieulofoy’s In the terminal ileum

Oozing seen from a lesion? Dieulofoy’s
In the terminal ileum

On flushing water the lesion started bleeding Actively

On flushing water the lesion started bleeding
Actively

 

 

 

 

 

 

 

 

Actively bleeding lesion seen on NBI

Actively bleeding lesion seen on NBI

After applying the first hemoclip the lesion started oozing actively

After applying the first hemoclip the lesion
started oozing actively

 

 

 

 

 

 

 

One more hemoclip applied, however the oozing Persisted and therefore three hemoclips were applied

One more hemoclip applied, however the oozing
Persisted and therefore three hemoclips were applied

Follow up ileo-colonoscopy after few days showed Complete hemostasis.

Follow up ileo-colonoscopy after few days showed
Complete hemostasis.

A 25 yrs female was referred to us for the favor of EUS sos ERCP for suspected block in the CBD leading to recurrent epigastric pain with mild LFT abnormality and no stones were seen in Gall bladder on USG abdomen, however, mild dilatation of CBD was seen without any obvious stone or filling defects. EUS at Endoscopy Asia revealed a large tubular structure in the dilated CBD and this was suspected to be a large round worm. There was no other pathology in the pancreato-biliary system apart from this findings and therefore ERCP was considered. ERCP showed a filling defect on cholangiogram and confirmed the EUS findings. Biliary sphincterotomy was performed and the round worm was extracted using a stone extraction balloon catheter. Few more live round worms were also seen in the third part of duodenum and therefore after ductal clearance a 7 fr stent was placed to ensure effective ductal drainage. Patient was treated on an OPD basis and sent home the same day.

Expert Comments: As we have seen in the previous case that patients with obstructive jaundice without a definitive diagnosis of etiology of obstructive jaundice can be diagnosed accurately on EUS.

Here we managed to clear the duct of a live round worm which was causing intermittent obstruction of the bile flow leading to mild LFT abnormality and severe epigastric pain. This patient was then given oral antihelminthic medication to take care of rest of the round worms. Since there are still some serious hygienic issues in our society especially in the rural and slum areas that we have to keep such pathology in mind at the time of management of such patients.

I would like to share here with our readers that it is a standard protocol at Endoscopy Asia that unless EUS proves that there is a definitive pathology in the bile duct that needs treatment we will not proceed with ERCP. In other words we at Endoscopy Asia do not have negative ERCP so to speak and in the era of such accurate modalities such as EUS & MRCP, diagnostic ERCP has no role in most cases.

Tubular filling defects seen in a dilated CBD-A live round worm

Tubular filling defects seen in a dilated CBD-A live round worm

ERCP-After selective cannulation of CBD biliary phincerotomy was performed

ERCP-After selective cannulation of CBD biliary phincerotomy was performed

 

 

 

 

 

 

 

 

ERCP-Cholangiogram showed a tubular filing defect in a midly dilated CBD

ERCP-Cholangiogram showed a tubular filing defect in a midly dilated CBD

Live round worm from CBD was removed with a stone extraction balloon catheter

Live round worm from CBD was removed with a stone extraction balloon catheter

 

 

 

 

 

 

 

 

To prevent reentry of the round worm a 7Fr stent was placed into the CBD

To prevent reentry of the round worm a 7Fr stent was placed into the CBD

Multiple live roundworms were seen in the third part of the duodenum,one of them managed to enter the bile duct and caused all the symtoms

Multiple live roundworms were seen in the third part of the duodenum,one of them managed to enter the bile duct and caused all the symtoms