A 25 yrs female was referred to us for the favor of EUS sos ERCP for suspected block in the CBD leading to recurrent epigastric pain with mild LFT abnormality and no stones were seen in Gall bladder on USG abdomen, however, mild dilatation of CBD was seen without any obvious stone or filling defects. EUS at Endoscopy Asia revealed a large tubular structure in the dilated CBD and this was suspected to be a large round worm. There was no other pathology in the pancreato-biliary system apart from this findings and therefore ERCP was considered. ERCP showed a filling defect on cholangiogram and confirmed the EUS findings. Biliary sphincterotomy was performed and the round worm was extracted using a stone extraction balloon catheter. Few more live round worms were also seen in the third part of duodenum and therefore after ductal clearance a 7 fr stent was placed to ensure effective ductal drainage. Patient was treated on an OPD basis and sent home the same day.

Expert Comments

As we have seen in the previous case that patients with obstructive jaundice without a definitive diagnosis of etiology of obstructive jaundice can be diagnosed accurately on EUS.

Here we managed to clear the duct of a live round worm which was causing intermittent obstruction of the bile flow leading to mild LFT abnormality and severe epigastric pain. This patient was then given oral antihelminthic medication to take care of rest of the round worms. Since there are still some serious hygienic issues in our society especially in the rural and slum areas that we have to keep such pathology in mind at the time of management of such patients.

I would like to share here with our readers that it is a standard protocol at Endoscopy Asia that unless EUS proves that there is a definitive pathology in the bile duct that needs treatment we will not proceed with ERCP. In other words we at Endoscopy Asia do not have negative ERCP so to speak and in the era of such accurate modalities such as EUS & MRCP, diagnostic ERCP has no role in most cases.

Tubular filling defects seen in a dilated CBD-A live round worm

Tubular filling defects seen in a dilated CBD-A live round worm

ERCP-After selective cannulation of CBD biliary phincerotomy was performed

ERCP-After selective cannulation of CBD biliary phincerotomy was performed

 

 

 

 

 

 

 

 

 

 

ERCP-Cholangiogram showed a tubular filing defect in a midly dilated CBD

ERCP-Cholangiogram showed a tubular filing defect in a midly dilated CBD

Live round worm from CBD was removed with a stone extraction balloon catheter

Live round worm from CBD was removed with a stone extraction balloon catheter

 

 

 

 

 

 

 

 

 

 

To prevent reentry of the round worm a 7Fr stent was placed into the CBD

To prevent reentry of the round worm a 7Fr stent was placed into the CBD

Multiple live roundworms were seen in the third part of the duodenum,one of them managed to enter the bile duct and caused all the symtoms

Multiple live roundworms were seen in the third part of the duodenum,one of them managed to enter the bile duct and caused all the symtoms

A 75 yrs male was referred to us for the favor of evaluation of exact etiology of obstructive jaundice. The total bilirubin was 23mg% and patient had few episodes of fever with chill recently. Hence EUS was considered to evaluate the exact etiology of obstructive jaundice. EUS revealed a large mass in the pancreatic head which appeared malignant and was seen invading the duodenal wall, lower CBD, MPD, SMA & SMV. Further more, large hypoechoic nodes were seen in the celiac axis region. In view of these findings EUS guided FNA was performed from the pancreatic head mass and the celiac axis nodes. Subsequently due to recurrent cholangitis ERCP was performed and after biliary sphincterotomy a self expandable. metal stent was placed into the CBD which showed free flow infected bile. The procedures were performed on OPD basis and patient was sent home the same evening.

Expert Comments:

As we can see in this case due to very advanced nature of pancreatic tumor which eventually turned out tobe a poorly differentiated adenocarcinoma on EUS guided FNA of the mass and nodes, a single step detection, diagnosis, staging and palliation of malignant obstructive jaundice was performed in one sedation on an OPD basis. Several studies have shown that whenever there is a patient of obstructive jaundice of uncertain diagnosis, EUS will provide accurate diagnosis in most cases. It is a standard protocol at Endoscopy Asia that if a patient has obstructive jaundice and if the diagnosis is not clear on previous other imaging studies,  then patient will be subjected to EUS sos EUS guided FNA if there is a mass lesion followed by ERCP and ductal clearance if stones are seen or stenting if a malignant lesion is encountered. Studies have shown that most patient who are diagnosed with Pancreatic adenocarcinoma who present with obstructive jaundice are advanced in their presentation and hence Surgery should be considered only if there is a chance of cure and R0 resection without nodal involvement, and in most centres across the world role of palliative surgery is now diminishing. Since the advent of EUS / FNA and Metal Biliary stenting / Duodenal stenting, endoscopic palliation is now a preferred approach. If patient has intractable pain due to advanced pancreatic cancer then in the same sedation we can also offer EUS guided Coeliac Plexus Neurolysis (EUS-CPN) thus completing the entire spectrum of palliative care.

