• A 27 year old male has a history of chronic back ache without any GI complaints
  • MRI dorsal spine–
  • incidental finding of 4 x 5 x 6 cm sized lesion in upper thoracic esophagus
  • partial luminal narrowing and extra luminal extension in to left Para tracheal location
  • benign soft tissue lesion/Leiomyoma
  • OGD Scopy- proximal esophageal submucosal lesion? GIST
  • EUS (Singapore) – Large cystic lesion and thick mucoid aspirate removed with 19 G needle.
  • Cytology – Pauci cellular mucoid aspirate
  • EUS – At Endoscopy Asia –
  • Large submucosal anechoic cystic lesion in the lower esophagus measuring 6 cm X 4 cm.
  • The cyst wall contained all the layers of the esophageal wall: Mucosa, muscularis mucosa, sub mucosa, Muscularis propria and adventitia
  • Diagnosis – Esophageal duplication cyst

EXPERT COMMENTS-

  • Esophageal duplication is an embryologic duplication of a portion of the muscle and submucosa of the esophagus without epithelial duplication
  • Maldevelopment of the posterior division of the primitive foregut is the embryologic defect responsible for esophageal cysts.
  • The lining of the cyst can vary and can include squamous columnar, cuboidal, pseudo stratified, ciliated, and gastric mucosa. Hemorrhage can be the presenting symptom if gastric mucosa is present in the cyst.
  • Video-assisted thoracoscopic surgery (VATS) is currently used to enucleate cysts and resects duplications

TAKE HOME MESSAGE –

  • Duplication cysts should never be aspirated in view of the risk of infection.
  • Asymptomatic lesions should not be intervened up on
  • Trans-oesophageal endoscopic marsupilisation of the cyst is a feasible option only in symptomatic cases.
Large submucosal lesion in mid esophagus

Large submucosal lesion in mid esophagus

NBI View

NBI View

 

 

 

 

 

 

 

 

 

A large submucosal anechoic cystic lesion

A large submucosal anechoic cystic lesion

An Esophageal duplication cyst

An Esophageal duplication cyst

  • 43 years old Male
  • Known case of HIV positive status, presented with severe jaundice for last 1 month
  • CT Scan Abdomen – Mass in the pancreatic head region  with Dilated IHBR
  • EUS – a large hypoechoic mass lesion (5X4 cm) near the head of pancreas which appeared like large
  • lymphnode mass compressing the entire lower CBD upto mid CBD.
  • Multiple Hypoechoic nodes in the porta and peripancreatic region near the body.
  • EUS FNA was then performed from the large mass in the head region and the porta node.
  • Cytological examination followed by histopatholoy and IHC study of the aspirated material revealed it to be a case of B cell Non-Hodgkins lymphoma.
  • Selective cannulation of CBD could be achieved only after pancreatic stent placement and precut sphincterotomy.
  • Cholangiogram revealed a long 10-12 cm stricture involving the entire lower CBD and mid CBD with dilated CHD and IHBR. Biliary sphincterotomy was then extended and with a great difficulty a 10 fr stent could be passed across the stricture. Free flow of bile was seen.
  • Follow-up EUS after 3 months of chemotherapy revealed complete resolution of the lymphomatous lesions and the placed pancreatic and biliary stents were removed.

Expert Comments:

  • Non-Hodgkin lymphoma has been reported to be cause of malignant biliary stenosis in 1-2 % of cases.
  • Case series of such peripancreatic lymphomatous lesion being mistaken for pancreatic neoplasm and getting operated for Whipple’s operation has been reported.
  • EUS guided FNA from such lesion prior to any definitive treatment provides accurate tissue diagnosis as well as locoregional staging of the disease.
  • Preparation of cell blocks from the EUS guided FNA material does enable histological characterization, improves accuracy with advantage of special staining (mucicarmine, Congo red) and Immunohistochemistry studies.

