A 77 years old male patient was referred to us for the favour of EUS sos ERCP for CBD stricture suspected on other imaging studies (Ultrasonography and CT scan of abdomen) which showed dilated CHD and IHBR with contracted gall bladder. Blood investigation revealed a normal LFT. Patient presented with severe epigastric pain. EUS revealed two large stones in CBD measuring 2 x 1.5 cms with wide cystic duct. One of the stones appeared like Mirrizi syndrome. In view of these findings, ERC was performed and cholangiogram confirmed the EUS findings of choledocholithiasis. In view of these findings, biliary sphincterotomy was performed followed by balloon sphincteroplasty with 15 mm CRE balloon at & ATM pressure and both the stones were extracted using balloon catheter and dormia basket with great difficulty, for complete ductal clearance. A 7 Fr double pigtail stent was then placed because of the aggressive endotherapy employed. Patient was again called after 6 weeks for stent removal.

Hence, endoscopic treatment for very large CBD stone is a safe and effective in expert hands and does not require surgical intervention or more expensive lithotripsy devices.

Expert Comments:

As we have seen in this case large CBD stones measuring upto 2 centimeters can be successfully extracted without lithotripsy with a modified technique with balloon sphincteroplasty. We have been practicing balloon sphincteroplasty for over 8 years in India with consistent results without any major complications. Selection of size of balloon in relation to the size of stone and lower CBD is critical for the outcomes of the procedure. Our experience is not to dilate beyond 15 – 16 mm with a balloon for safety. As a routine, we try and retrieve the extracted stone beyond 1.5 cms with dormia basket from the duodenum as it may lead to gall stone ileus.

Take Home Message:

Large CBD stones upto 2cms does not always require mechanical / laser lithotripsy. Small subset of patients (approximately 5%) of total patients with large CBD stones (>1.5 cms) may require lithotripsy procedures. Careful selection of patient, accessories and correct technique ensures predictable outcomes.

EUS showed  large 2.0 cms stone in the lower CBD

EUS showed large 2.0 cms stone in the lower CBD

After Biliary sphincterotomy, Balloon sphincteroplasty  was then performed with a 15 mm balloon

After Biliary sphincterotomy, Balloon sphincteroplasty was then performed with a 15 mm balloon

 

 

 

 

 

 

 

 

Cholangiogram showed large CBD stones

Cholangiogram showed large CBD stones

Stone extracted using stone extraction balloon catheter

Stone extracted using stone extraction balloon catheter

 

 

 

 

 

 

 

 

7 Fr double pigtail catheter placed

7 Fr double pigtail catheter placed

Stone retrieval from duodenum using dormia basket

Stone retrieval from duodenum using dormia basket

A 64 yrs female patient was referred to us for the favor of EUS sos ERC for suspected lower CBD obstruction leading to severe cholestatic symptoms. Patient had undergone radical hysterectomy few years back for cervical cancer and now has developed cholestatic symptoms with wt loss. Patient had undergone CT scan and MRCP, however, no definitive diagnosis could be made on conventional imaging and therefore EUS sos ERC was considered for a definitive diagnosis and biliary decompression. EUS revealed a small 1.5 cms x 1.0 cms hypoechoic lesion in the lower CBD which is confined to the bile duct wall and appeared resectable as there was no major invasion or nodes or minimal ascites.

In view of severe cholestatic symptoms, ERC was then performed and cholangiogram confirmed the EUS findings of stricture. After biliary sphincterotomy brushing was taken from the stricture and material was sent for cytological examination, a 10 fr plastic stent was then placed which showed free flow of dark bile. The cytology report showed an adenocarcinoma.

However, due to poor surgical status with comorbidities, no surgery was considered and therefore after 4 months patient again came to us with signs of cholangitis due to occluded stent. We then replaced the plastic stent with a Self Expandable Metal stent which showed free flow of purulent bile and patient’s symptoms settled immediately.

Expert comments:

As we can see here, accurate diagnosis was possible with the combination of EUS and ERC including staging of the disease. However, due to poor surgical status definitive resection was  ruled out and palliation of cholestatic symptoms was then carried out with a plastic stent initially and then once the stent was occluded we replaced it with a metal stent. We have seen at Endoscopy Asia, that in malignant biliary obstruction plastic stents get occluded very fast and therefore it is preferable to place self expandable metal stent during the pilot ERC.

