• 13 year, Female
  • Presented with severe pain in the abdomen for 20 days with vomiting and generalized itching without any jaundice
  • CT scan and USG abdomen showed a pancreatic head mass measuring 4.6 cm X 4.4 cm X 4.9 cm with Dilatation of Proximal CBD  with IHBRD and few sub centimeter sized mesenteric and paraaortic lymphnode
  • EUS revealed a large hypoechoic mass lesion measuring (4 cm X 3.5 cm) in the head of pancreas with a peripheral cystic component and central necrosis
  • EUS-FNA was performed with a 22 G needle under colour Doppler control (two pass) from the suspicious lesion in the pancreatic head mass and the peripheral cystic component and aspirated material was sent for cytological examination and immunohistochemistry study
  • Cytology report was suggestive of Small round cell tumor of pancreas

Expert Comments:

  • Small round cell tumor of the pancreas is a rare and highly aggressive neoplasm which is an often misdiagnosed neoplasm in children and adolescents.
  • The aggressiveness of the disease and propensity for serosal spread necessitates the accurate preoperative diagnosis for curative resection and determining the prognosis
  • Endoscopic ultrasound with guided biopsy of the tumor provides adequate samples for the cytology and immunohistochemistry of the tumor
  • Small round cell tumors express desmin that help to confirm the diagnosis on immunohistochemistry
  • Multidisciplinary approach involving  chemotherapy, extensive debunking surgery and abdominopelvic radiation have been reported to improve the survival of the patients

Take Home Message

  • Young adolescent patients presenting with pancreatic mass should be suspected of having small round cell tumor
  • There have been reported cases of failure to diagnose the small round cell tumor of pancreas preoperatively leading to suboptimal resection of the disease affecting the prognosis of the patients
  • However with endoscopic ultrasound guided biopsy of these tumors provides accurate diagnosis  preoperatively as well as assessment of locoregional nodal spread

References:

  1. Gerald WL, Rosai J. Case 2: Desmoplastic small round cell tumor with divergent differentiation. Pediatr Pathol.1989;9:177–83
  2. Lal DR, Su WT, Wolden SL, Loh KC, Modak S, La Quaglia MP. Results of multimodal treatment for desmoplastic round cell tumors. J Pediatr Surg. 2005; 40:251–5.
Pancreatic head mass

Pancreatic head mass

Dilatation of Proximal CBD  with IHBRD

Dilatation of Proximal CBD with IHBRD

 

 

 

 

 

 

 

 

Hypoechoic mass lesion in the head of pancreas

Hypoechoic mass lesion in the head of pancreas

Color doppler

Color doppler

 

 

 

 

 

 

 

 

 

EUS guided FNA

EUS guided FNA

Small round cell tumor of pancreas

Small round cell tumor of pancreas

  • 55 year old female
  • Patient was reffered to us for the favor of evaluation of suspected rectal mass seen on other imaging modalities
  • Colonoscopy showed a large submucosal lesion in the rectum about 4 cm from the anal verge
  • Rectal EUS –  A large hypoechoic 4 cms x 3 cms mixed echoic variegated lesion in the perirectal region, There was no evidence of hypoechoic nodes in the perirectal  region.
  • EUS guided FNA was then performed from the suspected lesion
  • Cytology report confirmed it to be a Rectal Benign Gastro intestinal stromal tumor

 

EXPERT COMMENTS:-

  • Endosonography of the rectal submucosal lesions help to assess tumor characteristics, obtain tumor histology and plan therapeutic option1
  • Features suggestive of Malignancy : 1
  1. Size greater than 4 cm
  2. Irregular outer margin
  3. Hypoechoic perirectal lymphnodes
  4. Echogenic foci
  5. Cystic spaces
  • EUS guided FNA and/or Tru Cut Biopsy are useful in the diagnostic evaluation and therapeutic plan in patients with rectal and perirectal lesion2

TAKE HOME MESSAGE:-

  • EUS and EUS guided FNA is a safe procedure for accurate diagnosis of the rectal submucosal region as well as evaluation of perirectal masses
  • Presence of perirectal malignant lymphomas and malignant GIST has been reported in literatures, which can be diagnosed on EUS-FNA
  • This helps to avoid unnecessary surgeries, having chance of anal sphincter-saving surgeries and timely administration of appropriate chemotherapy

REFERENCES:-

  1. Palazzo, L et al. Endosonographic features predictive of benign and malignant gastrointestinal stromal tumors. Gut 46:88-92, 2000
  2. Boo SJ et al. EUS guided fine needle aspiration and trucut needle biopsy for examination of rectal and perirectal lesions.Scand J Gastroentero.2011 Dec;46(12):1510-8
Colonoscopy showing Large rectal mass

Colonoscopy showing Large rectal mass

Endosonography showing the mass limited to the rectal wall

Endosonography showing the mass limited to the rectal wall

 

 

 

 

 

 

 

 

 

Colour Doppler showing  paucity of vascularity in the mass

Colour Doppler showing paucity of vascularity in the mass

EUS guided FNA of the rectal mass

EUS guided FNA of the rectal mass

  • 58 year old female
  • Recurrent jaundice (Total bilirubin – 8 mg %), recurrent fever with chills
  • known case of anastomotic stricture of the hepatico – duodenostomy site
  • EUS revealed dilated CHD and IHBR without any obvious hypo echoic mass lesion or stones.
  • Duodenoscopy- Hepatico-duodenostomy opening was identified in the duodenal bulb which appeared extremely small and edematous
  • Despite repeated attempts cannulation through the duodenal route was not possible
  • PTC rendezvous- A guide wire was passed through PTC route and sequential balloon dilatation was carried out of the stricture with an 8 mm balloon at 8 ATM pressure
  • Cholangiogram- Dilated bile duct with dilated right and left hepatic ductal system and a dominant narrowing at the anastomotic site
  • A 7 Fr double pigtail stent was placed in the right ductal system and a 5 Fr Teflon stent was placed in the left ductal system
  • Free flow of bile was seen from the placed stent at the end of the procedure.

