• A 78 yrs female patient came to us for the favor of endotherapy for a single angiomatous lesion seen on previous capsule endoscopy performed elsewhere. Patient has h/o occult G.I. blood loss that required blood transfusions and iron preparation repeatedly for the last 2 years.
  • Antegrade Single Balloon Enteroscopy was performed under general anaesthesia.
  • Scope was passed almost upto 90 cms beyond the DJ flexure and multiple (in total 7) angiodysplastic lesions were seen. No other lesions were seen distal to the last lesion.
  • All the lesions were fulgurated with bipolar heater probe coagulation and Coag grasper forceps to achieve complete haemostasis.

SBE showed angioplastic lesion seen in the Jejunum

Narrow band imaging showed classical spider like appearance of the angiodysplastic lesion

 

 

 

 

 

 

 

 

SBE showed multiple angioplastic lesion seen in the Jejunum

Bipolar heater probe coagulation was then performed on the lesion

 

 

 

 

 

 

 

 

Coag grasper forceps to achieve complete haemostasis

Post fulguration appearance of the treated lesion

A 4 yrs old female child was referred to us for the favour of EUS to evaluate a suspicious filling defect in the lower CBD seen on USG abdomen with essentially normal LFT. However, patient has pain in the right hypo quandrium and gall bladder also appeared distended with ? stone on other imaging. In view of these findings EUS and ERC was considered as LFT was essentially normal.

EUS revealed slightly dilated CBD 7 mm with a 5 mm stone badly impacted just above the ampulla of vater in the lower CBD.

  • Gall bladder appeared distended with sludge and imaging microliths with changes of cholecystitis and cholesterol polyp. Pancreas and MPD appeared normal
  • Selective cannulation of bile duct was achieved only after a precut sphincterotomy.
  • Cholangiogram confirmed the EUS findings.
  • Stone extraction was carried out with balloon catheter and dormia basket.
  • A 5 fr single pigtail stent was placed in the CBD to ensure free flow of bile and a 3 fr stent in the MPD to minimize the risk of pancreatitis

EUS revealed slightly dilated CBD 7 mm

5 mm stone badly impacted just above the ampulla of vater in the lower CBD

 

 

 

 

 

 

 

 

A precut sphincterotomy performed

Selective cannulation of CBD

 

 

 

 

 

 

 

Cholangiogram confirmed the EUS findings

Stone extraction was carried out with balloon catheter and dormia basket.

 

 

 

 

 

 

 

 

A 5 fr single pigtail stent was placed to ensure free flow of bile and a 3 fr stent
in the MPD

Stent was placed in the both duct on fluoroscopy

  • A 55 yrs old female was referred to us for the favor of ERC and metal biliary stenting for an advanced metastatic pancreatic cancer invading the duodenum leading to cholestatic symptoms
  • Duodenoscopy revealed large ulcerating mass in the second part of duodenum extending up to D3
  • The ampullary anatomy was completely distorted and despite several attempts selective cannulation of CBD failed
  • EUS was then performed which revealed a massively dilated CBD with a block at the lower end on color doppler and EUS guided puncture of the CBD was done
  • A guidewire was placed and sequential dilatation of the CD was carried out
  • A 4 cms completely covered metal stent was then deployed on endoscopy with the guidance of fluoroscopy

Large ulcerating mass in the second part of duodenum extending up to D3

Attempts at selective cannulation of the CBD transpapillary failed

 

 

 

 

 

 

 

 

A massively dilated CBD with a block at the lower end on color doppler

EUS GUIDED puncture of the CBD

 

 

 

 

 

 

 

 

A guidewire was placed and sequential dilatation of the CD

Fully covered metal stent passed through the duodenal bulb

 

 

 

 

 

 

 

 

A 4 cms completely covered metal stent was then deployed and free flow of bile was seen.

Fluoroscopy showed a 4 cms covered metal stent was deployed.

  • A 30 yrs old 7 months pregnant female patient was referred to us for the favour of EUS to evaluate the exact etiology of recurrent episodes of acute pancreatitis since 2012 and patient has been treated with conservative medication.
  • Patient has been in pain almost every day for the last few week requiring injectable analgesics and antispasmodic and hence after explaining all the risks of the procedure, EUS sos Endotherapy was considered once the relatives gave the informed consent.
  • EUS showed A 7.0mm stone and few concrements were seen in the Prepapillary portion of the MPD
  • MPD appeared dilated and irregular in the genu and body
  • Selective cannulation of MPD, Pancreatogram confirmed the EUS findings
  • Pancreatic sphincterotomy was performed.
  • Prepapillary Stones and concrements from the pancreatic duct was extracted with balloon catheter and complete ductal clearance was achieved.
  • A 7 fr stent was then placed in the MPD.

A 7.0mm Stones and few concrements were seen in the prepapillary portion of the MPD.

MPD appeared dilated (8 mm) in the head region with soft stones

 

 

 

 

 

 

 

 

MPD appeared dilated and irregular in the genu and body

Selective cannulation of MPD

 

 

 

 

 

 

 

 

Pancreatogram confirmed the EUS findings

Pancreatic Sphincterotomy was performed

 

 

 

 

 

 

 

 

Prepapillary Stones and concrements from the pancreatic duct was extracted with balloon catheter.

