• 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.
  • A 27 year old female presented with progressive dysphagia to liquids and weight loss of 5 kilos
  • past and family history- Unremarkable
  • Blood profile – normal
  • Barium study – “Parrot beak” appearance suggestive of achalasia cardia
  • High resolution manometry – Type 2 achalasia cardia
  • Patient had undergone esophageal balloon dilatations up to 12mm twice with no relief in symptom.
  • We elected to perform Per Oral Endoscopic Myotomy (POEM).

Expert comments

  • Adequate dilatation with 30mm TTS balloon is required for achalasia cardia
  • High Resolution Manometry is a must in all patients with dysphagia in whom OGD is normal
  • Barium swallow is an outdated investigation and adds little to the diagnosis and management of patients

Take home message

  • High Resolution Manometry is an excellent tool in diagnosing the various subtypes of achalasia cardia and the treatment should be tailor made accordingly
  • POEM (Per oral endoscopic myotomy) is a definitive novel endoscopic minimally invasive surgery compared to conventional Heller’s cardiomyotomy

A 65 years old Male

Presented with severe obstructive jaundice (Total bilirubin – 21mg %) associated with fever and chills

CT scan suggestive of a right lobe of liver mass

EUS – Stricturous lesion at the CHD leading to massively dilated right and left hepatic ducts and IHBR dilatation

Deep cannulation of the stricturous area of the CBD could not be achieved endoscopically.

Therefore PTC guided internalization was attempted which was not successful and a 8.5 Fr external drainage catheter was placed for biliary decompression

Repeat attempt of internalization was done after 3 days and guidewire could be negotiated across the stricture but the catheter could not be negotiated across.

In view of these findings PTC rendezvous with parallel cannulation alongside the drain was attempted with a sphincterotome cannula. After successful cannulation, the drain was progressively withdrawn, allowing retrograde therapeutic intervention.

ERC revealed hilar stricture with dilated right and left hepatic  duct and the distal CBD appeared dilated suggestive of a cholangiocarcinome in a setting of choledochal cyst.

Biliary brushing confirmed it to be a cholangiocarcinoma. A 10 cm self expandable metallic biliary stent was placed in the right hepatic duct. Free flow of bile seen from the placed stent.

Expert Comments:

Choledochal cyst complicated to cholangiocarcinoma in approximately 26 %.

PTC Rendezvous with Parallel cannulation is straightforward and effective, especially in cases of long standing cholestasis leading to edema at the stricturous site preventing antegrade cannulation.

Hilar strictures are challenge for stenting as infectious complications make the stricture more edematous and difficult to cannulate.

A complete Sphincterotomy with multiple stenting is necessary for adequate drainage of the bile, thus necessitating the need for endoscopic approach as compared to the PTC internalization

Take Home Message:

As hilar strictures are more for infectious complications. Therefore biliary decompression by temporary external drainage is necessary to facilitate subsequent intervention.

Cholangiocarcinoma complicating the choledochal cyst presents at an advanced stage as compared to the denovo cholangiocarcinoma, as in this case at the  presentation patient had wide spread hepatic involvement.

PTC guided External drainage with a 8.5 Fr Catheter

PTC guided External drainage with a 8.5 Fr Catheter

PTC rendezvous with Parallel cannulation of CBD across the stricture

PTC rendezvous with Parallel cannulation of CBD across the stricture

 

 

 

 

 

 

 

 

 

ERC showing hilar stricture with Type I choledochal cyst

ERC showing hilar stricture with Type I choledochal cyst

Self expandable metallic biliary stent in situ

Self expandable metallic biliary stent in situ

 

 

 

 

 

 

 

 

 

