• A 15 year old male
  • C/O Pain in abdomen radiating to back, associated with vomiting, multiple episodes 8 months, last episode 1 month back
  • CT Abdomen – Changes of acute on chronic pancreatitis with markedly dilated MPD  Thinning of parenchyma, pseudocyst formation with fat stranding Multiple sludge balls with stricture of MPD in neck region Perigastric peripancreatic collaterals with splenic vein thrombosis
  • MRCP – Inflammatory stricture in pancreatic duct in genu with dilated PD and atrophied pancreas with multiple calculi
  • EUS- Dominant narrowing was seen in genu of pancreas
    • Dilatation of MPD with small soft stones and dilated side branches
    • Pancreatic parenchyma appeared atrophied but no calcification was noted.
    • Small chronic pseudocyst was seen in tail region measuring around 2×1 cm in size
  • ERP done with Stricture dilatation with 8mm balloon up to 7 atm pressure.
  • Soft stones were extracted using stone extraction balloon catheter.
  • Two 7 Fr stents were placed to ensure effective ductal clearance and sustain the stricture dilatation.
  • Patient was relieved of any further attacks of pancreatitis thereafter.

EXPERT COMMENTS-

  • EUS uses a higher frequency and eliminates the decreased image quality resulting from bowel gas or subcutaneous fat and offers greater image resolution.1
  • has superior sensitivity to other commonly used tests in the diagnosis of microlithiasis and sludge.1
  • Endoscopic sphincterotomy with stone retrieval combined with ESWL gives 60-90 % stone clearance.
  • Encouraging short- and long-term follow-up (5 years) results showing improvements in pain (77-100% and 54-86%, respectively) have been reported.2
  • Early diagnosis and treatment has

TAKE HOME MESSAGE-

  • Many cases of acute recurrent pancreatitis which have been labeled as idiopathic earlier, has been found to have some or other treatable pathology seen on endoscopic ultrasound.
  • EUS-Endotherapy protocol that is being practiced at Endoscopy Asia, has shown to be useful in definitive diagnosis of the etiology, assessment of feasibility of the endoscopic treatment and subsequent treatment in the same sitting.

References

  1. Dahan P, Andant C, Levy P, et al. Prospective evaluation of Endoscopic ultrasonography and microscopic examination of Duodenal bile in the diagnosis of cholecystolithiasis in 45 Patients with normal conventional ultrasonography. Gut;1996;38:277–81.
  1. Delhaye M, Arvanitakis M, Verset G, Cremer M, Deviere J. Long-term clinical outcome after endoscopic pancreatic ductal Drainage for patients with painful chronic pancreatitis. Clin Gastroenterol Hepatol 2004;2:1096-1106.
Large stone in MPDwith pancreatic atrophy

Large stone in MPD with pancreatic atrophy

Dilated MPD with soft stones

Dilated MPD with soft stones

 

 

 

 

 

 

 

 

 

Pancreatic stone extraction with balloon catheter

Pancreatic stone extraction with balloon catheter

Placement of two 7 FR Teflon stents in the pancreatic duct

Placement of two 7 FR Teflon stents in the pancreatic duct

  • 73 year old Male
  • Presented with complaints of on and off abdominal pain with recurrent episodes of self-limiting abdminal distention
  • CT scan of the abdomen showed a 2.7 cm X 2.3 cm polyp in the transverse colon
  • Ileo-colonoscopy showed a large pedunculated lipomatous polyp in the transverse colon which was resected with snare and cautery; Also seen were multiple adenomatous polyps in the region of hepatic flexure and transverse colon which were resected with hot biopsy forceps and snare and cautery
  • Histopathological examination confirmed the colonoscopic findings
  • Patient was advised surveillance after 1 year.

