• 72/M patient has come to us with c/o increased stool frequency and bleeding per rectum for last few months with some wt loss. Recent CT Scan showed a possibility of mass in the rectum with nodes.
  • Ileo-Colonoscopic findings are suggestive of active ulcerative colitis affecting the recto sigmoid up to around 5 cms from the anal verge with large sessile lesion.
  • Rectal EUS was then performed with a radial echo endoscope, which revealed essentially mucosal lesion limited to the muscularis mucosa.
  • EMR (endoscopic mucosal resection) was then carried out with saline adrenaline injection followed by resection with snare and cautery. Complete resection was ensured and haemostasis was secured.
  • Resected specimen was retrieved and sent for HPE which was diagnosed as adenocarcinoma.

Large sessile lesion was seen in the rectum.

Rectal EUS showed mucosal lesion limited to the muscularis mucosa

 

 

 

 

 

 

 

 

Saline adrenaline injected.

EMR performed with snare and cautery

 

 

 

 

 

 

 

Resected specimen was retrieved.

Complete resection was ensured and haemostasis was secured

A 32 year male patient came with recurrent episodes of acute pancreatitis for last 1 year

Patient also complained of malena and mild drop in Hb 10.5gm%

All previous imaging were inconclusive

EUS showed dilated MPD with soft stones impacted in the head region with a Communicating blood vessel on color Doppler and changes of chronic pancreatitis.

Formal Angiography ruled out pseudoaneurysm

Duodenoscopy showed frank blood oozing out of major papilla. Cannulation of MPD and Pancreatogram showed soft stones impacted in the pre-papillary portion of the MPS.

Pancreatic sphincterotomy, balloon sphincteroplasty and stone extraction was achieved and a 7 fr stent was placed and bleeding stopped.

EUS should be performed in all patients who has recurrent acute pancreatitis and if the etiology is not ascertained on any conventional imaging.

Combination of high quality EUS and proper Endotherapy solved a rare case of Haemosuccus Pancreaticus due to impacted stones in the pancreatic duct.

EUS showed soft stones seen in the MPD

Frank bleeding from major papilla

 

 

 

 

 

 

 

 

Selective cannulation of MPD

Pancreatic Sphincterotomy was performed

 

 

 

 

 

 

 

Soft stones was removed with balloon catheter

A 7 fr stent was placed in the MPD

 

• A 37 year old patient with known alcohol excess
• Admitted with early satiety, abdominal pain and weight loss
• Serum Amylase, Lipase – Normal
• Routine Hematology, Biochemistry profile- Normal
• US/ CT scan – Large pseudocyst in the body of the pancreas compressing the stomach
• EUS- Large pseudocyst in the body of pancreas with debris++ and no obvious communication with MPD.

 
Take home message :
• Infected pseudocyst seldom resolves with conservative treatment
• WOPN can be treated successfully with SEMS placement and endoscopic necrosectomy
• Surgical necrosectomy and cysto gastrostomy are much more morbid procedures than endoscopic approach

 
Expert comments :
1. EUS guided Drainage can be performed for the cases which are not amenable to conventional endoscopic transmural drainage without any increased risks. ( Kahaleh et al)
2. Conventional endoscopic transmural drainage is possible only in 57% cases compared to 100%
efficacy for EUS guided drainage (Varadarajulu et al, 2007)
3. The rate of technical success of the drainage was significantly higher for the EUS group (94 %) than for the CTD group (72 %)

EUS image of large pseudocyst with debris

EUS guided cyst puncture

 

 

 

 

 

 

 

SEMS insertion

Xray showing SEMS and pig tail stent in the pseudocyst

  • A 36 year old female was admitted with a right pleural effusion 1 month ago.
  • She was diagnosed with TB and was on AKT medications.
  • She presented a month later with an empyema in the right pleural cavity and severe malnourishment.
  • Hb – 9.2, WBC – 21, Platelet – 564, CRP – 377, Albumin – 2.1
  • CXR – Large right pleural effusion- confirmed later as empyema.
  • In spite of prolonged treatment with intravenous antibiotics the empyema did not respond.
  • CT scan done at that stage showed an esophago-pleural fistula.
  • OGD – Confirmed a fistulous opening in the lower esophagus. This was successfully closed with an Ovescotm  clip after applying APC to the edges.
  • CXR , CT scan with oral gastrograffin and OGD 2 weeks later showed resolution of the pleural effusion and fistulous tract.

Take home message –

  • Non resolving Tuberculosis should prompt screening for MDR strains of TB as was in our case.
  • Persistent empyema in such patients would warrant a CT scan.
  • Ovescotm  clips are excellent devices for closure of fistulous tracts and perforations.