Take home message:

According to our recent protocol if a patient has severe cholestatic or cholangitic symptoms secondary to malignant biliary obstruction, in borderline cases of respectability based on EUS staging, we would suggest placement of metal stent rather than plastic stent. After ERC if the lesion is found unresectable for a variety of reasons,then patient does not require placement of plastic stent, here we prefer to place short metal stents ranging from 4.0cms to 6.0 cms depending on the length of the stricture. So even if patient undergoes resection, the placed metal stent will come out with the specimen. We believe that this is a very cost effective approach in select group of patients.

EUS shows dilated CBD with hypoechoic lesion in the bile duct

EUS shows dilated CBD with hypoechoic
lesion in the bile duct

After a precut needle knife sphincterotomy,selective bile duct cannulation could be achieved

After a precut needle knife sphincterotomy,selective bile duct cannulation could be achieved

 

 

 

 

 

 

 

 

Cholangiogram on ERC showed Bile duct stricture But did not show the stricture morphology clearly as seen on EUS cholangiogram

Cholangiogram on ERC showed Bile duct stricture But did not show the stricture morphology clearly as seen on EUS cholangiogram

Biliary brushing was taken for cytology

Biliary brushing was taken for cytology

 

 

 

 

 

 

 

 

Initially a 10 fr plastic stent was placed which was removed after few months as it was occluded

Initially a 10 fr plastic stent was placed which was removed after few months as it was occluded

Occluded plastic stent led to frank purulent cholangitis

Occluded plastic stent led to frank purulent cholangitis

 

 

 

 

 

 

 

 

A self expandable uncovered metal biliary stent was then placed, deployed stent seen at the duodenal end of the bile duct

A self expandable uncovered metal biliary stent was then placed, deployed stent seen at the duodenal end of the bile duct

Optimal stent placement seen on Fluoroscopy and all the contrast seen drained

Optimal stent placement seen on Fluoroscopy and all the contrast seen drained

A 22 yrs male patient was referred to us for the favor of EUS sos Endotherapy for recurrent acute pancreatitis. Patient has been suffering for multiple episodes of acute pancreatitis over the last 2 years and had more than 7 episodes of hospitalization. Unfortunately he was advised by his treating doctors that nothing can be done for recurrent acute pancreatitis and he has to live with it. Fortunately, he was then seen by a Surgeon and evaluated and found to have changes of chronic pancreatitis on other imaging studies and was then advised to come and see us.

Patient was then subjected to EUS which revealed a soft stone in the prepapillary portion of MPD with dilated MPD and possibility of pancreatic ductal anomaly. There was no evidence of any parenchymal disease and no calcification. In view of these findings in the same sedation, pancreatic Endotherapy was then performed. ERCP followed by pancreatic sphincterotomy, stone extraction and pancreatic stenting was performed. Immediately after pancreatic Endotherapy patient started having complete relief in symptoms and he is asymptomatic on follow up over the last few months. Patient was admitted only for a day for observation and was sent home the next day with uneventful recovery.

Expert Comments

As we can see here, accurate EUS Pancreatic evaluation of both the pancreatic duct and parenchyma allows us to offer the most optimal treatment option for this young patient. In our experience at Endoscopy Asia of over several hundred patients diagnosed and treated for recurrent acute pancreatitis and chronic pancreatitis, we have observed that a combined protocol of EUS sos Pancreatic Endotherapy has emerged as the most patient friendly approach in decision making regarding the long-term outcomes of these patients.  Published studies have shown that around 65-70% patients with chronic pancreatitis can be successfully treated with Endotherapy with reasonable long-term outcomes, however, patient selection in the chronic pancreatitis group is vital to success.

Take Home Message

This patient was suggested by his treating doctors that nothing can be done for recurrent acute pancreatitis and as you can see here that an appropriate approach with EUS evaluation of the etiology of pancreatitis, the ductal and parenchymal study allowed effective endoscopic treatment for this young patient, who is now relieved of his suffering. Hence, it is my appeal to all clinicians, that any patient who has suffered more than 2 episodes of acute pancreatitis should be evaluated thoroughly. In this event, EUS evaluation is considered as the most important imaging modality worldwide and we have been practicing this protocol for over 14 years now.

