- A 49 yrs female patient was sent to us for the favor of endoscopic palliation of obstructive jaundice. Patient is a known operated case of ca stomach in the past with Roux-en-y anastomosis.
- Now patient has severe cholangitis and cholestatic symptoms hence endoscopic palliation was considered.
- Endoscopic evaluation of the stomach showed oedematous stomach with patent g-j.Scope could be passed across all the loops of roux-en-y anastomosis, but due to a very long afferent loop even enteroscopic ERC was not feasible and hence EUS guided approach was considered.
- EUS showed extensive ascites and few liver mets and large mass and massively dilated system.
- In view of these findings, EUS -guided Hepatico-Gastrostomy was performed.
- EUS showed a dilated left hepatic duct and hence EUS guided needle puncture of the Left hepatic duct was performed. The tract was sequentially dilated with cystotomes to facilitate stent placement.
- A self expandable partially covered Giobor stent 10 cms and free flow of infected bile was seen from the stent in the stomach.
Take Home Message:
In cases where traditional ERC and biliary stenting is not feasible due to altered anatomy due to surgery or when PTC drainage too is not feasible due to ascites and liver mets, this unique technique of EUS guided Hepatico-gastrostomy allows us to decompress the obstructed biliary system and palliate cholestatic symptoms. First EUS guided Choledochoduodenostomy was performed by us was in 2001 and since then the technology and techniques have evolved.
Stomach showed edematous with patent G-J
Scope could be passed across all the loops of Roux-en-y anastomosis
EUS showed extensive ascites and few liver mets
EUS showed large mass and massively dilated system
EUS -guided hepatico-gastrostomy was performed
Fluoroscopy showed dilated left hepatic duct
Left hepatic duct was punctured and sequentially dilated with cystotome
A self expandable partially covered Giobor stent 10 cms and free flow of infected bile was seen from the stent.
- 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