- 43/M patient with symptoms of dyspepsia – tobacco chewer and smoker.
- OGD Scopy revealed abnormal vascular pattern in the middle third of esophagus at 29cm from incisura. As per KUDO’s pit pattern classification it appears like IPCL – type III. Biopsy was taken from it for HPE; which is suggestive of an intraepithelial lesion – low grade squamous dysplasia.
- EMR performed with saline adrenaline injection and snare technique.
- Complete resection of the affected area was confirmed on post resection evaluation of the area.
Take home message:
Patient with risk factors such as tobacco consumption with dysplastic lesions in the esophagus are at very high risk of developing invasive cancers. Timely detection for intraepithelial lesions such as this case, will enable endoscopic curative resection. Importance of magnification and electronic chromoendoscopy can be appreciated in this case.
Abnormal vascular pattern in the middle lower third of esophagus
Biopsy was taken for HPE
EMR performed with saline adrenaline injection and snare technique
Complete resection of the affected area was confirmed
- 31/F had come to us with recent episode of severe acute pancreatitis of unknown etiology
- All conventional imaging, USG abdomen, CT Scan and MRI was inconclusive of etiology
- EUS revealed multiple imaging microliths and small stones in the gall bladder and CBD. Pancreas appeared edematous with peripancreatic fat stranding in the body and tail region
- Hence Endotherapy was performed and CBD was cleared off stones
- In view of the severity of the acute pancreatitis a NJ tube was then placed across the DJ flexure under endoscopic and fluoroscopic control
- NJ tube should allow enteral nutrition till the pancreatitis settles down
Take Home Message:
Patient with acute pancreatitis of unknown etiology should undergo EUS evaluation prior to any other imaging if all biochemistry is inconclusive of etiology.
EUS-ERCP Interface is the most reliable method for a certain diagnosis and optimum management for vast majority of Pancreato-Biliary diseases.
EUS also allows us to stratify the severity of pancreatitis and at the same time we can perform NJ tube placement for enteral nutrition as seen in this case.
EUS showed multiple imaging micoroliths and Small stones in the gall bladder and CBD
Edematous pancreas with peripancreatic fat standing in the body and tail.
Selective cannulation of CBD
Cholangiogram showed dilated CBD with small stones
Biliary sphincterotomy performed
A 7fr stent was placed in the CBD
- 06/M child came with a severe pain in abdomen for the last few days
- EUS revealed a dilated fusiform intra pancreatic portion of the CBD and MPD with large soft stones leading to dilated CBD and MPD with changes of chronic pancreatitis.
- ERCP was considered – Selective cannulation of MPD was achieved and pancreatogram confirmed EUS findings
- All the soft stones were cleared from the MPD and a 5 fr single pigtail stent was placed into the MPD
- In view of abnormal LFT a 7 fr stent was then placed in the CBD, patient’s symptoms subsided immediately after the procedure
Take Home Message:
Irrespective of the age of the patient even in children, EUS-ERCP interface allowed us to provide accurate diagnosis and optimum immediate treatment. Patient will require a definitive surgical intervention once Cholangitis and Pancreatitis subsides.
EUS showing dilated MPD with large soft stones
Selective cannulation of MPD was achieved
Pancreatogram showed fusiform dilatation with soft stones
All the soft stones were cleared from the MPD
cholangiogram showed ductal anomaly
5fr single pigtail stent placed in the MPD and 7fr stent was placed in the CBD
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