A 7 fr stent was then placed in the MPD

  • An 84 yrs old female referred to us for the favor of OGD scopy sos EUS sos Duodenal stenting for a suspected mitotic lesion in the pyloric antrum leading to gastric outlet obstruction.
  • A large ulcerostenotic lesion in the pyloric antrum extending upto the pyloric opening
  • Scope could be passed with difficulty into the duodenum.
  • Multiple biopsies were taken from the lesion for HPE.
  • EUS revealed hypoechoic lesion in the antrum which has breached the serosa.
  • Few subcentimeter nodes were seen in the peritumorous region. Minimal free fluid was also noted in the perigastric region, suggestive of peritoneal dissemination.
  • A 9 cms uncovered pyloroduodenal stent was then placed across the stricture under fluoroscopic control
  • Optimal stent deployment was confirmed both on endoscopy and fluoroscopy.

 

Take Home Message:

As we can see in this case that an advanced mitotic lesion of the antrum leading to gastric outlet obstruction who has comorbidities, nodes and ascites was an ideal indication for one stage procedure of detection, diagnosis, staging and palliation secondary to a malignant gastric adenocarcinoma. Hence with this protocol, patient avoided any further imaging or intervention. Surgical palliation can be avoided with this approach. Recently EUS guided Gastrojejunostomy has been described with a success rate of 90%. Hence, the future of luminal obstruction palliation will be the domain of Endoscopists.

A large ulcerostenotic lesion in the pyloric
antrum

Scope could be passed with difficulty into the duodenum

 

 

 

 

 

 

 

Multiple biopsies were taken from the lesion for HPE.

EUS revealed hypoechoic lesion in the antrum which has breached the serosa.

 

 

 

 

 

 

 

Minimal free fluid was also noted in the perigastric region.

Few subcentimeter nodes were seen in the peritumorous region.

 

 

 

 

 

 

 

Optimal stent deployment was confirmed on endoscopy.

Optimal stent deployment was confirmed on fluoroscopy

A 51 yrs male patient was referred to us for the favor of endoscopic evaluation, eus sos erc for suspected mass in the mid cbd region / gall bladder on other imaging studies with porta nodes and cholestatic symptoms. Patient has significant wt loss and now sr bil of 35 mg%

  • OGD scopy revealed a massively dilated esophagus with candidiasis, a very tight les
  • EUS scope passage was possible only after a 15 mm cre balloon dilatation
  • An irregular hypoechoic lesion in the region of upper cbd with few hypoechoic nodes in the porta.
  • The mass seems to have invaded the gastroduodenal artery, no evidence of any hypoechoic lesions in the left lobe of liver or nodes in the mediastinum
  • Eus guided fna was performed- cytological diagnosis was metastatic adenocarcinoma
  • Selective cannulation of cbd, cholangiogram showed bismuth type 1 stricture with communication of lt and rt ductal system
  • Biliary brushing was taken from the stricture- was inconclusive on cytology
  • A self expandable uncovered metal stent (10.0 cms) was then placed into the lt ductal system

Take Home Message:

As you can see in this patient who turned out to be advanced metastatic gall bladder cancer with multiple nodes leading to obstructive jaundice as well as secondary achalasia cardia. Now that balloon dilatation followed by EUS guided FNA from the nodal mass allowed us final tissue diagnosis of metastatic adenocarcinoma (gall bladder origin). Definitive palliation of severe cholestatic symptoms was achieved with ERCP and Metal Biliary Stenting. Surgical resection was ruled out due to metastatic disease process. Hence, any patient with suspected malignant obstructive jaundice a combination of EUS and ERCP will provide the most optimal diagnosis and effective palliation.

A massively dilated esophagus with candidiasis

Tight les seen on retroflexion

 

 

 

 

 

 

 

Balloon dilatation of les performed to facilitate eus and ercp

An irregular hypoechoic lesion in the region of upper cbd / gall bladder

 

 

 

 

 

 

 

EUS guided fna was performed

Selective cannulation of CBD

 

 

 

 

 

 

 

Cholangiogram showed bismuth type 1 stricture with communication of lt and rt ductal system

A self expandable uncovered metal stent (10.0 cms) was then placed into the lt ductal system

  • A 49 yrs female patient was sent to us for the favor of endoscopic palliation of obstructive jaundice. Patient is a known operated case of ca stomach in the past with Roux-en-y anastomosis.
  • Now patient has severe cholangitis and cholestatic symptoms hence endoscopic palliation was considered.
  • Endoscopic evaluation of the stomach showed oedematous stomach with patent g-j.
  • Scope could be passed across all the loops of roux-en-y anastomosis, but due to a very long afferent loop even enteroscopic ERC was not feasible and hence EUS guided approach was considered.
  • EUS showed extensive ascites and few liver mets and large mass and massively dilated system.
  • In view of these findings, EUS -guided Hepatico-Gastrostomy was performed.
  • EUS  showed a dilated left hepatic duct and hence EUS guided needle puncture of the Left hepatic duct was performed. The tract was sequentially dilated with cystotomes to facilitate stent placement.
  • A self expandable partially covered Giobor stent 10 cms and free flow of infected bile was seen from the stent in the stomach.

