• 70 year old female
  • Significant weight loss within last 6 months
  • Painless jaundice since 10 days, Associated with on and off Low grade fever
  • CT Abdomen and pelvis – 8 x 2.2 cm sized enhancing mass lesion in peri Ampullary region
    • Involvement of second part of duodenum with peri lesional fat stranding,
    • Abrupt cut off of CBD, Central and peripheral IHBRD, Dilated PD
  • EUS – A4 cm X 1.3 cm sized Ampullary mass with extension into the bile duct
    • Dilated Common Bile Duct and Main Pancreatic Duct
    • Echogenic bile was seen in the bile duct suggestive of purulent Cholangitis
    • A large hypoechoic node was seen in the pericholedochal region
    • IHBR appeared dilated in left lobe of liver.
    • No evidence of any hypoechoic lesions were seen in the left lobe of liver
  • ERC – Duodenoscopy revealed Ampullary growth
    • Selective cannulation of bile duct was achieved
    • Biliary Sphincterotomy was performed and multiple biopsies were taken
    • a 6 cm uncovered self expandable metallic stent was placed in the CBD
    • Free flow of purulent bile was seen from the placed stent
  • Diagnosis – Adenocarcinoma

Expert comments:-

  • Biliary SEMS (short intra pancreatic or covered) do not impede pancreatic resection and may be used for preoperative biliary drainage in patients with malignant CBD obstruction when surgical status is unknown.
  • Endoscopic treatment of adenomas of the major duodenal papilla is a safe, well tolerated alternative to surgical therapy1.
  • In expert hands, complications are rare and surgery is generally not required1.

Take home message:-

  • Acute ascending Cholangitis may be an initial presentation of Ampullary tumor and requires urgent biliary decompression with endoscopic biliary drainage2.
  • In purulent Cholangitis, plastic stent tends to block. In such cases Self Expandable Biliary Metal stents provide effective ductal decompression.
  • In resectable cases, the short biliary self expandable metal stent can be removed at the time of definite surgical intervention.
A 1.4cm X 1.3cm Ampullary mass

A 1.4cm X 1.3cm Ampullary mass

Echogenic bile was seen in the bile duct

Echogenic bile was seen in the bile duct

 

 

 

 

 

 

 

 

 

Ampullary tumor

Ampullary tumor

Biliary Sphincterotomy

Biliary Sphincterotomy

 

 

 

 

 

 

 

 

 

Free flow of purulent bile from SEMS

Free flow of purulent bile from SEMS

Multiple biopsies from the Ampullary growth

Multiple biopsies from the Ampullary growth

 

 

 

 

 

 

 

 

 

Cholangiogram showing dilated CBD with abrupt cutoff

Cholangiogram showing dilated CBD with abrupt cutoff

A 6 cm uncovered self expandable metallic stent

A 6 cm uncovered self expandable metallic stent

  • 74 years oild Female
  • Presenting with pain in the abdomen on and off and vomiting with pain radiating to back.
  • No History of weight loss or jaundice
  • CT Scan abdomen – 2.6×3.5×4.5 cm sized ill defined soft tissue lesion in retro peritoneum anterior to aorta and posterior to pancreas? Neoplasm? Lymphoma? Lymphnodes.Small cystic lesion involving distal body and tail of pancreas? Cystic neoplasm
  • PET CT – Poorly marginated  metabolically active soft tissue in retro pancreatic space
  • CA 19.9- 254.52 U/ml
  • EUS revealed an irregular hypoechoic solid-cystic exophytic lesion in the tail of the pancreas encasing the splenic vein. The mass extends posteriorly upto the aorta. In view of these findings EUS FNA was performed (two pass) from the suspicious lesion in the tail of pancreas and aspirated material was sent for cytological examination.
  • Cytological examination confirmed it to be low grade solid cystic neoplasm of pancreas

Expert Comments:

  • Most pancreatic neoplasms are classified as ductal adenocarcinomas because they show a ductal phenotype, making a ductal origin very likely.
  • Patients with three or more first-degree relatives with pancreatic cancer have a 14 to 32-fold increased risk of developing pancreatic cancer, and this risk is significant. 1
  • Endoscopic ultrasound (EUS) is one of the best available technologies to image the pancreas2 and  EUS has been  used to screen asymptomatic, apparently healthy, members of families in which there have already been several pancreatic cancers
  • Several studies have suggested increased sensitivity and specificity of endoscopic ultrasound (EUS) compared with other imaging modalities.
  • The greatest advantage of EUS is that it allows fine needle aspiration (FNA) of the tumor to provide a tissue diagnosis.

