• 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.

• 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• 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.

 

 

 

 

 

 

 

 

 

 

• 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• 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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• 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