Amol Patil

Endoscopic ultrasound imaging of pancreatic duct ascariasis

Ascaris lumbricoides infestation is endemic in tropical countries. Most infections by A. lumbricoides are asymptomatic, but they can produce a wide spectrum of manifestations including hepatobiliary and pancreatic complications. Pancreatic ascariasis is a rare entity. In a study of 500 patients with hepatobiliary and pancreatic disease due to A. lumbricoides infection, only seven had pancreatic ascariasis [1], and there are few case reports of ascariasis-induced acute pancreatitis [2]. Mechanisms of acute pancreatitis associated with ascariasis include invasion of the pancreatic duct, the ampullary orifice, and both the common bile duct and the pancreatic duct [3]. Idiopathic pancreatitis is diagnosed when clinical, laboratory, and conventional radiologic methods do not provide a clear etiology for the episode. In the past, endoscopic retrograde cholangiopancreatography (ERCP) has been the imaging test of choice for evaluation of idiopathic recurrent acute pancreatitis, whereas now endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreaFig.1 Endoscopic ultrasonography (EUS) was done for investigation of idiopathic recurrent acute pancreatitis in a 30-year-old man. a A linear echogenic shadow was seen in the pancreatic duct within the head of the pancreas. b EUS from the duodenal bulb demonstrated the ascaris worm in the head of the pancreas. c EUS from the descending duodenum showed a linear shadow with two hyperechoic linear echogenic strips on either side of the longitudinal anechoic lumen of the ascaris worm. Fig.2 Side-viewing endoscopy showed two ascaris worms in the duodenal lumen; one was extruding from the papilla. They were removed with biopsy forceps.

Double Trouble in Acute Pancreatitis

Department of Gastroenterology, Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar pradesh, India 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 Question: A 16-year-old Indian girl presented with severe abdominal pain radiating to the back, associated with emesis. Clinical examination revealed icterus with abdominal tenderness. There was no history of alcohol or drug intake prior to the onset of symptoms. Laboratory investigations revealed the following: Total leukocyte count 17,000/L, differential showed: polymorphs, 64; lymphocytes, 24; eosinophils, 10; serum bilirubin 6 mg/dL (normal, 0.2–1); aspartate aminotransferase 130 U/L (normal, 5–50); alanine aminotransferase 156 U/L (normal, 0–50); serum alkaline phosphatase 540 U/L (normal, 25–125); blood urea 30 mg/dL; serum creatinine 1.1 mg/dL; serum amylase 1260 U (normal, 20–80); and serum lipase 560 U/L (normal, 0–190). Abdominal ultrasonography demonstrated a dilated common bile duct (8 mm) and a bulky pancreas. The gallbladder was normal. A linear endoscopic ultrasonography (EUS) was performed (Figures A-C). What is the diagnosis? 91 92 93 94 A. Bile duct and pancreatic duct stones

Endoscopic ultrasound of splenic artery pseudoaneurysm

A 48-year-old man was referred from an outside hospital with a recent episode of acute pancreatitis and hematemesis for the evaluation of a cystic lesion in the body of the pancreas, which was noted on computed tomography (CT) of the abdomen. Upper gastrointestinal endoscopy was normal. Linear endoscopic ultrasonography (EUS) performed from the stomach revealed a 25×22mm cystic-appearing lesion in the body of the pancreas. The lesion had a thick outer hypoechoic wall (12mm), with a central anechoic area that had the appearance of a “donut” (▶Fig. 1 a, b, ▶Video1). The surrounding pancreatic parenchyma was edematous with peripancreatic fluid collection E-Videos

Multiple Duodenal Strictures due to Eosinophilic Duodenitis

A 27-year-old Indian man presented with a 2-month history of recurrent vomiting. He had experienced postprandial fullness/bloating for the past month. He did not respond to proton pump inhibitors or an antiemetic. He had no history of food allergies or allergic disorders. Stool was negative for ova and cyst. Esophagogastroduodenoscopy revealed approximately six strictures with poststenotic dilation starting at the duodenal bulb and extending into the third part of the duodenum (a; arrows). These strictures were associated with mild circumferential erythema, ulceration, and diverticula (a; arrowhead). Biopsies from the duodenum revealed expansion of the lamina propria by intense inflammation. The submucosa showed Brunner’s glands, characteristic of duodenal biopsy (b; arrow). Biopsy showed prominent eosinophils (b; arrowhead) with focal clustering in the lamina propria. There were approximately 60 eosinophils/high-power field, confirming the diagnosis of eosinophilic duodenitis (ED). Computed tomography of the abdomen showed duodenal strictures with poststenotic dilation (c; arrows). The patient responded well to a course of oral steroids, and his symptoms continued to improve with maintenance steroids. There are few case reports of a single duodenal stricture due to ED. An extensive literature review indicates that this case, with approximately six duodenal strictures, is particularly rare. (Informed consent was obtained from the patient to publish these images.)

Endoscopic ultrasound of peritoneal spaces

The peritoneal cavity is subdivided into supracolic and infracolic compartments by transverse colon and its mesocolon. The supracolic compartment contains the liver, spleen, stomach, and lesser omentum. The infracolic compartment contains the coils of small bowel surrounded by ascending, transverse, and descending colon and the paracolic gutters. The imaging of different compartments is possible by various methods such as ultrasound (US) and computerized tomography. The treating physicians should be familiar with the relevant radiological anatomy of different compartments and spaces as accurate localization of fluid collection/lymph node in peritoneal cavity greatly aids in selection of a treatment strategy. The role of endoscopic US (EUS) is emerging for detail evaluation of all parts of peritoneal cavity as it provides an easy access for fine-needle aspiration from different compartments of peritoneal cavity. In this review, we describe the techniques of evaluation of different parts of supracolic compartments of peritoneum by EUS.

