• 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  • Barium swallow is an outdated investigation and adds little to the diagnosis and management of patients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 After successful cannulation, the drain was progressively withdrawn, allowing retrograde therapeutic intervention.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

  • 70 year old female
  • Significant weight loss within last 6 months
  • Painless jaundice since 10 days, Associated with on and off Low grade fever
  • CT Abdomen and pelvis – 8 x 2.2 cm sized enhancing mass lesion in peri Ampullary region
    • Involvement of second part of duodenum with peri lesional fat stranding,
    • Abrupt cut off of CBD, Central and peripheral IHBRD, Dilated PD
  • EUS – A4 cm X 1.3 cm sized Ampullary mass with extension into the bile duct
    • Dilated Common Bile Duct and Main Pancreatic Duct
    • Echogenic bile was seen in the bile duct suggestive of purulent Cholangitis
    • A large hypoechoic node was seen in the pericholedochal region
    • IHBR appeared dilated in left lobe of liver.
    • No evidence of any hypoechoic lesions were seen in the left lobe of liver
  • ERC – Duodenoscopy revealed Ampullary growth
    • Selective cannulation of bile duct was achieved
    • Biliary Sphincterotomy was performed and multiple biopsies were taken
    • a 6 cm uncovered self expandable metallic stent was placed in the CBD
    • Free flow of purulent bile was seen from the placed stent
  • Diagnosis – Adenocarcinoma

Expert comments:-

  • Biliary SEMS (short intra pancreatic or covered) do not impede pancreatic resection and may be used for preoperative biliary drainage in patients with malignant CBD obstruction when surgical status is unknown.
  • Endoscopic treatment of adenomas of the major duodenal papilla is a safe, well tolerated alternative to surgical therapy1.
  • In expert hands, complications are rare and surgery is generally not required1.

Take home message:-

  • Acute ascending Cholangitis may be an initial presentation of Ampullary tumor and requires urgent biliary decompression with endoscopic biliary drainage2.
  • In purulent Cholangitis, plastic stent tends to block. In such cases Self Expandable Biliary Metal stents provide effective ductal decompression.
  • In resectable cases, the short biliary self expandable metal stent can be removed at the time of definite surgical intervention.
A 1.4cm X 1.3cm Ampullary mass

A 1.4cm X 1.3cm Ampullary mass

Echogenic bile was seen in the bile duct

Echogenic bile was seen in the bile duct

 

 

 

 

 

 

 

 

 

Ampullary tumor

Ampullary tumor

Biliary Sphincterotomy

Biliary Sphincterotomy

 

 

 

 

 

 

 

 

 

Free flow of purulent bile from SEMS

Free flow of purulent bile from SEMS

Multiple biopsies from the Ampullary growth

Multiple biopsies from the Ampullary growth

 

 

 

 

 

 

 

 

 

Cholangiogram showing dilated CBD with abrupt cutoff

Cholangiogram showing dilated CBD with abrupt cutoff

A 6 cm uncovered self expandable metallic stent

A 6 cm uncovered self expandable metallic stent

  • 74 years oild Female
  • Presenting with pain in the abdomen on and off and vomiting with pain radiating to back.
  • No History of weight loss or jaundice
  • CT Scan abdomen – 2.6×3.5×4.5 cm sized ill defined soft tissue lesion in retro peritoneum anterior to aorta and posterior to pancreas? Neoplasm? Lymphoma? Lymphnodes.Small cystic lesion involving distal body and tail of pancreas? Cystic neoplasm
  • PET CT – Poorly marginated  metabolically active soft tissue in retro pancreatic space
  • CA 19.9- 254.52 U/ml
  • EUS revealed an irregular hypoechoic solid-cystic exophytic lesion in the tail of the pancreas encasing the splenic vein. The mass extends posteriorly upto the aorta. In view of these findings EUS FNA was performed (two pass) from the suspicious lesion in the tail of pancreas and aspirated material was sent for cytological examination.
  • Cytological examination confirmed it to be low grade solid cystic neoplasm of pancreas