Expert Comments:

  • The reported incidence of colonic lipomas ranges from 0.2% to 4.4%1.
  • Lipomas of the large intestine are most commonly seen (in order of decreasing frequency) in the cecum, ascending colon, and sigmoid colon1.
  • The most common presentations of symptomatic patients with lipomas greater than 2 cm in size include abdominal pain, hemorrhage, diarrhea, or constipation2.
  • An accessible pedunculation and normal complete blood counts, blood chemistry, and carcinoembryonic antigen levels warrant endoscopic rather than surgical resection3.

Take Home Message:

  • There are reported incidence of co-existence of colonic lipomas with adenocarcinoma.
  • As in this case also multiple adenomas were detected in the presence of a large colonic lipoma.
  • There might be a correlation of the development of adenoma-carcinoma in the presence of a such lesions.
  • As the presenting patients are in their 60s, they must be followed up with yearly surveillance colonoscopy for at least 1st 3 years, after which the interval can be increased.

Referrences:

  1. Geetha Nallamothu, Douglas G. Adler. Large Colonic Lipomas. Gastroenterol Hepatol (N Y). Jul 2011; 7(7): 490–492
  2. Daniel J. Gould, Anne MorrisonKathleen R. Liscum, Eric J. Silberfein. A Lipoma of the Transverse Colon Causing Intermittent Obstruction: A Rare Cause for Surgical Intervention. Gastroenterol Hepatol (N Y). Jul 2011; 7(7): 487–490
Large colonic lipoma

Large colonic lipoma

Complete hemostasis at the resection margin

Complete hemostasis at the resection margin

 

 

 

 

 

 

 

 

 

Post resection 3 cm colonic lipoma

Post resection 3 cm colonic lipoma

Co-existing adenomatous polyp in the transverse colon

Co-existing adenomatous polyp in the transverse colon

 

 

 

 

 

 

 

 

 

Microscopic picture howing adipose tissue with normal mucosa (H & E staining)

Microscopic picture howing adipose tissue with normal mucosa (H & E staining)

Microscopic picture of the resected adenoma ( H & E staining)

Microscopic picture of the resected adenoma ( H & E staining)

  • A 58 year old female
  • Massive hemetemesis after a bout of vomiting associated with an episode of syncope
  • Blood pressure 80mm Hg (systolic), Pulse rate 120/min, and O2 saturation 98% on air.
  • Resuscitated with IV fluids.
  • OGD scopy- A linear tear of 1.5 cm just distal to Gastro-esophageal junction with an actively bleeding vessel.
  • Multiple haemostatic clip application with diluted saline adrenaline injection at the bleeding site.
  • Complete haemostasis achieved.
  • Patient was discharged the next day after an uneventful overnight hospital stay.

EXPERT COMMENTS-

  • Endoscopy in patients with upper GI bleeding is effective in diagnosing and treating most causes of Upper GI bleeding
  • Associated with a reduction in blood transfusion requirements and length of intensive care unit/total hospital stay.
  • Early endoscopy(within 24 hours of hospital admission) has a greater impact on length of hospital stay and requirements for blood transfusions.

TAKE HOME MESSAGE-

  • Mallory-Weiss tear is a common cause of upper gastro intestinal bleeding.
  • Nearly half of the patients have no antecedent symptoms and presents for the first time with upper gastrointestinal bleeding.
  • Endoscopic therapy is very effective and safe in producing haemostasis in these patients.
Mallory- Weiss tear

Mallory- Weiss tear

Multiple haemostatic clips ensuring complete hemostasis

Multiple haemostatic clips ensuring complete hemostasis

 

 

 

 

 

 

 

 

 

 

 

Injection of diluted saline adrenaline at bleeding site

Injection of diluted saline adrenaline at bleeding site

 

  • A 64 years old male,
  • Diagnosed Unresectable carcinoma of head of pancreas with severe obstructive jaundice
  • Biliary sphincterotomy done and the stricture dilated with 10Fr Soehendra dilator
  • Uncovered self-expandable 8cm Nitinol stent deployed across the stricture
  • After 3 months, patient developed cholangitis with gastric outlet obstruction.
  • Duodenoscopy revealed a stricture in the D1-D2 junction due to tumor overgrowth with
  • Near total occlusion of the previously placed metallic biliary stent due to tumor ingrowth.
  • Restenting of the bile duct done with a 10 cm self-expandable metallic biliary stent and
  • A 12 cm self-expandable pyloro-duodenal metallic stent was placed to relieve the gastric outlet obstruction.