Take Home Message:

In cases where traditional ERC and biliary stenting is not feasible due to altered anatomy due to surgery or when PTC drainage too is not feasible due to ascites and liver mets, this unique technique of EUS guided Hepatico-gastrostomy allows us to decompress the obstructed biliary system and palliate cholestatic symptoms. First EUS guided Choledochoduodenostomy was performed by us was in 2001 and since then the technology and techniques have evolved.

Stomach showed edematous with patent G-J

Stomach showed edematous with patent G-J

Scope could be passed across all the loops of Roux-en-y anastomosis

Scope could be passed across all the loops of Roux-en-y anastomosis

 

 

 

 

 

 

 

EUS showed extensive ascites and few liver mets

EUS showed large mass and massively dilated system

 

 

 

 

 

 

 

EUS -guided hepatico-gastrostomy was performed

EUS -guided hepatico-gastrostomy was performed

Fluoroscopy showed dilated left hepatic duct

 

 

 

 

 

 

 

 

Left hepatic duct was punctured and sequentially dilated with cystotome

A self expandable partially covered Giobor stent 10 cms and free flow of infected bile was seen from the stent.

 

  • 43/M patient with symptoms of dyspepsia – tobacco chewer and smoker.
  • OGD Scopy revealed abnormal vascular pattern in the middle third of esophagus at 29cm from incisura. As per KUDO’s pit pattern classification it appears like IPCL – type III. Biopsy was taken from it for HPE; which is suggestive of an intraepithelial lesion – low grade squamous dysplasia.
  • EMR performed with saline adrenaline injection and snare technique.
  • Complete resection of the affected area was confirmed on post resection evaluation of the area.

Take home message:

Patient with risk factors such as tobacco consumption with dysplastic lesions in the esophagus are at very high risk of developing invasive cancers. Timely detection for intraepithelial lesions such as this case, will enable endoscopic curative resection.  Importance of magnification and electronic chromoendoscopy can be appreciated in this case.

Abnormal vascular pattern in the middle lower third of esophagus

Biopsy was taken for HPE middle lower third of esophagus

 

 

 

 

 

 

 

EMR performed with saline adrenaline injection and snare technique

Complete resection of the affected area was confirmed

  • 31/F had come to us with recent episode of severe acute pancreatitis of unknown etiology
  • All conventional imaging, USG abdomen, CT Scan and MRI was inconclusive of etiology
  • EUS revealed multiple imaging microliths and small stones in the gall bladder and CBD. Pancreas appeared edematous with peripancreatic fat stranding in the body and tail region
  • Hence Endotherapy was performed and CBD was cleared off stones
  • In view of the severity of the acute pancreatitis a NJ tube was then placed across the DJ flexure under endoscopic and fluoroscopic control
  • NJ tube should allow enteral nutrition till the pancreatitis settles down.

Take Home Message:

Patient with acute pancreatitis of unknown etiology should undergo EUS evaluation prior to any other imaging if all biochemistry is inconclusive of etiology.

EUS-ERCP Interface is the most reliable method for a certain diagnosis and optimum management for vast majority of Pancreato-Biliary diseases.

EUS also allows us to stratify the severity of pancreatitis and at the same time we can perform NJ tube placement for enteral nutrition as seen in this case.

EUS showed multiple imaging micoroliths and Small stones in the gall bladder and CBD

Edematous pancreas with peripancreatic fat standing in the body and tail.

 

 

 

 

 

 

 

Selective cannulation of CBD

Cholangiogram showed dilated CBD with small stones

 

 

 

 

 

 

 

 

Biliary sphincterotomy performed

A 7fr stent was placed in the CBD

 

 

 

 

 

 

  • 06/M child came with a severe pain in abdomen for the last few days
  • EUS revealed a dilated fusiform intra pancreatic portion of the CBD and MPD with large soft stones leading to dilated CBD and MPD with changes of chronic pancreatitis.
  • ERCP was considered – Selective cannulation of MPD was achieved and pancreatogram confirmed EUS findings
  • All the soft stones were cleared from the MPD and a 5 fr single pigtail stent was placed into the MPD
  • In view of abnormal LFT a 7 fr stent was then placed in the CBD, patient’s symptoms subsided immediately after the procedure

Take Home Message:

Irrespective of the age of the patient even in children, EUS-ERCP interface allowed us to provide accurate diagnosis and optimum immediate treatment. Patient will require a definitive surgical intervention once Cholangitis and Pancreatitis subsides.

EUS showing dilated MPD with large soft stones

Selective cannulation of MPD was achieved

 

 

 

 

 

 

 

Pancreatogram showed fusiform dilatation with soft stones

All the soft stones were cleared from the MPD

 

 

 

 

 

 

 

cholangiogram showed ductal anomaly

5fr single pigtail stent placed in the MPD and 7fr stent was placed in the CBD