Expert Comments:

  • Most pancreatic neoplasms are classified as ductal adenocarcinomas because they show a ductal phenotype, making a ductal origin very likely.
  • Patients with three or more first-degree relatives with pancreatic cancer have a 14 to 32-fold increased risk of developing pancreatic cancer, and this risk is significant. 1
  • Endoscopic ultrasound (EUS) is one of the best available technologies to image the pancreas2 and  EUS has been  used to screen asymptomatic, apparently healthy, members of families in which there have already been several pancreatic cancers
  • Several studies have suggested increased sensitivity and specificity of endoscopic ultrasound (EUS) compared with other imaging modalities.
  • The greatest advantage of EUS is that it allows fine needle aspiration (FNA) of the tumor to provide a tissue diagnosis.

Take Home Message:

  • The identification and detection of pancreatic ductal adenocarcinoma at its beginning, preferably at preinvasive stage, improves patient survival.
  • The precursor lesions of pancreatic ductal adenocarcinomas include intraductal papillary mucinous neoplasms (IPMN) and Mucinous neoplasm, which are rare.
  • Pancreatic ductal neoplasias have been reported in 11% of patients of chronic pancreatitis, however patient’s age and duration of the disease does not correlate with the grade of such lesions.
  • Following were candidates for screening: First-degree relatives (FDRs) of patients with Pancreatic Cancers from a familial Panncreatic Cancer kindred with at least two affected FDRs; patients with Peutz-Jeghers syndrome; and p16, BRCA2 and hereditary non-polyposis colorectal cancer (HNPCC) mutation carriers with ≥ 1 affected FDR.
Solid-cystic mass in the tail of pancreas

Solid-cystic mass in the tail of pancreas

The mass encasing the aorta

The mass encasing the aorta

 

 

 

 

 

 

 

 

 

EUS guidd FNA from the suspicious mass lesion in the pancreas

EUS guidd FNA from the suspicious mass lesion in the pancreas

  • 48 year old male
  • H/O Abdominal pain radiating towards back since 6 month, last episode 15 days back
  • Associated with nausea and low grade fever
  • USG Abdomen – dilated pancreatic duct with calculus within
  • CT Abdomen – Acute pancreatitis with parenchymal calcifications, Dilated MPD with stones
  • EUS- massively dilated MPD (1.7 cm) in the head, body and tail region with a chain of calculi and filled with purulent materials
    • Side branch dilatation, atrophic pancreatic parenchyma in the head and body region
    • Few reactive nodes were seen
  • ERP- Duodenoscopy revealed a bulging ampulla with an impacted large pancreatic duct stone.
    • Precut sphincterotomy followed by selective cannulation of the MPD was achieved
    • Pancreatogram confirmed EUS findings. Pancreatic sphincterotomy was performed
    • MPD was swept with a stone extraction balloon catheter which showed extraction of large amount of purulent material with large stones and necrotic material
    • Two 7 Fr stents were placed in the MPD for free flow of pancreatic juice

Expert Comments

  • Endoscopic therapy alone was found to be successful in 72% of patients with a 68% symptomatic improvement1
  • 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 disease2
  • In one study Kozarek et al were able to show that surgery was avoided in 80% of patients who underwent ESWL. with decrease in narcotic use and reduction in hospitalizations2

Take Home Message

  • Endoscopic ultrasound mapping of pancreas prior to the endotherapeutic intervention provides adequate information regarding plan of management.
  • Endoscopic treatment of such a case of chronic calculous pancreatitis has significantly decreased morbidity due to surgical interventions in addition to decrease in hospital admissions
  • Pancreatic endotherapy has shown significant improvement in the endocrine and exocrine pancreatic insufficiency, evidenced by decrease in the requirement of insulin and switch to the oral hypoglycemic agents from the insulin dependence in our patients.
Endosonography showing Massively dilated MPD with stone and purulent material