Take Home Message:

  • Lesions of lymphnodal origin (tuberculous granuloma or lymphoma) should be suspected in cases of HIV presenting with peripancreatic mass leading to obstructive jaundice.
  • EUS guided FNA must be done for all such mass lesions prior to any definitive operative intervention.
  • Stenting of the bile duct at the time of diagnosis of such lymphomatous lesion with removal after 3 months should be undertaken to evaluate the response to the chemotherapy treatmen.
  • Covered Self expandable metallic biliary stenting can be considered in cases refractory to treatment with plastic biliary stents.
EUS showing Peripancreatic mass lesion

EUS showing Peripancreatic mass lesion

EUS guided FNA from the mass lesion

EUS guided FNA from the mass lesion

 

 

 

 

 

 

 

 

 

Cholangiogram showing long segment CBD stricture with dilated proximal CBD and CHD

Cholangiogram showing long segment CBD stricture with dilated proximal CBD and CHD

Bile duct stent in situ

Bile duct stent in situ

 

 

 

 

 

 

 

 

 

Fluoroscopy showing CBD stent in situ

Fluoroscopy showing CBD stent in situ

Follow-up EUS showing complete resolution of the lymphnode mass

Follow-up EUS showing complete resolution of the lymphnode mass

 

  • A 15 year old female presented with pain in abdomen radiating to back since 1 year
  • lateral pancreatico-jejunostomy two years back for chronic calculus pancreatitis
  • EUS- MPD appeared dilated (6.5mm) in head region with multiple stone
  • ERP-
  • Selective cannulation through major papilla and Sphincterotomy was performed.
  • Guide wire was passed deep in to the jejunum across the anastomotic site
  • Pancreatogram- pre papillary stricture with stricture at anastomotic site with multiple stones in head and tail region. Stricture dilatation was performed with 8mm balloon
  • A 7 Fr double pig tail stent was placed across the anastomotic site.
  • Patient underwent few sessions of ESWL for residual stones
  • Follow up ERP after 3 months-
  • Previously placed 7 Fr stent was removed. Selective cannulation of MPD
  • Pancreatogram- dilated MPD, resolved pre papillary and anastomotic site stricture
  • Complete ductal clearance was achieved with stone extraction balloon catheter
  • Patient was asymptomatic on further clinical follow ups

EXPERT COMMENTS-

  • Endotherapy in conjunction with ESWL has been shown to increase stone clearance rates and to improve long-term outcomes in patients with stone and stricture disease
  • Surgery can be avoided in more than 80% of patients who underwent pancreatic endotherapy in conjunction with ESWL ,with decrease in narcotic use and reduction in need for hospitalizations
  • Surgical drainage is associated with a mortality rate of up to 5%, and long-term prognosis is not as good because pain may recur in up to 50% of patients within 5 years after surgery

TAKE HOME MESSAGE-

  • Advances in understanding the pathogenesis of CP combined with progress in technology have led to an emerging role of endoscopy in the management of CP
  • Experts believe that endoscopic management has an important role in patients as a primary therapeutic measure
Dilated MPD with multiple stones

Dilated MPD with multiple stones

Major papilla sphincterotomy

Major papilla sphincterotomy

 

 

 

 

 

 

 

 

 

Stricture dilatation with 8 mm balloon

Stricture dilatation with 8 mm balloon

A 7 Fr double pig tail stent was placed

A 7 Fr double pig tail stent was placed

 

 

 

 

 

 

 

 

 

Pancreatogram showing pre papillary stricture with stricture at anastomotic site with multiple stones

Pancreatogram showing pre papillary stricture with stricture at anastomotic site with multiple stones

A 7 Fr double pig tail stent in situ

A 7 Fr double pig tail stent in situ

 

 

 

 

 

 

 

 

 

 