Expert Comments:

  • Occlusion of self-expandable metallic biliary stent has been reported in approximately 5%-40% cases, mostly due to tumor ingrowth.
  • The management of stent occlusion involves a second stent insertion (plastic stent, covered metallic stent, uncovered metallic stent), mechanical cleaning and percutaneous drainage.
  • The type of stent is determined by the level of obstruction (hilar lesion have shorter stent patency time) and survival time (e.g. presence or absence of liver metastasis).
  • Mechanical cleaning with balloon is ineffective.
  • Approximately 5 % of the pancreatic neoplasms develop duodenal obstruction which can be relieved effectively by deploying a self-expandable pyloro-duodenal metallic stent with results comparable with surgical bypass.

Take Home Message:

  • Symptoms of cholangitis in a case of endoscopically palliated malignant obstructive jaundice with self-expandable metallic stents points towards occlusion of the placed stent
  • Restenting with either plastic or metallic sent has shown similar survival benefit,
  • Patients with longer survival time (absence of liver metastasis) should be offered restenting with metallic stents as plastic stents get blocked earlier requiring the need for repeated ERCP.
Precut sphincterotomy in a edematous ampulla

Precut sphincterotomy in a edematous ampulla

Cholangiogram showing distal CBD obstruction

Cholangiogram showing distal CBD obstruction

 

 

 

 

 

 

 

 

 

Self-expandable metallic biliary stent with free flow of dark bile

Self-expandable metallic biliary stent with free flow of dark bile

Complete blockage of the stent with tumor overgrowth and debris

Complete blockage of the stent with tumor overgrowth and debris

 

 

 

 

 

 

 

 

 

 

Cholangiogrm showing complete obstruction of the metallic biliary stent

Cholangiogrm showing complete obstruction of the metallic biliary stent

Restenting of the bile duct

Restenting of the bile duct

 

 

 

 

 

 

 

 

 

 

Pyloro-duodenal stent in place

Pyloro-duodenal stent in place

Fluoroscopy showing both the pyloro-duodenal stent and metallic biliary stent in situ

Fluoroscopy showing both the pyloro-duodenal stent and metallic biliary stent in situ

A 75 year old female presented to us with complaints of chronic anemia ( Hb – 5 gm%)  for last 3 years.  Despite on iron and folic acid supplements, she had to take multiple blood transfusions in the past. There was no history of malena but stool for occult blood was positive. Upper GI endoscopy and colonoscopy done elsewhere were showing only antral gastritis.  So a repeat OGD scopy was performed which showed features of classical gastric antral vascular ectasia (GAVE). In view of these findings argon plasma coagulation (APC) was carried out of the vascular ectasia in the pyloric antral region. Patient responded well to the treatment and rise in hemoglobin was observed.

Expert Comments:

GAVE syndrome is an important diagnosis to consider in older patients with severe anemia and occult or profuse gastrointestinal bleeding. The incidence of GAVE syndrome is especially high in the setting of heart, liver and kidney disease. The endoscopic appearance of GAVE is often mistaken as portal hypertensive gastropathy or antral gastritis for which the vast majority of GAVE syndromes are underdiagnosed.

Take home message:

The diagnosis of GAVE requires high degree of suspicion and confirmation by the high definition and precision endoscopic examination. For optimal management of the condition patient requires thorough fulguration of the telangiectatic sites with argon plasma coagulation ( APC), as any  left over lesion will continue to cause occult blood loss with failure of treatment. APC is an extremely safe treatment option for such superficial bleeding and risk of perforation is extremely low.