Endosonography showing Massively dilated MPD with stone and purulent material

Duodenoscopy showing impacted pancreatic duct stone at the ampulla

Duodenoscopy showing impacted pancreatic duct stone at the ampulla

 

 

 

 

 

 

 

 

 

 

Cannulation of MPD after precut sphincterotomy of the pancreatic orifice

Cannulation of MPD after precut sphincterotomy of the pancreatic orifice

Pancreatogram showing dilated and irregular MPD with large stones

Pancreatogram showing dilated and irregular MPD with large stones

 

 

 

 

 

 

 

 

 

 

Pancreatic ductal clearance with stone extraction balloon catheter

Pancreatic ductal clearance with stone extraction balloon catheter

Placement of two 7 Fr pancreatic duct stents

Placement of two 7 Fr pancreatic duct stents

 

 

 

 

 

 

 

 

 

 

Fluoroscopy showing optimal placement of the pancreatic duct stent

Fluoroscopy showing optimal placement of the pancreatic duct stent

  • A 84 year old female, known diabetic and hypertensive
  • History of upper abdominal pain with low grade fever
  • Referred for evaluation of dilated CBD in a setting of cholelithiasis on other imaging studies with Normal Liver Function Tests
  • EUS – Dilated CBD with a 17 mm stone impacted in the lower CBD
  • Distended gall bladder without sludge and imaging microliths
  • Duodenoscopy- Small peri vaterian diverticulum with normal ampulla
  • ERC- Cholangiogram confirmed the EUS findings Biliary balloon dilatation was carried out with 12-15 mm CRE balloon Biliary Sphincterotomy was performed; free flow of purulent bile was seen  Stone extraction was carried out with stone extraction balloon catheter
  • In view of gall bladder in situ and purulent cholangitis despite a Sphincterotomy a 7 Fr double pig tail stent was placed to ensure free flow of bile

EXPERT COMMENTS

  • Elderly patients with long standing diabetes can present with mild or absent constitutional symptoms in spite of presence of large bile duct stones causing purulent cholangitis
  • Endoscopic extraction of large stones in the presence of a perivaterian diverticulum can be problematic and may lead to inadvertent complications in the presence of severe inflammatory process 1
  • Endoscopic Sphincterotomy followed by Large Balloon Dilatation are promising due to its safety and effective alternative technique for large stone therapy but in experienced hands1
  • Endoscopic mechanical lithotripsy can be employed in refractory cases 2

TAKE HOME MESSAGE

  • Endoscopic ultrasound prior to the ERC helps to anticipate difficult procedures and avoid complications
  • 95% of all CBD stones can be managed effectively by endoscopic methods.3
  • Treatment of difficult CBD stones is accomplished by multimodal approach combining conventional methods such as sphincterotomy, use of extraction balloons and baskets and mechanical lithotripsy with newer techniques such as cholangioscopy guided laser/electro hydraulic lithotripsy.3

REFERENCES

  1. Stefanidis G et al. Endoscopic extraction of large stones, world journal of gastroenterology
  2. CLEVE CLIN J MED 1993; 60:38-42
  3. Trikudanathan G et al. Endoscopic management of CBD stones, world journal of Gastroenterology
Large CBD stone (1.7 mm)

Large CBD stone (1.7 mm)

CBD stone with empty Gall Bladder

CBD stone with empty Gall Bladder

 

 

 

 

 

 

 

 

 

Fluoroscopy showing large CBD stone

Fluoroscopy showing large CBD stone

Wide sphincterotomy with free flow of purulent bile

Wide sphincterotomy with free flow of purulent bile

 

 

 

 

 

 

 

 

 

Balloon sphincteroplasty with a 12-15 mm CRE balloon

Balloon sphincteroplasty with a 12-15 mm CRE balloon

Stone extraction with balloon catheter

Stone extraction with balloon catheter

 

 

 

 

 

 

 

 

 

A 7 Fr double pig tail stent in situ

A 7 Fr double pig tail stent in situ

7 Fr Double pigtail stent in situ

7 Fr Double pigtail stent in situ