• 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

  • 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