  1. Lorrenzo Fuccio et al. Diagnosis and management of gastric antral vascular ectasia.World J of Gastrointest endoscopy.2013 January 16;5(1):6-13
Gastric antral vascular ectasia showing typical watermelon appearance

Gastric antral vascular ectasia showing typical watermelon appearance

Argon plasma coagulation of the vascular ectasia

Argon plasma coagulation of the vascular ectasia

 

 

 

 

 

 

 

 

 

 

Completely fulgurated gastric antrum

Completely fulgurated gastric antrum

A  65  year  old  female  presented  to  us  with  bile  in  the  abdominal  drain  post  open  cholecystectomy  10  days  back.  The  drain  was  draning  almost  300-400  ml  of  bile  every  day.      Patient  had  mild  pain  in  the  abdomen  with  normal  LFT.  Therefore  patient  was  considered  for  endoscopic  retrograde  cholangiography  (ERC).  Selective  cannulation  of  CBD  could  be  achieved  only  after  precut  sphinchterotomy  and  5  Fr  pancreatic  stenting.  Guidewire  could  be  negotiated  deep  into  the  right  ductal  system  with  difficulty.  Cholangiogram  revealed  near  total  cut-off  at  the  proximal  CBD  with  resultant  dilatation  of  right  and  left  hepatic  ductal  system.  The  level  of  the  iatrogenic  stricture  was  approximately  1  cm  distal  to  the  confluence  of  right  and  left  hepatic  duct.  Attempt  to  dilate  the  stricture  was  not  possible  due  to  severity  of  stricture,  therefore  a  5  Fr  plastic  stent  was  placed  in  the  bileduct.  The  drain  output  though  reduced,  it  was  not  completely  nil,  and  was  draining  approximately  50-100ml  per  day.  Patient  was  considered  again  for  endotherapy.  The  5  Fr  stent  was  removed  and  repeat  attempt  of  dilatation  was  successful  upto10  Fr  Soehendra  dilator.  A  10  Fr  Teflon  stent  was  placed  in  the  bile  duct  which  showed  free  flow  of  bile.  The  bile  leak  completely  stopped  after  7  days  and  the  drain  was  removed.

Expert  Comments:

Endoscopic  management  of  the  iatrogenic  biliary  stricture  has  been  a  gold  standard  in  the  modern  era.  With  advances  in  the  procedural  expertise  as  well  as  technical  advances,  complex  strictures  can  also  be  managed  endoscopically.  Complex  strictures  may  require  multiple  sessions  of  endotherapy  with  placement  of  gradually  increasing  diameter  dilators  and  plastic  stents.  Caution  must  be  taken  to  avoid  aggressive  dilatation  of  the  stricture,  especially  in  case  of  iatrogenic  stricture,  that  may  cause  disruption  of  the  stricturous  site.

Take  home  message: 

Almost  90  percent  of  iatrogenic  bile  duct  injuries  can  be  managed  endoscopically.  Now  even  complete  transection  of  the  bile  duct  can  be  managed  by  Extra-anatomical  endoscopic-radiological  reconstruction  technique1.  In  refractory  cases  patients  can  be  managed  with  fully  covered  metallic  biliary  stenting  which  can  be  removed  at  a  later  stage2.  Placement  of  fully  covered  metal  biliary  stents  will  perhaps  reduce  multiple  endoscopic  interventions  and  provide  sustained  effective  dilatation.  These  stents  can  be  removed  after  a  period  of  6  months.  Hence,  patient  with  iatrogenic  biliary  leak  or  injury  should  undergo  an  attempt  of  Endotherapy  as  a  first  line  of  management.