Take Home Message:

  • The identification and detection of pancreatic ductal adenocarcinoma at its beginning, preferably at preinvasive stage, improves patient survival.
  • The precursor lesions of pancreatic ductal adenocarcinomas include intraductal papillary mucinous neoplasms (IPMN) and Mucinous neoplasm, which are rare.
  • Pancreatic ductal neoplasias have been reported in 11% of patients of chronic pancreatitis, however patient’s age and duration of the disease does not correlate with the grade of such lesions.
  • Following were candidates for screening: First-degree relatives (FDRs) of patients with Pancreatic Cancers from a familial Panncreatic Cancer kindred with at least two affected FDRs; patients with Peutz-Jeghers syndrome; and p16, BRCA2 and hereditary non-polyposis colorectal cancer (HNPCC) mutation carriers with ≥ 1 affected FDR.
Solid-cystic mass in the tail of pancreas

Solid-cystic mass in the tail of pancreas

The mass encasing the aorta

The mass encasing the aorta

 

 

 

 

 

 

 

 

 

EUS guidd FNA from the suspicious mass lesion in the pancreas

EUS guidd FNA from the suspicious mass lesion in the pancreas

  • 48 year old male
  • H/O Abdominal pain radiating towards back since 6 month, last episode 15 days back
  • Associated with nausea and low grade fever
  • USG Abdomen – dilated pancreatic duct with calculus within
  • CT Abdomen – Acute pancreatitis with parenchymal calcifications, Dilated MPD with stones
  • EUS- massively dilated MPD (1.7 cm) in the head, body and tail region with a chain of calculi and filled with purulent materials
    • Side branch dilatation, atrophic pancreatic parenchyma in the head and body region
    • Few reactive nodes were seen
  • ERP- Duodenoscopy revealed a bulging ampulla with an impacted large pancreatic duct stone.
    • Precut sphincterotomy followed by selective cannulation of the MPD was achieved
    • Pancreatogram confirmed EUS findings. Pancreatic sphincterotomy was performed
    • MPD was swept with a stone extraction balloon catheter which showed extraction of large amount of purulent material with large stones and necrotic material
    • Two 7 Fr stents were placed in the MPD for free flow of pancreatic juice

Expert Comments

  • Endoscopic therapy alone was found to be successful in 72% of patients with a 68% symptomatic improvement1
  • 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 disease2
  • In one study Kozarek et al were able to show that surgery was avoided in 80% of patients who underwent ESWL. with decrease in narcotic use and reduction in hospitalizations2

Take Home Message

  • Endoscopic ultrasound mapping of pancreas prior to the endotherapeutic intervention provides adequate information regarding plan of management.
  • Endoscopic treatment of such a case of chronic calculous pancreatitis has significantly decreased morbidity due to surgical interventions in addition to decrease in hospital admissions
  • Pancreatic endotherapy has shown significant improvement in the endocrine and exocrine pancreatic insufficiency, evidenced by decrease in the requirement of insulin and switch to the oral hypoglycemic agents from the insulin dependence in our patients.
Endosonography showing Massively dilated MPD with stone and purulent material

Endosonography showing Massively dilated MPD with stone and purulent material

Duodenoscopy showing impacted pancreatic duct stone at the ampulla

Duodenoscopy showing impacted pancreatic duct stone at the ampulla

 

 

 

 

 

 

 

 

 

 

Cannulation of MPD after precut sphincterotomy of the pancreatic orifice

Cannulation of MPD after precut sphincterotomy of the pancreatic orifice

Pancreatogram showing dilated and irregular MPD with large stones

Pancreatogram showing dilated and irregular MPD with large stones

 

 

 

 

 

 

 

 

 

 

Pancreatic ductal clearance with stone extraction balloon catheter

Pancreatic ductal clearance with stone extraction balloon catheter

Placement of two 7 Fr pancreatic duct stents

Placement of two 7 Fr pancreatic duct stents

 

 

 

 

 

 

 

 

 

 

