Category Archives: Gastrovision Cases | Ea – Best Gastroenterologist Doctors Mumbai

• 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 Ovesco^tm  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.
• Ovesco^{tm Â} clips are excellent devices for closure of fistulous tracts and perforations.

Expert comments –

• Ovesco^tm  clips are useful in acute bleeding to achieve hemostasis.
• Ovesco^tm  clips  are useful in compression as well as approximation of tissue,
• Ovesco^tm  clips offer large volume of tissue, higher stability and minimal strain at the surrounding site.
• Ovesco^tm  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

• 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