References:

  1. Gianfranco   Extra-anatomical  endoscopic-radiological  reconstruction  of  iatrogenic  complete  transection  of  common  bile  duct.  Presenteed  at  Digestive  Disease  Week,  May  19-21,  Florida,Orlando
  2. Baron   Covered  self  expandable  metal  stents  for  benign  biliary  disease.  Current  Opin  Gastroenterology  2011  May;27(3)262-7 
Precut  sphinchterotomy  and  prophylactic  pancreatic  stenting  prior  to  bile  duct  cannulation

Precut sphinchterotomy and prophylactic pancreatic stenting prior to bile duct cannulation

Cholangiogram  showing  complete  obstruction  to  at  the  level  of  CHD

Cholangiogram showing complete obstruction to at the level of CHD

 

 

 

 

 

 

 

 

 

 

5  Fr CBD  stent  in  situ  with  free  flow  of  bile

5 Fr CBD stent in situ with free flow of bile

5 Fr stent removed

5 Fr stent removed

 

 

 

 

 

 

 

 

 

Stricture  being  dilated  with  a  10  Fr  Soehendra  dilator

Stricture being dilated with a 10 Fr Soehendra dilator

10  Fr  biliary  stent  in  place  with  free  flow  of  bile

10 Fr biliary stent in place with free flow of bile

A 27 years old female, presented to us with recurrent pain in abdomen radiating to back for 2 months. It was associated with vomiting. Blood investigations were suggestive of normal CBC and LFT but persistently increased amylase (340 IU/L) and lipase (214 IU/L) levels. USG and CT scan abdomen was suggestive of bulky pancreas with dilated pancreatic duct. Patient was being treated conservatively without any relief for last 2 months. Patient was diagnosed as idiopathic recurrent pancreatitis by the treating physician. Patient was considered for endoscopic ultrasound to evaluate the etiology of the pancreatitis and to map the pancreas regarding the parenchymal and ductal morphology. EUS revealed a dilated MPD throughout its length with soft stones in the head region. Parenchymal atrophy was seen in body and tail. In view of these findings patient underwent ERCP and wide pancreatic sphincterotomy was then performed and extraction of pancreatic duct stones were done with stone extraction balloon catheter. Complete ductal clearance was achieved. In view of short segment narrowing in the pre-papillary part of MPD, a 10 Fr Teflon stent was placed. Free flow of pancreatic juice was seen. Placed pancreatic stent was removed after three months. Patient is completely asymptomatic thereafter.

Expert Comments: EUS provides the accurate real time imaging of the pancreatic parenchyma and pancreatic duct. All pancreatitis cases should undergo endoscopic ultrasound for the evaluation of the etiology of pancreatitis as well as the examination of the pancreatic parenchyma and ductal status. EUS has the highest sensitivity and specificity, when compared to all other imaging modalities, to detect small soft stones in the pancreatic duct and small pancreatic masses (less than 2 cm) which cause obstruction of the pancreatic duct and cause initial attack of pancreatitis. EUS-ERCP interface protocol does provide the required therapeutic intervention for the etiology of pancreatitis in the same sitting.

Take home message: This case was labeled as idiopathic recurrent pancreatitis initially and was being treated symptomatically for approximately 2 months without any relief. As you can see here that an appropriate approach with EUS evaluation of etiology of acute pancreatitis, the ductal and parenchymal study allowed effective endoscopic treatment for this young patient. Hence it is an appeal to all clinicians that even after the first of episode of pancreatitis, patient should be subjected for EUS evaluation. In this case as there were soft stones, endoscopic stone extraction could be performed easily, however, if patient has hard stones in the pancreatic duct, then patient may require ESWL (Extracorporeal Shockwave Lithotripsy).