Fluoroscopy showing optimal placement of the pancreatic duct stent

Fluoroscopy showing optimal placement of the pancreatic duct stent

  • A 84 year old female, known diabetic and hypertensive
  • History of upper abdominal pain with low grade fever
  • Referred for evaluation of dilated CBD in a setting of cholelithiasis on other imaging studies with Normal Liver Function Tests
  • EUS – Dilated CBD with a 17 mm stone impacted in the lower CBD
  • Distended gall bladder without sludge and imaging microliths
  • Duodenoscopy- Small peri vaterian diverticulum with normal ampulla
  • ERC- Cholangiogram confirmed the EUS findings Biliary balloon dilatation was carried out with 12-15 mm CRE balloon Biliary Sphincterotomy was performed; free flow of purulent bile was seen  Stone extraction was carried out with stone extraction balloon catheter
  • In view of gall bladder in situ and purulent cholangitis despite a Sphincterotomy a 7 Fr double pig tail stent was placed to ensure free flow of bile

EXPERT COMMENTS

  • Elderly patients with long standing diabetes can present with mild or absent constitutional symptoms in spite of presence of large bile duct stones causing purulent cholangitis
  • Endoscopic extraction of large stones in the presence of a perivaterian diverticulum can be problematic and may lead to inadvertent complications in the presence of severe inflammatory process 1
  • Endoscopic Sphincterotomy followed by Large Balloon Dilatation are promising due to its safety and effective alternative technique for large stone therapy but in experienced hands1
  • Endoscopic mechanical lithotripsy can be employed in refractory cases 2

TAKE HOME MESSAGE

  • Endoscopic ultrasound prior to the ERC helps to anticipate difficult procedures and avoid complications
  • 95% of all CBD stones can be managed effectively by endoscopic methods.3
  • Treatment of difficult CBD stones is accomplished by multimodal approach combining conventional methods such as sphincterotomy, use of extraction balloons and baskets and mechanical lithotripsy with newer techniques such as cholangioscopy guided laser/electro hydraulic lithotripsy.3

REFERENCES

  1. Stefanidis G et al. Endoscopic extraction of large stones, world journal of gastroenterology
  2. CLEVE CLIN J MED 1993; 60:38-42
  3. Trikudanathan G et al. Endoscopic management of CBD stones, world journal of Gastroenterology
Large CBD stone (1.7 mm)

Large CBD stone (1.7 mm)

CBD stone with empty Gall Bladder

CBD stone with empty Gall Bladder

 

 

 

 

 

 

 

 

 

Fluoroscopy showing large CBD stone

Fluoroscopy showing large CBD stone

Wide sphincterotomy with free flow of purulent bile

Wide sphincterotomy with free flow of purulent bile

 

 

 

 

 

 

 

 

 

Balloon sphincteroplasty with a 12-15 mm CRE balloon

Balloon sphincteroplasty with a 12-15 mm CRE balloon

Stone extraction with balloon catheter

Stone extraction with balloon catheter

 

 

 

 

 

 

 

 

 

A 7 Fr double pig tail stent in situ

A 7 Fr double pig tail stent in situ

7 Fr Double pigtail stent in situ

7 Fr Double pigtail stent in situ

  • 13 year, Female
  • Presented with severe pain in the abdomen for 20 days with vomiting and generalized itching without any jaundice
  • CT scan and USG abdomen showed a pancreatic head mass measuring 4.6 cm X 4.4 cm X 4.9 cm with Dilatation of Proximal CBD  with IHBRD and few sub centimeter sized mesenteric and paraaortic lymphnode
  • EUS revealed a large hypoechoic mass lesion measuring (4 cm X 3.5 cm) in the head of pancreas with a peripheral cystic component and central necrosis
  • EUS-FNA was performed with a 22 G needle under colour Doppler control (two pass) from the suspicious lesion in the pancreatic head mass and the peripheral cystic component and aspirated material was sent for cytological examination and immunohistochemistry study
  • Cytology report was suggestive of Small round cell tumor of pancreas

Expert Comments:

  • Small round cell tumor of the pancreas is a rare and highly aggressive neoplasm which is an often misdiagnosed neoplasm in children and adolescents.
  • The aggressiveness of the disease and propensity for serosal spread necessitates the accurate preoperative diagnosis for curative resection and determining the prognosis
  • Endoscopic ultrasound with guided biopsy of the tumor provides adequate samples for the cytology and immunohistochemistry of the tumor
  • Small round cell tumors express desmin that help to confirm the diagnosis on immunohistochemistry
  • Multidisciplinary approach involving  chemotherapy, extensive debunking surgery and abdominopelvic radiation have been reported to improve the survival of the patients

Take Home Message

  • Young adolescent patients presenting with pancreatic mass should be suspected of having small round cell tumor
  • There have been reported cases of failure to diagnose the small round cell tumor of pancreas preoperatively leading to suboptimal resection of the disease affecting the prognosis of the patients
  • However with endoscopic ultrasound guided biopsy of these tumors provides accurate diagnosis  preoperatively as well as assessment of locoregional nodal spread

