Malay Sharma

Portal Cavernoma Cholangiopathy: Consensus Statement of a Working Party of the Indian National Association for Study of the Liver

Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.

Portal Cavernoma Cholangiopathy: An Endoscopic Ultrasound Based Imaging Approach

In patients with portal cavernoma cholangiopathy (PCC), appearance and location of collateral channels depends on extent and location of occlusive thrombus in the porto-mesenteric venous system. If the porto-mesenteric venous system is occluded near the formation of portal vein, blood tends to flow through collateral channels that form varices in and around the common bile duct. Though endoscopic ultrasound (EUS) is considered the investigative modality of choice for evaluating common bile duct obstruction, its role in evaluating collateral pathways in and around the common bile duct is poorly defined. This article reviews the anatomy, genesis and appearance of these collateral pathways in PCC. EUS identifies different layers of the common bile duct (CBD) wall and, in PCC, where varices are in close contact with or part of these different layers, can establish the relationship between them. Thus, EUS appears to be the investigation of choice for tracing the origin and course of collaterals in PCC. Careful study of varices in the common bile duct wall prior to ERCP for bile duct stones or biliary strictures may help to plan the procedure and to manage anticipated complications such as hemobilia.

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.

Imaging of peritoneal ligaments by endoscopic ultrasound (with videos).

Double layered peritoneal folds or ligaments act as conduits for the passage of blood vessels in intraperitoneal organs and also provide a pathway for the spread of disease. It is difficult to identify these normal peritoneal folds at imaging. Computed tomography is the most common imaging modality used to detect diseases of the peritoneum. The ultrasound (US) has been also used for evaluation of diseases involving ligaments. Endoscopic ultrasound (EUS) is being increasingly used both for diagnostic and interventional purposes in abdomen. In this article, we have described the normal EUS anatomy of the peritoneal ligaments.

Dysphagia due to tubercular mediastinal lymphadenitis diagnosed by endoscopic ultrasound fine-needle aspiration

10.4103/2303-9027.170447 A 50-year-old male presented with a history of dysphagia to solids, anorexia and weight loss for last 3 months without any pain during swallowing. EGD revealed an ulcerated lesion in the upper esophagus lesion at “27 cm from incisors” without any luminal narrowing [Figure 1]. Biopsy from ulcerated site was inconclusive. EUS revealed multiple large necrotic lymph nodes [Figure 2]. The cluster of lymph nodes was forming mediastinal abscess with breach in the esophageal wall [Figure 3]. EUS guided fine-needle aspiration (FNA) was done using the Pro Core (Echotip Pro Core, Cook Medical, Bloomington) 22-gauge needle using “fanning” technique with 10 passes. On-site evaluation by pathologist revealed caseating granulomas [Figure 4a]. Smear examination revealed acid-fast bacilli positivity [Figure 4b]. CT chest revealed necrotic mediastinal lymphadenopathy [Figure 5a] with presence of air within the lymph node [Figure 5b].

Endoscopic ultrasound in mediastinal tuberculosis

Background: Tubercular lymphadenitis is the commonest extra pulmonary manifestation in cervical and mediastinal locations. Normal characteristics of lymph nodes (LN) have been described on ultrasonography as well as by Endoscopic Ultrasound. Many ultrasonic features have been described for evaluation of mediastinal lymph nodes. The inter and intraobserver agreement of the endosonographic features have not been uniformly established. Methods and Results: A total of 266 patients underwent endoscopic ultrasound guided fine needle aspiration and 134 cases were diagnosed as mediastinal tuberculosis. The endoscopic ultrasound location and features of these lymph nodes are described. Conclusion: Our series demonstrates the utility of endoscopic ultrasound guided fine needle aspiration as the investigation of choice for diagnosis of mediastinal tuberculosis and also describes various endoscopic ultrasound features of such nodes.

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

A child with unexplained etiology of acute pancreatitis diagnosed by endoscopic ultrasound.

10.4103/2303-9027.131042 A 3-year-old child presented with severe abdominal pain radiating to back. His investigations revealed high serum amylase and lipase levels, normal biochemistries and ultrasound abdomen. An endoscopic ultrasound (EUS) was done (with endobronchial ultrasound, Pentax eb-1970 UK), it showed a linear echogenic structure with central linear anechoic defect completely filling pancreatic duct (PD) suggestive of Ascaris as shown in Figure 1a and 1b. It was removed with the help of Dormia basket. The child had rapid recovery.

Seagulls of endoscopic ultrasound

The analogical description of a shape may be helpful in better understanding of anatomical structures during imaging. Seagull is a popular name for a seabird with a heavy body and two long wings. The “seagull sign ”has been used in cardiology for evaluation of the mitral valve and in orthopedics for erosive osteoarthritis.[1-3] On a plain X-ray abdomen, a triradiate collection of a dark shadow of nitrogen gas within gallstone creates a “seagull sign”.[4]

Imaging of the pancreatic duct by linear endoscopic ultrasound

The current gold standard investigation for anatomic exploration of the pancreatic duct (PD) is endoscopic retrograde cholangiopancreatography. Magnetic resonance cholangiopancreatography is a noninvasive method for exploration of the PD. A comprehensive evaluation of the course of PD and its branches has not been described by endoscopic ultrasound (EUS). In this article, we describe the techniques of imaging of PD using linear EUS.