This approach of EUS sos ERCP provides accurate diagnosis and optimal management of obstructive jaundice in most patient without any additional investigations or interventions. This has been our practice for over 13 years since I pioneered Pancreato-biliary EUS in India and we hope that more such centres across the country will incorporate such a protocol in years to come.

EUS showed a large hypoechoic mass In the pancreatic head leading to obstructive jaundice

EUS showed a large hypoechoic mass In the pancreatic head leading to obstructive jaundice

Large hypoechoic mass in the pancreatic head invading the SMA and SMV

Large hypoechoic mass in the pancreatic
head invading the SMA and SMV

 

 

 

 

 

 

 

 

 

 

Hypoechoic nodes were seen in the celiac axis region- suggestive of distant nodal metastasis

Hypoechoic nodes were seen in the celiac axis region- suggestive of distant nodal metastasis

EUS guided FNA of the pancreatic head mass performed. Needle was passed transduodenally under EUS guidance.

EUS guided FNA of the pancreatic head mass performed. Needle was passed transduodenally under EUS guidance.

 

 

 

 

 

 

 

 

 

 

ERCP showed dilated upper CBD with a stricture In the region of pancreatic head

ERCP showed dilated upper CBD with a stricture In the region of pancreatic head

ERCP and placement of Self expandable  Metal biliary stent

ERCP and placement of Self expandable
Metal biliary stent

A 53yrs Female, was referred to us with a diagnosis of poorly differentiated Squamous Carcinoma of Lower 1/3rd Esophagus for Staging sos Palliation of absolute Dysphagia with severe Comorbidities.

Endoscopic & EUS staging showed T3N2Mx. Since patient was reluctant for neoadjuvant treatment, a Self Expandable Covered Antireflux Metal Stent was then placed across the stricture after Balloon Dilatation under Endoscopic & Fluoroscopic control.

Patient started taking oral feeds few hours after stent placement and was sent home the same evening uneventfully.

 

Expert Comments :

As we can see in this case, patient with absolute dysphagia due to advanced lower 1/3rd esophageal malignancy with extensive nodal metastasis, who is a poor surgical risk and who does not want neoadjuvant treatment. We feel that this approach of Endoscopic staging and palliation with a metallic stent placement was ideal in such a patient. The procedure was done on a daycare  basis and patient was sent home the same day.

A large ulceroproliferative stemotic lesion at 35cms from the incisors teeth

A large ulceroproliferative stemotic lesion at 35cms from the incisors teeth

Balloon dilatation was performed

Balloon dilatation was performed

 

 

 

 

 

 

 

 

 

 

The lesion seems to have invaded the cardia on retroflexion

The lesion seems to have invaded the cardia on retroflexion

EUS staging showed T3N2Mx

EUS staging showed T3N2Mx

 

 

 

 

 

 

 

 

 

A self expandable covered antireflux metal stent was deployed across the stricture

A self expandable covered antireflux metal stent was deployed across the stricture

Optimal stent deployment was confirmed on constrast study on fluroscopy

Optimal stent deployment was confirmed on constrast study on fluroscopy

A 48yrs/ F was referred to us for the favor of colonoscopy to evaluate the exact etiology of bleeding per rectum off and on for last 6 months leading to drop in Hb. Patient was treated conservatively for colitis and piles by a family physician. However, patient continued to have symptoms despite several months of treatment and hence went to see a Surgeon who asked for a colonoscopic evaluation.

Ileo-colonoscopic evaluation revealed a large 4 cms bilobed polyp with a thick stalk at the recto-sigmoid junction. Rest of the colon upto the caecum and also the last 15 cms of terminal ileum was normal. Polypectomy was then performed with a snare and cautery after injection of diluted saline adrenaline into the stalk. Complete resection of the polyp was achieved and was sent for HPE, which revealed tubulovillous adenoma without dysplasia. Patient was sent home the same evening.