References:

  1. Gerald WL, Rosai J. Case 2: Desmoplastic small round cell tumor with divergent differentiation. Pediatr Pathol.1989;9:177–83
  2. Lal DR, Su WT, Wolden SL, Loh KC, Modak S, La Quaglia MP. Results of multimodal treatment for desmoplastic round cell tumors. J Pediatr Surg. 2005; 40:251–5.
Pancreatic head mass

Pancreatic head mass

Dilatation of Proximal CBD  with IHBRD

Dilatation of Proximal CBD with IHBRD

 

 

 

 

 

 

 

 

Hypoechoic mass lesion in the head of pancreas

Hypoechoic mass lesion in the head of pancreas

Color doppler

Color doppler

 

 

 

 

 

 

 

 

 

EUS guided FNA

EUS guided FNA

Small round cell tumor of pancreas

Small round cell tumor of pancreas

  • 55 year old female
  • Patient was reffered to us for the favor of evaluation of suspected rectal mass seen on other imaging modalities
  • Colonoscopy showed a large submucosal lesion in the rectum about 4 cm from the anal verge
  • Rectal EUS –  A large hypoechoic 4 cms x 3 cms mixed echoic variegated lesion in the perirectal region, There was no evidence of hypoechoic nodes in the perirectal  region.
  • EUS guided FNA was then performed from the suspected lesion
  • Cytology report confirmed it to be a Rectal Benign Gastro intestinal stromal tumor

 

EXPERT COMMENTS:-

  • Endosonography of the rectal submucosal lesions help to assess tumor characteristics, obtain tumor histology and plan therapeutic option1
  • Features suggestive of Malignancy : 1
  1. Size greater than 4 cm
  2. Irregular outer margin
  3. Hypoechoic perirectal lymphnodes
  4. Echogenic foci
  5. Cystic spaces
  • EUS guided FNA and/or Tru Cut Biopsy are useful in the diagnostic evaluation and therapeutic plan in patients with rectal and perirectal lesion2

TAKE HOME MESSAGE:-

  • EUS and EUS guided FNA is a safe procedure for accurate diagnosis of the rectal submucosal region as well as evaluation of perirectal masses
  • Presence of perirectal malignant lymphomas and malignant GIST has been reported in literatures, which can be diagnosed on EUS-FNA
  • This helps to avoid unnecessary surgeries, having chance of anal sphincter-saving surgeries and timely administration of appropriate chemotherapy

REFERENCES:-

  1. Palazzo, L et al. Endosonographic features predictive of benign and malignant gastrointestinal stromal tumors. Gut 46:88-92, 2000
  2. Boo SJ et al. EUS guided fine needle aspiration and trucut needle biopsy for examination of rectal and perirectal lesions.Scand J Gastroentero.2011 Dec;46(12):1510-8
Colonoscopy showing Large rectal mass

Colonoscopy showing Large rectal mass

Endosonography showing the mass limited to the rectal wall

Endosonography showing the mass limited to the rectal wall

 

 

 

 

 

 

 

 

 

Colour Doppler showing  paucity of vascularity in the mass

Colour Doppler showing paucity of vascularity in the mass

EUS guided FNA of the rectal mass

EUS guided FNA of the rectal mass

  • 58 year old female
  • Recurrent jaundice (Total bilirubin – 8 mg %), recurrent fever with chills
  • known case of anastomotic stricture of the hepatico – duodenostomy site
  • EUS revealed dilated CHD and IHBR without any obvious hypo echoic mass lesion or stones.
  • Duodenoscopy- Hepatico-duodenostomy opening was identified in the duodenal bulb which appeared extremely small and edematous
  • Despite repeated attempts cannulation through the duodenal route was not possible
  • PTC rendezvous- A guide wire was passed through PTC route and sequential balloon dilatation was carried out of the stricture with an 8 mm balloon at 8 ATM pressure
  • Cholangiogram- Dilated bile duct with dilated right and left hepatic ductal system and a dominant narrowing at the anastomotic site
  • A 7 Fr double pigtail stent was placed in the right ductal system and a 5 Fr Teflon stent was placed in the left ductal system
  • Free flow of bile was seen from the placed stent at the end of the procedure.