EUS showing dilated Pancreatic Duct ( 9.2 mm) with parenchymal atrophy

EUS showing dilated Pancreatic Duct ( 9.2 mm) with parenchymal atrophy

EUS showing dilated MPD with stones within

EUS showing dilated MPD with stones within

 

 

 

 

 

 

 

 

 

Fluorosscopy showing severely dilated pancreatic duct with a filling defect at the head of pancreas

Fluorosscopy showing severely dilated pancreatic duct with a filling defect at the head of pancreas

Pancreatic duct clearance done with removal of soft stones

Pancreatic duct clearance done with removal of soft stones

 

 

 

 

 

 

 

 

 

Pancreatic stent insitu showing free flow of  pancreatic juice

Pancreatic stent insitu showing free flow of
pancreatic juice

A 19 year old male was referred for endotherapy with diagnosed complex pancreatic pseudocyst, one at the head and one at the tail of pancreas, not resolving for last 8 months. EUS revealed a large 8cm X 8cm pseudocyst at the head of pancreas leading to dilated MPD in body and tail with a small irregular 4 cm x 3.5 cms pseudocyst at the tail. EUS guided cysto-duodenostomy was performed for the head pseudocyst and to decompress the pancreatic ductal system pancreatic duct stenting was performed. Pancreatogram did not reveal any ductal communication with the tail Pseudocyst and therefore EUS guided tail pseudocyst aspiration was carried out with a 19 G needle under colour Doppler control. Follow up USG after 1 month showed complete resolution of both the pseudocysts and patient was relieved of abdominal symptoms.

 

Expert Comments:

EUS guided pancreatic Pseudocyst drainage is less invasive, less morbid with least complication and highest efficacy ratesin draining the pseudocyst. EUS-GD has specific advantages ofdistinguishing pancreatic pseudocyst from other abdominal fluid collections, determine the nature of content of pseudocyst, reduce the risk of bleeding with the use of colour Doppler.  Also for non-bulging pseudocysts and high risk patients, such as patients with portal hypertension, EUS-GD is mandatory

 

Take Home Message:

 

Recently at the National Conference of Indian Society of Gastroenterology, I was given a topic to talk on role of EUS in bulging Pseudocyst and there I had conveyed that, since the last 14 years eversince we pioneered EUS guided Interventions in India, we have always resorted to EUS guided drainage of symptomatic Pseudocyst, be it trans-duodenal, trans-gastric, trans-esophageal or trans-jejunal. Therefore, I would urge my colleagues to prefer EUS guided drainage rather than blind endoscopic drainage as we all know that the complication rates, without EUS guidance is high. In December, 2013 I would like to make a comment that almost all (98%) symptomatic pseudocysts can now be effectively managed with minimal or no complications with EUS guided intervention and we feel that patient does not require Laparoscopic or Open Surgery for that in today’s day and age anymore.

MRCP showing the Pancreatic Head  and tail Pseudocyst

MRCP showing the Pancreatic Head and tail Pseudocyst

EUS picture of the Pancreatic Head Pseudocyst showing Homogenous clear content

EUS picture of the Pancreatic Head Pseudocyst showing Homogenous clear content

 

 

 

 

 

 

 

 

 

 

EUS Picture Showing smaller Pancreatic Tail Pseudocyst

EUS Picture Showing smaller Pancreatic Tail Pseudocyst

Fluoroscopy showing Dilated Pancreatic Duct Without any communication to the TailPseudocyst with 8Fr Double Pigtail stent in situ

Fluoroscopy showing Dilated Pancreatic Duct Without any communication to the TailPseudocyst with 8Fr Double Pigtail stent in situ

 

 

 

 

 

 

 

 

 

 

Endoscopic View Showing Free Flow of Cyst Fluid and Pancreatic Juice

Endoscopic View Showing Free Flow of Cyst Fluid and Pancreatic Juice

Fluoroscopy Showing the 8Fr Double Pigtail stent PostCysto-duodenostomy for Pancreatic Head Pseudocystand pancreatic duct stent

Fluoroscopy Showing the 8Fr Double Pigtail stent PostCysto-duodenostomy for Pancreatic Head Pseudocystand pancreatic duct stent

 

 

 

 

 

 

 

 

 

 

EUS guided Aspiration of  Pancreatic Tail Pseudocyst

EUS guided Aspiration of Pancreatic Tail Pseudocyst

EUS showing Completely Aspirated Pancreatic Tail Pseudocyst

EUS showing Completely Aspirated Pancreatic Tail Pseudocyst