Expert comments

Patient above the age of 45 yrs with h/o bleeding per rectum should be investigated in detail and empirical treatment without a definitive diagnosis should be avoided. In this case patient suffered for almost 6 months before getting the a definitive diagnosis and effective endoscopic treatment in the same sedation and was cured of her symptoms. Pedunculated or even flat sessile colonic lesions can be successfully resected with endoscopic techniques such as polypectomy as in this case or we can employ more sophisticated tools that can perform EMR ( Endosocpic Mucosal Resection ) or ESD ( Endoscopic Submucosal Dissection).

It is our policy at Endoscopy Asia to inspect 10-15 cms of terminal ileum in all patients referred to us for Colonoscopy and more so if we are looking for a lesion that could bleed. It is also important to perform these procedures under one sedation at the pilot endoscopy, both the diagnostic and therapeutic aspects when we deal with bleeding per rectum in an infrastructure which is equipped enough with all the methods of endoscopic haemostasis.

Large bilobed polyp with thick stalk seen in Recto-sigmoid region

Large bilobed polyp with thick stalk seen in Recto-sigmoid region

Diluted saline adrenaline injected in the stalk

Diluted saline adrenaline injected in the stalk

 

 

 

 

 

 

 

 

 

 

. The stalk strangulated with a polypectomy Snare

. The stalk strangulated with a polypectomy
Snare

No evidence of bleeding from the resected site

No evidence of bleeding from the resected site

 

 

 

 

 

 

 

 

 

 

Polyp retrieved with a Roth net.

Polyp retrieved with a Roth net.

Bilobed resected polyp was sent for  histopathological examination

Bilobed resected polyp was sent for
histopathological examination

A 36 yrs/ Male referred to us for the favor of EUS ( Endoscopic Ultrasound) sos guided drainage of Pancreatic pseudocyst secondary to an episode of severe acute pancreatitis ( alcohol related) about 11 months back. The size of pseudocyst was around 11 cms x 10 cms and there was no regression of size in the last 11 months and patient complained of intermittent pain and vomiting and hence EUS was considered.

EUS showed a large pseudocyst with some compression on stomach without any abnormal vessels or pseudoaneurysm. EUS guided cystogastrostomy was then performed with a therapeutic EUS scope. After placement of double pigtail stent the pseudocyst regressed immediately and patient was observed overnight and sent home the next day. On follow up patient is symptomatic and stent has been removed, so far in 23 months of follow up there is no recurrence.

Expert comments:

It is well known that after an episode of acute pancreatitis some patient may develop pseudocyst of pancreas. Almost 2/3rd of them resolve spontaneously over a period of 6-8 months and about 1/3 of them may become symptomatic which requires treatment. Traditionally the treatment of Pancreatic Pseudocyst has been Surgical – either open surgery or Laparoscopic.

However, with the advent of EUS guided drainage, in our experience for last 1 decade eversince we pioneered the Interventional EUS in Mumbai and India, almost 95-97% of symptomatic Pseudocysts at Endoscopy Asia can be managed with EUS guided drainage procedure. Published studies have shown similar conclusion that most patients with Pancreatic pseudocyst either secondary to acute or chronic pancreatitis can be managed successfully with EUS guided drainage, hence the role of Surgery is there only if EUS infrastructure and expertise are not available, especially if there is a non bulging pseudocyst..

Though large bulging pseudocysts can be drained even endoscopically, whenever possible EUS guided drainage will provide a safer window of puncture across the gut wall and thereby prevent complications such as bleeding and perforation that can occur.

EUS showed large pseudocyst without debris

EUS showed large pseudocyst without debris

EUS guided transgastric puncture

EUS guided transgastric puncture

Puncture tract dilated with cystotome

Puncture tract dilated with cystotome

Tract further dilated with a 6 mm balloon

Tract further dilated with a 6 mm balloon

Double pigtail stent draining clear Pseudocyst fluid into the stomach

Double pigtail stent draining clear
Pseudocyst fluid into the stomach

Fluoroscopy shows double pigtail stent Placed across the stomach wall into the  Pseudocyst. Echoendoscope seen.

Fluoroscopy shows double pigtail stent
Placed across the stomach wall into the
Pseudocyst. Echoendoscope seen.