Complete ductal clearance achieved

Complete ductal clearance achieved

Resolved pre papillary and anastomotic site stricture

Resolved pre papillary and anastomotic site stricture

  • 67 year old male presented with Right upper quadrant pain for 2 months, weight gain of 2 kilos and abdominal distension
  • Past medical history- Diabetes type 2 for 20 years, hypertension
  • Blood profile –
  • Hb – 9.7gm/dl, Platelets – 81,000/cmm
  • Total Bilirubin- 3.2gm/dl, ALT- 121, AST- 167, ALP-155, GGT- 212
  • Hepatitis B and C- Non reactive, ANA – Negative, S.Ferritin- 145 ug/dl
  • AFP – 1245 IU/ml
  • INR 2.5,S. Albumin- 2.4
  • cirrhotic liver, large 9×8 cm lesion in the left lobe if liver with arterial enhancement
  • PV thrombosis, Moderate ascites
  • CT Abdomen and Pelvis –

EXPERT COMMENTS-

  • 20 % of HCC have normal AFP so one must not rely on it
  • In a cirrhotic liver arterially enhancing lesion with venous washout is virtually diagnostic of HCC
  • <1cm focal liver lesion can be observed with serial MRI / CT imaging

TAKE HOME MESSAGE-

  • NASH is the likely etiology of this cirrhosis and decompensate liver disease is often secondary to development of HCC.
  • Decompensate liver disease and Child Pugh stage B, C is a contraindication to definitive surgery.
  • TACE/RFA ablation may not be feasible in view of portal vein thrombosis, size and patient condition
  • A 37 year old lady presented with history of fatigue, generalized itching and weight loss of 2 kilos since  2 month
  • Past History- Grave’s disease 1 year back and had been on propylthiouracil (PTU) since then
  • Examination – unremarkable
  • Blood tests –
  • CBC :– normal,T. Bilirubin:- 1.4mg/dl, SGOT:- 40, SGPT: – 36, ALP: -334, GGT :– 425
  • Serum electrophoresis :– Normal, AMA:- Negative, P-anca :- Negative
  • USG Abdomen – NAD
  • CT Abdomen – NAD
  • Radiological Imaging Studies –
  • Provisional diagnosis- Propylthiouracil induced cholestasis
  • Patient was treated with Ursodeoxycholic acid 8mg/kg/day in divide doses and PTU stopped
  • Liver biopsy- minimal bile plugs but no ductopenia, eosinophils or lymphocytes
  •  Follow up examination- No symptomatic improvement after 3 months
  • Blood tests: – ALP – 463, GGT – 499, SGOT – 41, SGPT – 38, Bilirubin – 1.5mg/dl
  • MRCP – Dominant stricture in the right hepatic duct with features consistent with PSC
  • ERCP – MRCP findings confirmed, brushing taken and 10 French stent placed.
  • Final diagnosis- Primary Sclerosing Cholangitis

Expert comments-

  • MRCP is a far superior investigation in unexplained cholestasis than CT abdomen
  • Liver biopsy should have at least 10-12 portal tracts for accurate diagnosis

Take home message –

  • Drugs must be considered as the causative agent although if withdrawal does not resolve the liver biochemistry an alternative diagnosis should be sought
  • Drug induced liver injury (DILI) can often persist beyond six months
  • Most cases of PSC are associated with concurrent ulcerative colitis and annual screening colonoscopies are mandatory to rule out colorectal cancer.
  • A 27 year old female presented with progressive dysphagia to liquids and weight loss of 5 kilos
  • past and family history- Unremarkable
  • Blood profile – normal
  • Barium study – “Parrot beak” appearance suggestive of achalasia cardia
  • High resolution manometry – Type 2 achalasia cardia
  • Patient had undergone esophageal balloon dilatations up to 12mm twice with no relief in symptom.
  • We elected to perform Per Oral Endoscopic Myotomy (POEM).

Expert comments

  • Adequate dilatation with 30mm TTS balloon is required for achalasia cardia
  • High Resolution Manometry is a must in all patients with dysphagia in whom OGD is normal
  • Barium swallow is an outdated investigation and adds little to the diagnosis and management of patients

Take home message

  • High Resolution Manometry is an excellent tool in diagnosing the various subtypes of achalasia cardia and the treatment should be tailor made accordingly
  • POEM (Per oral endoscopic myotomy) is a definitive novel endoscopic minimally invasive surgery compared to conventional Heller’s cardiomyotomy