EXPERT COMMENTS:-

  • In patients following choledochoduodenostomy, recurrent ascending cholangitis due to bile reflux is noted in 0-4%.
  • PTC combined with ERCP for rendezvous techniques provides a non-surgical treatment for complex biliary strictures.1
  • Endoscopic therapy shares an equal long-term success rate in comparison with primary surgery and hence is the preferred approach for the management of benign biliary stricture.2

TAKE HOME MESSAGE:-

  • Sphincterotomy and endoscopic balloon dilatation alone is not a reliable method of treating benign strictures.3
  • Per cutaneous treatment by balloon dilatation followed by short- to intermediate term stent placement appears to provide a more durable result.3
  • In refractory cases placement of a fully covered self-expandable metallic stent can be considered.

REFERENCES:-

  1. Quality in Endoscopy: ERCP, Munich 2011
  2. Medical journal armed forces india 68 (2012) 299e303
  3. Judah JR, Draganov PV. Endoscopic therapy of benign biliary strictures. World J Gastroenterol. 2007;13(26):3531e3539
Severe anastomotic stricture of the hepatico-duodenostomy site

Severe anastomotic stricture of the hepatico-duodenostomy site

Cholangiogram showing complete obstruction at anastomotic site

Cholangiogram showing complete obstruction at anastomotic site

 

 

 

 

 

 

 

 

 

 

PTC guided cannulation of bile duct

PTC guided cannulation of bile duct

Balloon dilatation of stricture at anastomotic site

Balloon dilatation of stricture at anastomotic site

 

 

 

 

 

 

 

 

 

7 Fr double pig tail stent placement in right ductal system and 5 Fr Teflon stent in left ductal system

7 Fr double pig tail stent placement in right ductal system and 5 Fr Teflon stent in left ductal system

Fluoroscopy showing bilateral  stents in situ

Fluoroscopy showing bilateral stents in situ

  • A 79 years old Female
  • Presented with pain in the abdomen radiating to back
  • No H/O Fever, vomiting, Jaundice or Weight Loss
  • USG Abdomen – Normal
  • CT Abdomen – Hypodense area in the body of pancreas, 9 mm peripancreatic node superior to the lesion, Fat stranding around the pancreas S/O Focal  Pancreatitis
  • EUS revealed an irregular hypoechoic lesion at the junction of genu and body of pancreas (3 cm X 1.8 cm) which was adherent to splenic artery with few hypoechoic sub centimeter lymph nodes in the peritumorous region. Lesion was obstructing the main pancreatic duct leading to dilated MPD in body and tail of pancreas.
  • EUS FNA with 22 G needle under color Doppler control was performed
  • Cytological examination report suggested it to be adenocarcinoma of pancreas

Expert Comments:

  • The accuracy of conventional US for diagnosing pancreatic tumors is only 50-70%1
  • Sensitivity for detection of  pancreatic cancer of less than 2 cm size with CT scan and EUS is 40 % and 100% respectively2
  • Sensitivity for detection of pancreatic cancers of size 2-3 cm with CT scan and EUS is 84% and 100% respectively2
  • EUS is highly sensitive in detecting invasion of major vascular structure along with small lymphnode metastasis

Take Home Message:

  • More than 50% of the pancreatic cancers are diagnosed at stage IV of the disease
  • Reason being the low sensitivity and specificity of CT, MRI and PET scan in detecting small tumors, vascular invasion and subcentimeter sized lymphnodes
  • Elderly patient’s should be suspected of pancreatic neoplasm in the event of recent onset diabetes, first episode of pancreatitis, weight loss and jaundice as in this case this old female ( 79 years) presented with features of pancreatitis without any other disease defining signs or symptoms

References:

  1. Fumihiko Miura, Tadahiro Takada, Hodaka Amano, Masahiro Yoshida, Shigeru Furui, Koji Takeshita. Diagnosis of pancreatic cancer. HPB, 2006; 8: 337-342
  2. Agarwal B, Abu-Hamda E, Molke KL, Correa AM, Endoscopic ultrasound-guided fine needle aspiration and multidetector spiral CT in the diagnosis of pancreatic cancer. Am J Gastroenterol. 2004 May;99(5):844-50
3 cm X 1.8 cm Pancreatic mass

3 cm X 1.8 cm Pancreatic mass

0.9 cm peripancreatic lymphnode

0.9 cm peripancreatic lymphnode

 

 

 

 

 

 

 

 

 

Pancreatic mass in close proximity of splenic artery

Pancreatic mass in close proximity of splenic artery

EUS guided FNA from the pancreatic mass

EUS guided FNA from the pancreatic mass

  • 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