EUS shows normal CBD and Gall bladder

EUS shows normal CBD and Gall bladder

A soft 6 mm stone is seen in the    prepapillary portion of dilated main pancreatic duct

A soft 6 mm stone is seen in the prepapillary portion of dilated main pancreatic duct

 

 

 

 

 

 

 

After selective cannulation of MPD       pancreatic sphincterotomy was performed

After selective cannulation of MPD pancreatic sphincterotomy was performed

Pancreatogram showed changes of chronic pancreatitis on ERP with a stone in MPD

Pancreatogram showed changes of chronic pancreatitis on ERP with a stone in MPD

 

 

 

 

 

 

 

 

Soft stone from the Pancreatic duct was  extracted with stone extraction balloon catheter

Soft stone from the Pancreatic duct was
extracted with stone extraction balloon catheter

After stone extraction and complete pancreatic ductal clearance, a 5 fr stent was placed to ensure       effective ductal decompression

After stone extraction and complete pancreatic ductal clearance, a 5 fr stent was placed to ensure effective ductal decompression

A 32 yrs female patient was referred to us for the favor of EUS sos ERCP to our unit for a suspected block in the MPD leading to dilated pancreatic duct in the body and tail. Patient came to us with MRCP which showed these changes, but there was no evidence of any obvious obstructing lesion on MRI or CT scan. Patient’s only complaints were of dull upper abdominal pain without wt loss.

EUS was then performed at Endoscopy Asia which revealed a small 11 mm x 10 mm hypoechoic small well circumscribed lesion in the neck region of pancreas occluding the pancreatic duct, leading to dilated MPD in the body and tail. The sonomorphological appearance of the lesion was classical of a neoplasm. Since, the patient and the referring surgeon insisted on tissue diagnosis, EUS guided FNA was then performed and the cytological examination revealed that this lesion is a neuroendocrine tumor of pancreas. Subsequently the material was also processed for Immunohistochemical studies too and finally patient was advised surgical resection.

Expert comments:

Endoscopic Ultrasound is considered to be the most sensitive imaging modality to detect any tumor less than 1.0 cms in pancreas. All the conventional imaging modalities as seen here failed to detect the lesion. Not only it is possible to detect but if require EUS guided FNA can procure tissue diagnosis. Traditionally, once we detect resectable tumors in Pancreas, FNA is not mandatory and patient can be taken up for surgical resection without tissue diagnosis. However, as we all know that majority of Pancreatic Neoplasms by the time they clinically become symptomatic are usually in advanced stage of disease and most will have local infiltration which may preclude R0 resection.

Take Home Message:

Endoscopic Ultrasound is an indispensable imaging modality for assessment of Pancreatic diseases, especially Pancreatic tumors as it has the ability to detect tumors less than 1.0 cms in size in the Pancreas. EUS guided FNA is now a preferred mode of tissue acquisition in all advanced centres in the world and slowly but surely most leading Gastroenterology Institutes are moving away from CT guided FNA of Pancreas as it carries some risk of tumor cell seeding in the needle tract. Hence when more centres across the country will have EUS facility and expertise, EUS–FNA will become preferred mode of achieving tissue diagnosis.

Prepapillary portion of CBD and MPD seen

Prepapillary portion of CBD and MPD seen

A well circumscribed hypoechoic lesion measuring 11mm x 10 mm seen in the pancreatic genu with dilated MPD

A well circumscribed hypoechoic lesion measuring 11mm x 10 mm seen in the pancreatic genu with dilated MPD

 

 

 

 

 

 

 

 

On color Doppler the Portal vein confluence Is seen clearly not invaded by the lesion

On color Doppler the Portal vein confluence
Is seen clearly not invaded by the lesion

EUS guided FNA of the small lesion being performed. The needle tip is seen in the lesion

EUS guided FNA of the small lesion being performed. The needle tip is seen in the lesion

A 17 yrs/M was referred to us for the favor of endoscopic evaluation of etiology of recurrent acute pancreatitis and the current status of chronic pancreatitis. Endoscopic Ultrasound (EUS) revealed dilated main pancreatic duct (MPD) with stones impacted in the head of pancreas region with upstream dilatation of pancreatic duct without parenchymal calcification. In view of these findings, ERCP was considered and pancreatic sphincterotomy was performed followed by stone extraction and pancreatic ductal clearance. A 7fr pancreatic stent was placed to ensure free flow of pancreatic juice. This patient underwent a few sessions of endotherapy and now for the last 18 months follow-ups she has been asymptomatic.

Expert Comments

In this case as we can see, patient had recurrent episodes of acute pancreatitis, ultimately developed chronic pancreatitis with stones in the main pancreatic duct. EUS showed dilated MPD with few soft stones which were removed after pancreatic sphincterotomy and balloon sphincteroplasty. Thus, in patients with predominant ductal disease with dilated ducts and soft stones, they are ideal candidates for endotherapy.

