• 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)
  1. Conventional endoscopic transmural drainage is possible only in 57% cases compared to 100%

efficacy for EUS guided drainage (Varadarajulu et al, 2007)

  1. 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 image of large pseudocyst with debris

EUS guided cyst puncture

EUS guided cyst puncture

 

 

 

 

 

 

 

 

 

SEMS insertion

SEMS insertion

Xray showing SEMS and pig tail stent in the pseudocyst

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

oesophago-pleural fistula

APC applied to the edges

APC applied to the edges

 

 

 

 

 

 

 

 

 

 

Ovesco clip placement.

Ovesco clip placement.

OGD – 2 weeks – healed fistulous tract

OGD – 2 weeks – healed fistulous tract

 

  • 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

Mixed echoic node in peri pancreatic region with areas of necrosis

EUS guided FNA from suspicious mediastinal node

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

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

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.

graph

  • A 28 year old female presented with pain in abdomen over RHC, fever and jaundice since 1 month
  • EUS- dilated CBD with a sludge and hydatid daughter cysts within
  • ERC- Duodenoscopy revealed bulging ampulla with hydatid daughter cyst at the opening
  • Cholangiogram- sludge and hydatid daughter cysts within CBD with massively dilated right ductal system
  • Biliary Sphincterotomy was performed. Hydatid daughter cyst extraction was carried out with balloon catheter. Sudden gush of infected bile and hydatid daughter cysts were seen
  • A 7 Fr double pigtail stent was placed in to the right ductal system to ensure free flow of bile
  • Follow up after 6 weeks- patient was asymptomatic. Duodenoscopy revealed biliary stent in situ.
  • Previously placed double pig tail stent was removed.
  • Cholangiogram showed the hydatid cyst cavity in the right lobe and right ductal system with daughter cyst membranes. Hydatid daughter cyst membrane extraction was carried out with balloon catheter.
  • In view of residual hydatid cyst membranes in to the right ductal system and right lobe of liver a 7 Fr double pigtail stent was placed in to the right ductal system and a 7 Fr Teflon stent was placed in to the left ductal system to ensure free flow of bile.
  • Patient underwent laparoscopic marsupialization procedure for residual cavity and stent removal was performed after 4 weeks. Patient was asymptomatic on further clinical follow ups.

Expert comments-

  • Early diagnosis and proper management are mandatory in these patients, since serious clinical complications with an increased mortality may ensue
  • ERC proved to be a choice offering excellent immediate and short-term post procedure results. The success rate of endoscopic treatment appears to be satisfactory at 90 – 100%

Take home message-

  • Endoscopic treatment is one of the therapeutic options of a ruptured hepatic hydatid cyst into the biliary tract9 and it is both safe and effective
  • Percutaneous approach with PAIR (Percutaneous aspiration instillation and re aspiration) should not be performed in patients with cyst-biliary communication
Dilated CBD with daughter cysts within

Dilated CBD with daughter cysts within

Massively dilated right ductal system

Massively dilated right ductal system

 

 

 

 

 

 

 

 

 

Hydatid cyst extraction with balloon catheter

Hydatid cyst extraction with balloon catheter

A 7 Fr double pigtail stent in situ

A 7 Fr double pigtail stent in situ

 

 

 

 

 

 

 

 

 

Residual hydatid cavity in right lobe and ductal system

Residual hydatid cavity in right lobe and ductal system

A 7 Fr double pigtail and a 7 Fr Teflon stent was placed in to the right  and left ductal system

A 7 Fr double pigtail and a 7 Fr Teflon stent was placed in to the right and left ductal system

 

 

 

 

 

 

 

 

  • 78 year old female presented with history of chronic diarrhea and significant weight loss since 2 months
  • Known case of chronic pancreatitis
  • CT Abdomen – Dilated MPD with suspicious enhancing lesion in the head of pancreas
  • EUS – An irregular solid-cystic lesion (16 mm X 14 mm) was seen in the head of pancreas with mural nodules.
  • Pancreatic parenchyma appeared atrophied in the head and body region.
  • MPD appeared dilated (7 mm) in the body and tail region
  • EUS guided FNA was performed with 22 G needle under color Doppler guidance
  • EUS guide FNA cytology was suggestive of low grade cystic neoplasm

EXPERT COMMENTS –

  • Contrast harmonic -EUS can differentiate between benign and malignant pancreatic nodule
  • Elderly male with history of chronic pancratitis are at significantly higher risk to develop malignancy
  • EUS in combination with EUS guided FNA has 100 % sensitivity and specificity to diagnose the pancreatic  solid-cystic neoplasms.
An irregular solid-cystic lesion was seen in the head of pancreas

An irregular solid-cystic lesion was seen in the head of pancreas

An irregular solid-cystic lesion was seen in the head of pancreas – with Doppler imaging

An irregular solid-cystic lesion was seen in the head of pancreas – with Doppler imaging

 

 

 

 

 

 

 

 

 

 

EUS FNA was performed (two pass) from the suspicious lesion

EUS FNA was performed (two pass) from the suspicious lesion

Fish mouth appearance of ampulla typical of Mucinous cystic neoplasms

Fish mouth appearance of ampulla typical of Mucinous cystic neoplasms

  • 69 year old female was presented with Dysphagia to solids and weight loss of 15 kilos
  • Past medical history:- Interstitial lung disease on intermittent immune modulation
  • Blood tests:- Mild iron deficiency anaemia
  • Previous endoscopic biopsy:- Inconclusive
  • OGD Scopy:- severe esophageal candidiasis in the mid- and lower esophagus
  • Tight stricture at the lower esophageal junction.
  • The mucosa over the stricturous area appeared normal.
  • Esophagus proximal to the stricturous area appeared dilated
  • Scope could be negotiated across the stricture with difficulty
  • High Resolution Manometry: – Achalasia cardia type II
  • EUS :- performed with a blind Esophagoprobe
  • circumferential hypoechoic mass lesion was seen just proximal to the G-E junction
  • The mass appeared to invade the adventitia with loss of interface with the aorta
  • EUS guided FNA:- adenocarcinoma of the oesophagus

EXPERT COMMENTS-

  • EUS in achalasia would show hypertrophied circular muscle which is cut during Per Oral Endoscopic Myotomy
  • Type 2 achalasia is best suited for POEM treatment hence a HRM is a must before treatment
  • Mucosal biopsies do NOT exclude pseudo achalasia and EUS guided FNA is often diagnostic

TAKE HOME MESSAGE–

  • Short history and dramatic weight loss should always raise the possibility of pseudo-achalasia
  • EUS is a useful way of differentiating achalasia from pseudo achalasia
Extensive esophageal candidiasis

Extensive esophageal candidiasis

Tight Lower esophageal sphincter

Tight Lower esophageal sphincter

 

 

 

 

 

 

 

 

 

Circumferential hypo echoic mass just proximal to GE Junction

Circumferential hypo echoic mass just proximal to GE Junction

Mass invading the adventitia with loss of interface with aorta

Mass invading the adventitia with loss of interface with aorta

 

 

 

 

 

 

 

 

 

 

EUS guided FNA

EUS guided FNA

Generalised failure of peristalsis – type 2 achalasia cardia

Generalised failure of peristalsis – type 2 achalasia cardia