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
- A 37 year old patient with known alcohol excess
- Admitted with early satiety, abdominal pain and weight loss
- Serum Amylase, Lipase – Normal
- Routine Hematology, Biochemistry profile- Normal
- US/ CT scan – Large pseudocyst in the body of the pancreas compressing the stomach
- EUS- Large pseudocyst in the body of pancreas with debris++ and no obvious communication with MPD.
Take home message –
- Infected pseudocyst seldom resolves with conservative treatment
- WOPN can be treated successfully with SEMS placement and endoscopic necrosectomy
- Surgical necrosectomy and cysto gastrostomy are much more morbid procedures than endoscopic approach
Expert comments –
- EUS guided Drainage can be performed for the cases which are not amenable to conventional endoscopic transmural drainage without any increased risks. ( Kahaleh et al)
- Conventional endoscopic transmural drainage is possible only in 57% cases compared to 100%
efficacy for EUS guided drainage (Varadarajulu et al, 2007)
- The rate of technical success of the drainage was significantly higher for the EUS group (94 %) than for the CTD group (72 %)
EUS image of large pseudocyst with debris
EUS guided cyst puncture
Xray showing SEMS and pig tail stent in the pseudocyst
- 53 years old Male
- Complaining of Pain in the abdomen – 2 months without any ither constitutional symptoms
- CT Abdomen – Multiple well defined nodular lesions in both lobes of liver
- MRI abdomen – Multiple bi lobar liver lesions, largest measuring 2.5 cm in segment IV A
- PET CT- SRS expressing hypo dense lesion in both lobes of liver and in gastrohepatic, para-aortic nodes
- CT guided biopsy of liver lesion – Neuro Endocrine Tumor grade II
- chromogranin – 2325 ng/ml ( Normal Less than 36 ng/ml)
- Endoscopic ultrasound of the pancreato-biliary system was performed to find out the primary site of the tumor
A single round hypoechoic lesion measuring 12 mm X 12 mm was seen at the junction of genu and body of pancreas.
No other lesion could be seen in the pancreas.
MPD appeared normal.
Multiple round hypoechoic lesions were seen in the left lobe of liver suggestive of metastatic tumor deposits.
No evidence of nodes or free fluids seen.
- Endoscopic ultrasound has 100 % sensitivity and specificity for pancreatic lesions of size less than 20 mm which are not detectable in any other imaging modalities including PET-CT.
Hypoechoic lesion measuring 12 mm X 12 mm was seen at the junction of genu and body of pancreas
Multiple round hypoechoic lesions were seen in the left lobe of liver