EXPERT COMMENTS:-

  • In patients following choledochoduodenostomy, recurrent ascending cholangitis due to bile reflux is noted in 0-4%.
  • PTC combined with ERCP for rendezvous techniques provides a non-surgical treatment for complex biliary strictures.1
  • Endoscopic therapy shares an equal long-term success rate in comparison with primary surgery and hence is the preferred approach for the management of benign biliary stricture.2

TAKE HOME MESSAGE:-

  • Sphincterotomy and endoscopic balloon dilatation alone is not a reliable method of treating benign strictures.3
  • Per cutaneous treatment by balloon dilatation followed by short- to intermediate term stent placement appears to provide a more durable result.3
  • In refractory cases placement of a fully covered self-expandable metallic stent can be considered.

REFERENCES:-

  1. Quality in Endoscopy: ERCP, Munich 2011
  2. Medical journal armed forces india 68 (2012) 299e303
  3. Judah JR, Draganov PV. Endoscopic therapy of benign biliary strictures. World J Gastroenterol. 2007;13(26):3531e3539
Severe anastomotic stricture of the hepatico-duodenostomy site

Severe anastomotic stricture of the hepatico-duodenostomy site

Cholangiogram showing complete obstruction at anastomotic site

Cholangiogram showing complete obstruction at anastomotic site

 

 

 

 

 

 

 

 

 

 

PTC guided cannulation of bile duct

PTC guided cannulation of bile duct

Balloon dilatation of stricture at anastomotic site

Balloon dilatation of stricture at anastomotic site

 

 

 

 

 

 

 

 

 

7 Fr double pig tail stent placement in right ductal system and 5 Fr Teflon stent in left ductal system

7 Fr double pig tail stent placement in right ductal system and 5 Fr Teflon stent in left ductal system

Fluoroscopy showing bilateral  stents in situ

Fluoroscopy showing bilateral stents in situ

  • A 79 years old Female
  • Presented with pain in the abdomen radiating to back
  • No H/O Fever, vomiting, Jaundice or Weight Loss
  • USG Abdomen – Normal
  • CT Abdomen – Hypodense area in the body of pancreas, 9 mm peripancreatic node superior to the lesion, Fat stranding around the pancreas S/O Focal  Pancreatitis
  • EUS revealed an irregular hypoechoic lesion at the junction of genu and body of pancreas (3 cm X 1.8 cm) which was adherent to splenic artery with few hypoechoic sub centimeter lymph nodes in the peritumorous region. Lesion was obstructing the main pancreatic duct leading to dilated MPD in body and tail of pancreas.
  • EUS FNA with 22 G needle under color Doppler control was performed
  • Cytological examination report suggested it to be adenocarcinoma of pancreas

Expert Comments:

  • The accuracy of conventional US for diagnosing pancreatic tumors is only 50-70%1
  • Sensitivity for detection of  pancreatic cancer of less than 2 cm size with CT scan and EUS is 40 % and 100% respectively2
  • Sensitivity for detection of pancreatic cancers of size 2-3 cm with CT scan and EUS is 84% and 100% respectively2
  • EUS is highly sensitive in detecting invasion of major vascular structure along with small lymphnode metastasis

Take Home Message:

  • More than 50% of the pancreatic cancers are diagnosed at stage IV of the disease
  • Reason being the low sensitivity and specificity of CT, MRI and PET scan in detecting small tumors, vascular invasion and subcentimeter sized lymphnodes
  • Elderly patient’s should be suspected of pancreatic neoplasm in the event of recent onset diabetes, first episode of pancreatitis, weight loss and jaundice as in this case this old female ( 79 years) presented with features of pancreatitis without any other disease defining signs or symptoms

References:

  1. Fumihiko Miura, Tadahiro Takada, Hodaka Amano, Masahiro Yoshida, Shigeru Furui, Koji Takeshita. Diagnosis of pancreatic cancer. HPB, 2006; 8: 337-342
  2. Agarwal B, Abu-Hamda E, Molke KL, Correa AM, Endoscopic ultrasound-guided fine needle aspiration and multidetector spiral CT in the diagnosis of pancreatic cancer. Am J Gastroenterol. 2004 May;99(5):844-50
3 cm X 1.8 cm Pancreatic mass

3 cm X 1.8 cm Pancreatic mass

0.9 cm peripancreatic lymphnode

0.9 cm peripancreatic lymphnode

 

 

 

 

 

 

 

 

 

Pancreatic mass in close proximity of splenic artery

Pancreatic mass in close proximity of splenic artery

EUS guided FNA from the pancreatic mass

EUS guided FNA from the pancreatic mass