Fluoroscopy showing Self expandable metallic biliary stent in situ

Fluoroscopy showing Self expandable metallic biliary stent in situ

  • A 33 years old Male
  • Presented with recurrent attacks of pancreatitis 3 episodesin last 2 months
  • EUS : CBD and Gall bladder.
  • MPD appeared dilated (4 mm) in the head region with prepapillary narrowing of the MPD and dilated side branches.  A small stone and few concrements were seen in the prepapillary portion of the MPD.  Extensive  parenchymal calcification was seen in the head and body of the pancreas with atrophy of pancreatic parenchyma in the tail region.  A pseudocyst ( 17 mm X 12 mm) was seen in the body region communicating with the MPD.
  • ERP- Pancreatogram revealed dilated and irregular MPD with a cystic collection in the body region with contrast leak at the tail region pancreatic sphincterotomy was performed.  MPD was swept with stone extraction balloon catheter which showed protein plugs and soft stones  a 7 fr double pigtail stent was then placed to ensure ductal decompression.
  • Patient was completely asymptomatic in the following 3 months when the placed stent was removed. No subsequent episode of pancreatitis was noted in the 2 year follow-up period

Expert Opinion:

  • Pancreatic pseudocysts complicate the course of CP in 20% to 40% of case
  • Pseudocyst drainage should be considered for symptomatic lesions, infections and/or progressive enlargement even if asymptomatic
  • avoid drainage of cystic neoplasms and noninflammatory fluid collections.
  • EUS does distinguishes  between inflammatory and non inflammatory fluid collections and the malignant potentials of the cystic lesions
  • Endoscopic therapy is successful in closing the leak in approximately 60% of patients

Take Home Message

  • Chronic pseudocysts rarely resolve on conservative management and cause recurrent attack of acute on chronic pancreatitis if left untreated
  • Endoscopic ultrasound characterizes the nature of the cyst and the etiology of chronic pancreatitis that guides the treatment plan
EUS showing pancreatic pseudocyst with pancreatic ductal leak

EUS showing pancreatic pseudocyst with pancreatic ductal leak

EUS showing pancreatic head calcification

EUS showing pancreatic head calcification

 

 

 

 

 

 

 

 

 

 

Pancreatogram showing dilated MPD with pseudocyst and ductal leak

Pancreatogram showing dilated MPD with pseudocyst and ductal leak

Pancreatic ductal stone cleared with balloon catheter

Pancreatic ductal stone cleared with balloon catheter

 

 

 

 

 

 

 

 

 

 

Pancreatic stent in situ

Pancreatic stent in situ

 

 

 

 

  • 61 year old female
  • 6 month history of intermittent rectal bleeding, peri anal pain and low grade fever
  • No red flag signs
  • Past medical history -unremarkable
  • On Examination – No Abnormality Detected
  • Blood Reports – Hb -12.1 gm/dl, WBC- 6000 mm3, Platelet- 238 mm3, CRP- 17.4mg/L, ESR- 77
  • CT Scan Abdomen and Pelvis – circumferential wall thickening of the rectum and distal 7cm of ileum, multiple peri portal, mediastinal, Hilar and retro peritoneal lymph nodes.
  • Colonoscopy –  A large exophytic ulcerated lesion at the ileo-caecal region
        • extending to the terminal ileum with thickened abnormal mucosa of the rectum
        • multiple biopsies were taken for histology and Immuno Histo Chemistry
  • Rectal EUS- circumferential Hypoechoic wall thickening involving the mucosal layer.
  • Diagnosis – Diffuse large B cell Non Hodgkin’s Lymphoma

Expert comments:-

  • 70% of colonic lymphomas are proximal to the hepatic flexure
  • Secondary vs. primary colonic lymphomas carry a poor prognosis
  • Immuno Histo Chemistry is essential in accurate diagnosis of the nature of lymphoma

Take home message:-

  • The most common histological subtype occurring in the colon and rectum is diffuse large B-cell lymphoma with frequency ranging from 47%-81%
  • There is a higher chance of GI lymphomas in patients with HIV, IBD and following organ transplantation
  • A good histo- pathologist is essential in diagnosing unusual colonic lesions
Large exophytic lesion in ileo-ceacal region

Large exophytic lesion in ileo-ceacal region

Biopsy for histology and IHC

Biopsy for histology and IHC

 

 

 

 

 

 

 

 

 

NBI view showing exophytic mass

NBI view showing exophytic mass

Hypoechoic wall thickening involving the mucosal layer

Hypoechoic wall thickening involving the mucosal layer