One has to exercise caution that not all patients with chronic pancreatitis will benefit from endotherapy. Therefore, we feel that at our institute Endoscopy Asia, with the help of EUS we can map the pancreas and evaluate the exact status of the disease and then decide which set of patients will benefit from endotherapy and which patients should go for other treatment options such as medical treatment or surgery.

Furthermore, I would like to add that since I pioneered pancreato-biliary EUS in India we have seen that patients who have more than 2 (two) episodes of acute pancreatitis would benefit from evaluation with EUS to look for etiology of acute pancreatitis which could be small stones in Gall bladder or CBD. EUS will also allow to rule out congenital ductal anomaly such as Pancreas Divisum in most cases. Hence, it is a protocol at our unit that patients with h/o acute pancreatitis without definitive etiology will be subjected to EUS first prior to any further interventions.

Dilated MPD with two stones seen. CBD appeared normal on Endoscopic Ultrasound (EUS).

Dilated MPD with two stones seen. CBD appeared normal on Endoscopic Ultrasound (EUS).

Pancreatic sphincterotomy after  cannulation in process.

Pancreatic sphincterotomy after cannulation in process.

 

 

 

 

 

 

 

 

Dilated MPD seen with few stones on pancreatogram – ERP.

Dilated MPD seen with few stones on pancreatogram – ERP.

Balloon sphincteroplasty of pancreatic sphincter to facilitate stone extraction.

Balloon sphincteroplasty of pancreatic sphincter to facilitate stone extraction.

 

 

 

 

 

 

 

 

Pancreatic ductal stone extraction  performed with stone extraction balloon catheters and dormia basket.

Pancreatic ductal stone extraction performed with stone extraction balloon catheters and dormia basket.

A 7 fr pancreatic stent placed in the MPD to ensure free flow pancreatic juice.

A 7 fr pancreatic stent placed in the MPD to ensure free flow pancreatic juice.

A 19 yrs male was referred to us for the favor of EUS evaluation and guided treatment of a large Pancreatic Pseudocyst ( 8 cms x 6 cms) seen on other imaging studies. Patient had a severe acute necrotizing pancreatitis 3 months back and has been severe abdominal symptoms off an on since then. For the last few days, patient had severe pain with fever and chills off and on and the total WBC count was 19,000 on the day we saw him for the pilot EUS. Patient has loss of appetite and wt.

All the other imaging studies did not show any other pathology except for Pseudocyst. EUS revealed normal CBD, however, gall bladder showed multiple imaging microliths and small stones which were completely missed on all the previous imaging studies. Gall stones can explain severe necrotizing pancreatitis and its sequelae in the form of infected Pseudocyst. EUS also showed turbid contents of a large Pseudocyst which was non bulging on the gastric wall. In view of these findings EUS guided Cystogastrostomy was then performed and a 8.5 fr double pigtail stent was placed which showed infected purulent fluid draining out of the Pseudocyst, hence a Naso-cystic catheter was placed by the side to gently flush the cavity over period of 4 days. After four days patient was then brought again and under fluoroscopic control the naso-cystic catheter was removed and the stent was left in the place. Patient had an uneventful recovery and started having his normal diet and was completely asymptomatic at the time of discharge.

Expert Comments:

Endoscopic treatment without the use of EUS guidance is also a feasible option, however, when there is no gastric bulge in such situation, EUS guided drainage procedure is the safest option as seen in this case. It has been our standard practice over the last 12 years that majority of our patient referred to us with Pseudocyst, we have always performed EUS guided drainage either transgastric, transesophageal or transduodenal depending on the site and feasible location of drainage.

EUS guided drainage allows us to avoid intervening vessels or pseudoaneurysms on color Doppler control. We feel that placement of Naso-cystic catheter allowed effective decompression of the infected Pseudocyst and prevented stent occlusion as well. Hence, EUS guided treatment will become the most preferred method of treatment when more centres across the country will have access to EUS equipment and the necessary expertise.

Take Home Message:

Symptomatic Pancreatic Pseudocyst whether bulging or non bulging on the luminal wall can be safely treated with EUS guided drainage in most patient (98%). Careful selection of patient, indication, site of access and technique will determine the outcomes.