Expert comments –

  • Ovescotm  clips are useful in acute bleeding to achieve hemostasis.
  • Ovescotm  clips  are useful in compression as well as approximation of tissue,
  • Ovescotm  clips offer large volume of tissue, higher stability and minimal strain at the surrounding site.
  • Ovescotm  clips are often used for perforations after endoscopic sub mucosal dissection, full thickness dissections and post surgical complications.

oesophago-pleural fistula

APC applied to the edges

 

 

 

 

 

 

 

 

Ovesco clip placement.

OGD – 2 weeks – healed fistulous tract

OGD – 2 weeks – healed fistulous tract

  • A 73 year old female presented with abdominal pain, jaundice and weight loss since 1 month
  • Co-morbidities:- DM, HT and CABG. USG Abdomen- calculus CBD obstruction
  • MRCP- suspected CHD tumor. ERC (outside)- 10 Fr stent was placed, brush cytology was inconclusive
  • Patient was primarily sent for tissue diagnosis and palliation in view of high surgical risk
  • EUS- a short segment hypo echoic lesion measuring 1 x 0.8 cm in the upper CBD below
  • CHD leading to dilated IHBR in both lobes of liver.
  • No evidence of hypo echoic nodes or lesion was seen in left lobe liver.
  • Gall bladder showed imaging microliths. Pancreas and MPD appeared normal.
  • ERC- selective cannulation of CBD achieved. Biliary sphincterotomy was performed.
  • Cholangiogram- bismuth type I stricture
  • Biliary brushing was taken from the biliary stricture and the brushing material was sent for cytological examination. Intraductal biopsy was attempted and material was sent for histopathological examination.
  • An 8 cm self expandable uncovered nitinol stent was placed. Free flow of bile was seen and complete drainage of contrast was seen from both lobes of liver and free passage of air was seen from the stent.
  • Brush cytology and intra ductal biopsy- cholangiocarcinoma

Expert comments-

  • Several case series report that the sensitivity and specificity of EUS-guided FNA (EUS-FNA) for diagnosing extra hepatic cholangiocarcinoma is 53% to 89%
  • EUSFNA has also been shown to be more accurate than CT or positron emission tomography for the evaluation of regional lymph node metastases in patients with cholangiocarcinoma

Take home message-

  • The majority of patients with HC manifest too late for resection. Therefore, palliation is the goal in the majority of patients
  • ERCP is usually preferred in view of its being less invasive and faster

Previously placed plastic stent was removed

Short segment hypo echoic lesion in upper CBD

 

 

 

 

 

 

 

Short segment hypo echoic lesion measuring Approximately 1 x 0.8 cm

Dilated IHBR in left lobe of liver

 

 

 

 

 

 

 

 

Cholangiogram showing bismuth type I stricture

Brush cytology from upper CBD stricture

Brush cytology from upper CBD stricture

 

 

 

 

 

 

 

Intra ductal biopsy

Free flow of bile and air was seen in both lobes of liver

 

 

 

 

 

 

 

An 8 cm SEMS in situ

 

 

  • A 55 year old female presented with abdominal pain, jaundice and fever since 2 days
  • EUS- dilated CBD with multiple large stones in the lower CBD and echogenic bile.
  • Gall bladder appeared distended with sludge and stones
  • Duodenoscopy- bulging ampulla with perivaterian diverticulum
  • ERC- Selective cannulation of bile duct was achieved.
  • Cholangiogram confirmed the EUS findings. Biliary sphincterotomy was performed. Ampullary stone was seen extruding out just after sphincterotomy.
  • In view of large size of the stone biliary sphincteroplasty was performed.
  • Mechanical lithotripsy was performed for the large impacted stone in the CBD. Bile duct was swept clear with stone extraction balloon catheter. Complete ductal clearance was confirmed.
  • In view of gall bladder in situ, purulent cholangitis and perivaterian diverticulum despite a sphincterotomy a 7 Fr double pigtail stent was placed to ensure free flow of bile.

Expert comments-

  • Mechanical lithotripsy leads to complete bile-duct clearance in 80% to 90% cases
  • Relative ease of use makes mechanical lithotripsy the first-line approach to difficult bile-duct stones and appropriate for use in routine clinical practice

Take home message-

  • Mechanical Basket Lithotripsy is a simple, safe, effective and inexpensive procedure in experienced hands and has emerged as the procedure of choice for endoscopic management of difficult stones

EUS showing dilated CBD with multiple large stones and echogenic bile

Cholangiogram showing large impacted stone

Cholangiogram showing large impacted stone

 

 

 

 

 

 

 

 

Biliary sphincterotomy with extruding impacted ampullary stone

Balloon sphincteroplasty

 

 

 

 

 

 

 

 

Mechanical lithotripsy

Complete CBD clearance and 7 Fr stent in CBD

  • 17 year old female presented with on and off fever, anorexia and occasional vomiting since 1 month.
  • There was no history of abdominal pain and weight loss.
  • CBC with ESR- normal
  • Chest X-ray- normal
  • CT Abdomen- Multiple heterogeneously enhancing centrally necrotic lymph nodes in intra peritoneal and retroperitoneal regions
  • EUS- multiple mixed echoic conglomerates of nodes were seen in peri pancreatic, peri porta region with areas of necrosis.
  • Multiple hypoechoic conglomerates of nodes were seen in the mediastinal region
  • EUS FNA was performed (two passes) from conglomerates of nodes in the mediastinal region under color Doppler control and aspirated material was sent for cytological examination as well as for AFB culture and sensitivity
  • Cytology report- tuberculous lymphadenitis
  • Patient was started on AKT and was symptoms free on further clinical follow ups.