Endoscopic ultrasound-guided fine-needle aspiration of peritoneal deposits in patients with ascites of unknown cause (with videos)

A 50-year-old male with no significant medical history presented with loss of weight, anorexia, and abdominal distension for last 1 month. Physical examination showed ascites. Laboratory examination revealed low serum ascites albumin gradient ascites. Diagnostic workup including upper gastrointestinal endoscopy, colonoscopy, echocardiography, ascitic fluid malignant cytology and adenosine deaminase levels were non-contributory. Contrast-enhanced computed tomography (CECT) of the abdomen revealed ascites and thickened omentum. Endoscopic ultrasonography (EUS) was performed from the stomach with the aim of doing fine-needle aspiration (FNA) of peritoneal/omental deposits. It revealed anechoic ascites and multiple hyperechoic loose floating structures suggestive of peritoneal/ omental deposits [Figure 1a, b and Video 1]. EUS-guided FNA with 22-gauge needle (Expect; Boston Scientific, Natick, Massachusetts, USA) from omental deposits was performed [Figure 2a and Video 1]. Cytopathology showed epithelial cells with moderate atypia with abundant mucin confirming the diagnosis of pseudomyxoma peritonei [Figure 2b]. The patient underwent cytoreductive surgery with heated intraperitoneal chemotherapy but unfortunately he died.

Endoscopic ultrasound of bile duct ascariasis (with video)

A 40‐year‐old male with no significant medical history was admitted to the hospital with yellowish discoloration of eyes, mild right upper quadrant pain, and intermittent fever for last 1 week. Physical examination revealed icterus and hepatomegaly. Laboratory examination showed obstructive jaundice (aspartate transaminase‐230 U/L, alanine transaminase-180 U/L, alkaline phosphatase-370 U/L, and billirubin-3 mg/dL). Ultrasonography abdomen (USG) revealed dilated common bile duct (CBD) (9 mm) with ill‐defined echogenic shadows. Endoscopic ultrasonography (EUS) was performed with a linear echoendoscope (Pentax EG 3830 UT) using Hitachi Avius‐processor at 7.5 MHz frequency for evaluation of echogenic shadow. It revealed linear echogenic mobile shadow coiling in CBD confirming the diagnosis of biliary ascariasis. This linear shadow had two hyperechoic linear echogenic strips on either side of the longitudinal anechoic lumen of the Ascaris [Video 1 and Figure 1]. On side-viewing endoscopy, the worm was visualized partially lying outside the papilla. The worm was extracted with biopsy forceps and identified as Ascaris lumbricoides [Video 1 and Figure 2]. The worm was 9 cm long and creamy white. Subsequently, deworming was done with albendazole. On follow-up visit, the patient was asymptomatic and USG revealed normal CBD. Biliary ascariasis is a common problem in tropical countries. Abdominal USG, which is the first modality for evaluation of such patients, can allow biliary ascariasis to be diagnosed in 85% of cases. The characteristic sonographic features of worms in the CBD are multiple, long, linear, parallel echogenic strips, usually without acoustic shadowing.[1] Both EUS and magnetic resonance cholangiopancreatography are used for evaluation of dilated CBD. However, EUS appears to be an investigation of choice for dilated CBD.[2,3] On EUS, A. lumbricoides appears as long echogenic structure with central anechoic linear defect, without producing shadow effect. It appears as linear echogenic shadow with two hyperechoic linear echogenic strips on either side of the longitudinal anechoic lumen.[4] Endoscopic intervention has become the treatment of choice. Worms visible at the ampulla can be extracted endoscopically with dormia basket or biopsy forceps. Endoscopic retrograde cholangiopancreatography should be performed if a roundworm has migrated or is present inside the bile duct. Sphincterotomy should be avoided for worm extraction because an open biliary sphinctercan lead to recurrence if worm reinfestation occurs.[5]

Primary Peritoneal Hydatidosis.

A 40-year-old man presented with progressive abdominal distension and abdominal discomfort, which he had had for a month. Abdominal ultrasonography revealed hydatid cysts with well-defined, mobile, round anechoic areas with thin echogenic walls within abdominal free fluid with no liver involvement, suggestive of primary peritoneal hydatidosis (video). There were small mobile echoes and debris suggestive of hydatid sand. Endoscopic ultrasonography of the stomach yielded similar results: small, well-defined, and mobile round anechoic areas with thin echogenic walls, suggestive of hydatid cysts. It also showed ascites and small mobile echoes and debris, which were suggestive of hydatid sand (video and image). (Informed consent was obtained from the patient to publish these images.)

An Unusual Cause of Splenomegaly

DIS 5.4.0 DTD YGAST60544 proof 1 September 2016 11:51 am ce Gastr 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 A 58-year-old Indian man presented with one-month history of dull pain and mass in the left upper quadrant of abdomen. There was no history of fever or weight loss. Clinical examination revealed splenomegaly. Hemoglobin, renal and liver function tests were 83 84 85 86 87 88 within normal limits. Abdominal computed tomography (CT) revealed a 5 6 cm nonenhancing heterogeneous cystic lesion in pancreatic tail infiltrating the spleen. A provisional diagnosis of pancreatic cystic neoplasm was made and the patient was referred for endoscopic ultrasonography (EUS). A linear endoscopic ultrasonography EUS was performed (Figures A-B).