EUS showed multiple imaging microliths in the Gall bladder which could be the etiology of Severe acute necrotizing pancreatitis

EUS showed multiple imaging microliths in the Gall bladder which could be the etiology of
Severe acute necrotizing pancreatitis

A large 8.0 cms x 5.5 cms Pseudocyst was seen in the body region of pancreas with thick echogenic contents and some debris on the floor of the Pseudocyst. EUS guided puncture of the Pseudocyst being performed, the needle is seen very well on EUS

A large 8.0 cms x 5.5 cms Pseudocyst was seen in the body region of pancreas with thick echogenic contents and some debris on the floor of the Pseudocyst. EUS guided puncture of the Pseudocyst being performed, the needle is seen very well on EUS

 

 

 

 

 

 

 

 

 

Frank pus was seen exuding from the puncture site by the side of cystotome, suggestive of infected   Pseudocyst.

Frank pus was seen exuding from the puncture site by the side of cystotome, suggestive of infected Pseudocyst.

EUS guided cystogastrostomy and passage of  cystotome Seen on fluoroscopy

EUS guided cystogastrostomy and passage of cystotome Seen on fluoroscopy

 

 

 

 

 

 

 

 

Two guidewires were placed, one each for a stent placement       and one for the naso-cystic catheter. Frank pus is seen draining from the double pigtail stent.

Two guidewires were placed, one each for a stent placement and one for the naso-cystic catheter. Frank pus is seen draining from the double pigtail stent.

Contrast injection on Fluoroscopy showed placed double  pigtail stent and nasocystic catheter

Contrast injection on Fluoroscopy showed placed double pigtail stent and nasocystic catheter

A 62 yrs male patient was referred to us for the favor of EUS evaluation and endoscopic management of suspected upper CBD block on USG abdomen, CT scan and MRCP. Patient has multiple co morbidities and severe cholestatic symptoms with wt loss. LFT showed Sr. Bilirubin of 29mg%. In view of these findings EUS was considered. EUS revealed an irregular hypoechoic lesion measuring 26 mm x 14 mm in the CHD suggestive of Klastkin tumor. Few hypoechoic peritumorous nodes were seen suggestive of nodal dissemination. Minimal free fluid was also noted in the perihepatic space. In view of these findings, EUS guided FNA from the Hilar lesion was performed and the material was sent for cytological examination which revealed poorly differentiated adenocarcinoma.

In view of severe cholestatic symptoms and advanced age of patient with comorbidities, definitive endoscopic palliation of cholestatic symptoms was considered. ERC was performed and Bismuth Type IIIb stricture was seen on cholangiogram leading to independent block of Right and Left ductal systems. Stricture dilatation was performed after sphincterotomy and two self expandable uncovered metal biliary stents were deployed simultaneously through the working channel of the scope. Free flow contrast was seen flowing from both the stents. Patient was followed up meticulously and she passed away after 7 months of the procedure and did not have any cholestatic symptoms after stenting for those 7 months.

Expert Comments:

Here, we can see that an advanced Bismuth type IIIb stricture secondary to a hilar cholangiocarcinoma leading to severe cholestatic symptoms can be very effectively palliated with placement of two uncovered self expandable metal stents simultaneously through a single working channel of a therapeutic duodenoscope. Routinely those centers which palliate such cases across the world have experience with Y shaped metal stents delivered one after the other. We feel that this is one of the first few reports of a technique that allows simultaneous deployment of two stents together through the working channel of a duodenoscope.

Take Home Message

Palliation of Cholestatic symptoms secondary to an inoperable Hilar Cholangiocarcinoma upto Bismuth type III strictures can be successfully managed with Endoscopic Placement of Bilateral Metal stents either simultaneously as shown in this case of a “Y” shaped stents designed for such lesions. We feel that Metal stent placement in such cases should be considered and plastic stents should be avoided as plastic stents get occluded invariably which leads to severe cholangitis and morbidity.

EUS showed an irregular hypoechoic mass at CHD measuring 26mm x 14 mm.

EUS showed an irregular hypoechoic mass at CHD
measuring 26mm x 14 mm.

EUS guided transgastric FNA of the Hilar tumor was performed and the material showed poorly differentiated adenocarcinoma

EUS guided transgastric FNA of the Hilar tumor was performed and the material showed poorly differentiated adenocarcinoma

 

 

 

 

 

 

 

 

Selective cannulation of CBD was achieved

Selective cannulation of CBD was achieved

Cholangiogram revealed Bismuth Type IIIb stricture, two guidewires seen placed one each in right and left ductal system

Cholangiogram revealed Bismuth Type IIIb stricture, two guidewires seen placed one each in right and left ductal system

 

 

 

 

 

 

 

 

Two self expandable uncovered metal stents passed through  the working channel of the duodenoscope and both the stents were deployed simultaneously.