Expert comments-

  • Peripancreatic tuberculous lymphadenitis and isolated pancreatic tuberculosis are uncommon clinical entities, particularly in immuno-competent individuals, even in endemic areas.1
  • Diagnostic accuracy of EUS-FNA is reported to be 76% to 95% for pancreatic cancer and for focal inflammations

Take home message-

  • EUS-FNA has emerged as an excellent tool for image and sample pancreatic lesions.2
  • Pancreatic EUS guided-FNA allows an accurate and safe diagnosis in majority of cases without the risk, cost and time expenditure of an open biopsy or laparotomy
  • Prognosis of pancreatic TB is good, once a diagnosis is established. Anti-tubercular therapy cures disease in almost all cases

References-

  1. Ray S, Das K, Mridha AR. Pancreatic and peripancreatic nodal tuberculosis in immuno-competent patients: report of three cases. JOP. 2012; 13(6): 667- 70.
  2. Gress FG, Hawes RH, Savides TJ, Ikenberry SO, Lehman GA. Endoscopic ultrasound guided fine needle aspiration biopsy using linear array and radial scanning endosonography. Gastrointest Endosc 1997; 45:243-50.

Mixed echoic node in peri pancreatic region with areas of necrosis

EUS guided FNA from suspicious mediastinal node

  • 53 years old Male
  • Complaining of Pain in the abdomen – 2 months without any ither constitutional symptoms
  • CT Abdomen – Multiple well defined nodular lesions in both lobes of liver
  • MRI abdomen – Multiple bi lobar liver lesions, largest measuring 2.5 cm in segment IV A
  • PET CT- SRS expressing hypo dense lesion in both lobes of liver and in gastrohepatic, para-aortic nodes
  • CT guided biopsy of liver lesion – Neuro Endocrine Tumor grade II
  • chromogranin – 2325 ng/ml ( Normal Less than 36 ng/ml)
  • Endoscopic ultrasound of the pancreato-biliary system was performed to find out the primary site of the tumor
  • EUS:

A single round hypoechoic lesion measuring 12 mm X 12 mm was seen at the junction of genu and body of pancreas.

No other lesion could be seen in the pancreas.

MPD appeared normal.

Multiple round hypoechoic lesions were seen in the left lobe of liver suggestive of metastatic tumor deposits.

No evidence of nodes or free fluids seen.

  • Endoscopic ultrasound has 100 % sensitivity and specificity for pancreatic lesions of size less than 20 mm which are not detectable in any other imaging modalities including PET-CT.

Hypoechoic lesion measuring 12 mm X 12 mm was seen at the junction of genu and body of pancreas

Multiple round hypoechoic lesions were seen in the left lobe of liver

  • A 58 year old male presented with significant weight loss in recent past
  • Past history- hepatitis B carrier, not on Rx.
  • Serological examination- Negative for HCV,  HIV and Liver screen
  • Other laboratory tests- elevated levels of ALP (140 IU/L), CEA (9.81 ng/ml), (AFP-95.4 IU/ml), (CA 19.9-504.2 U/ml) and AST (58 IU/L), Bilirubin ( 1.1mg/dl), INR (1.4), Albumin (3.2gm/dl)
  • Hepatitis B – Started on antiviral treatment with Tenofovir 245mg OD before operation.
  • Child Pugh Turcott – Stage A, no co-morbidities.
  • CT Abdomen- 9 x 9 cm heterogeneously enhancing mass in the right lobe of liver with cirrhotic changes and right portal vein thrombosis
  • Management- right hepatectomy with cholecystectomy
  • Microscopic examination of specimen- predominantly HCC with cirrhotic parenchyma
  • IHC study- dual phenotypic differentiation of tumor in to both hepatocytes and biliary epithelium

Expert comments-

  • CHC is a rare primary liver neoplasm containing both elements of hepatocellular and cholangiocarcinoma
  • Clinically, CHC has overlapping features with HCC; hepatic cirrhosis and common viral markers are often positive, and the AFP level is frequently elevated.
  • Although CHC is more closely related to HCC than to CC, it follows a more aggressive clinical course than that of ordinary HCC

Take home message-

  • Most hepatocellular carcinoma arises in the setting of chronic liver disease.
  • HCC is usually diagnosed multiple imaging modalities because of its arterial phase enhancement & venous phase washout.
  • 20% of HCC are AFP non secretors.