• 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

  • 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.