Two self expandable uncovered metal stents passed through the working channel of the duodenoscope and both the stents were deployed simultaneously.

Self expandable stents in both right and left ductal system contrast seen draining through the stents.

Self expandable stents in both right and left ductal system contrast seen draining through the stents.

A 20yr young male was referred to us for the favor of ERCP for a suspected mass lesion in the pancreatic head leading to obstructive jaundice. Patient had Sr. bilirubin of 12mg% and elevated Sr. Alkaline phosphatase with dilated CBD and IHBR seen on other imaging studies including CT Scan , MRI and MRCP. All the previous imaging raised a high suspicion of a neoplastic lesion in the pancreas leading to symptoms. Patient does not have any other h/o major illness in the past. Though patient did complain of pain in the upper abdomen with anorexia and wt loss with severe pruritus. In view of this clinical picture we discussed the approach with patient and the referring physician that ideally we should perform EUS first prior to ERCP and they agreed for it.

EUS showed a large 2.5 cms x 2.0 cms hypoechoic mass like area in the pancreatic head leading to classical double duct sign as seen in neoplastic process. Few subcentimeter nodes were seen in the peripancreatic region. Upper CBD and IHBR appeared dilated with structuring of the intrapancreatic portion of the CBD. There was no ascites. In view of these findings EUS guided FNA was then performed from the pancreatic head region and material was sent for cytological examination, followed by ERCP and biliary sphincterotomy, brush cytology from the biliary stricture and placement of a 10 fr plastic stent for biliary decompression.

The cytological examination of the EUS- FNA material showed tubercular pancreatitis, where as the brush cytology from the ERCP was inconclusive. Post procedure patient had relief in symptoms, however, in the due course patient developed Pott’s spine and had to undergo treatment for the same followed by physiotherapy. Patient was again sent to us after 5 months of AKT for stent removal and repeat cholangiogram. This time after stent removal on cholangiogram the stricture that was seen earlier had completely resolved and free flow of contrast was seen from the ampulla and therefore no further intervention was considered necessary.

Expert Comments:

As we have seen there that a young patient with obstructive jaundice secondary to a suspicious mass lesion in the pancreatic head where all the previous imaging studies such as CT scan, MRI and MRCP failed to reach a conclusive diagnosis, could be very effective managed with a combination of EUS-FNA and ERC with biliary stenting. Accurate diagnosis and effective treatment was possible due to EUS-ERCP Interface and optimal use of these imaging modalities. Hence, at Endoscopy Asia it is a standard protocol that whenever there is no definitive diagnosis of etiology of obstructive jaundice we would always proceed with EUS sos EUS-FNA and followed by ERCP if required in the same sedation.

Take Home message:

If this patient would have undergone only ERCP as per the referral note, then we would not have had a definitive diagnosis, as brush cytology during ERCP was inconclusive. EUS-FNA managed to get us a definitive diagnosis of tubercular lesion of the pancreas leading to obstructive jaundice. Therefore, whenever a young patient presents with obstructive jaundice due to a suspicious mass lesion in or around pancreas or the lower CBD, the protocol of EUS sos ERCP would allow us an accurate diagnosis and optimal treatment design for predictable outcomes.

EUS showed a large hypoechoic irregular lesion in the  Head of pancreas, leading to obstruction of lower CBD

EUS showed a large hypoechoic irregular lesion in the Head of pancreas, leading to obstruction of lower CBD

EUS guided FNA from the pancreatic head lesion performed       just below the level of CBD stricture site which showed pancreatic TB

EUS guided FNA from the pancreatic head lesion performed just below the level of CBD stricture site which showed pancreatic TB

 

 

 

 

 

 

 

 

Selective cannulation of CBD was achieved

Selective cannulation of CBD was achieved

Pilot Cholangiogram showed long intrapancreatic stricture      of the bile duct with a dilated CBD and IHBR

Pilot Cholangiogram showed long intrapancreatic stricture of the bile duct with a dilated CBD and IHBR

 

 

 

 

 

 

 

 

Dark  bile seen flowing free from a 10 fr plastic stent.

Dark bile seen flowing free from a 10 fr plastic stent.

Follow up cholangiogram at the time of stent removal after       5 months of AKT, previously seen lower CBD stricture has  resolved completely.

Follow up cholangiogram at the time of stent removal after 5 months of AKT, previously seen lower CBD stricture has resolved completely.