Piyush Somani

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-guided fine needle aspiration of a pericardial mass

The prevalence of primary pericardial neoplasms ranges from about 0.001%– 0.007%. Primary malignant pericardial mesothelioma is extremely rare, with a reported prevalence of 0.0022% in autopsy series [1]. Although malignant mesothelioma is the most common primary malignancy of the pericardium, only approximately 350 cases of pericardial mesothelioma have been reported in the literature. Diagnosing pericardial disease can be challenging, with an antemortem diagnosis of pericardial mesothelioma obtained in only 10%–20% of cases. Cross-sectional imaging is useful for diagnosis, but cytological and/or histological examinations are required to obtain a definitive diagnosis. Cytological analysis of the pericardial fluid often yields negative results; therefore, the diagnosis usually requires histologic evaluation of tissue obtained during surgery or at autopsy. In patients with metastasis, half have regional lymph node involvement; hence, as already reported, endoscopic ultrasound (EUS)/endobronchial ultrasound can be used to diagnose pericardial mesothelioma [2]. Because of the proximity of the heart to the esophagus, transesophageal EUS-guided access to the heart has been performed safely in animal models and humans [3]. There are a few case reports of EUS-guided fine needle aspiration (FNA) of atrial and pericardial tumors [4, 5]. A 55-year-old man presented with progressive dyspnea on exertion over the preceding 4 months. Computed tomography (CT) of the thorax revealed a welldefined heterogeneously enhancing lesion, 2.1×1.8×1.8cm in size, attached to the posterior pericardium and a pericardial effusion (● Fig.1). Pericardiocentesis was performed, but analyses for malignant cells and tuberculosis were negative. Given thenecessityofobtaininga tissuediagnosis, an EUS-guided transesophageal FNA of the mass was considered, and was performed in the endoscopy room after the cardiologist and cardiovascular surgical teams had been alerted. Linear EUS reFig.1 Computed tomography (CT) scan of the thorax showing a well-defined heterogeneously enhancing lesion, 2.1×1.8×1.8cm in size, attached to the posterior pericardium and a pericardial effusion. Fig.2 Linear endoscopic ultrasound (EUS) images showing: a a pericardial effusion with normal chambers of the heart; b a mixed echogenic pericardial mass with a pericardial effusion; c the pericardial mass being punctured with a fine needle aspiration (FNA) needle. Cases and Techniques Library (CTL) E45

Endoscopic ultrasound of pancreatic duct ascariasis.

A 30-year-old Indian woman presented with severe abdominal pain radiating to the back, associated with emesis. On clinical examination, she had tenderness over the epigastrium. There was no history of alcohol or drug intake prior to the onset of symptoms. Laboratory investigations revealed the following: serum bilirubin 1 mg/dL (normal, 0.2–1); aspartate aminotransferase 40 U/L (normal, 5–50); serum alkaline phosphatase 124 U/L (normal, 25–125); serum amylase 1260 U (normal, 20–80); and serum lipase 560 U/L (normal, 0–190). Abdominal ultrasonography demonstrated bulky pancreas with normal gallbladder. Linear endoscopic ultrasonography (EUS) was carried out for etiological evaluation of acute pancreatitis. Linear EUS showed linear echogenic structure without acoustic shadow in the pancreatic duct (PD) (Figs 1, 2a). This linear shadow had two hyperechoic linear strips on either side of the longitudinal anechoic lumen which confirmed the diagnosis of Ascaris lumbricoides (Fig. 1a). On side-viewing endoscopy, one creamy white worm was seen in the duodenal lumen extruding from the papilla (Fig. 2b). The worm was removed with biopsy forceps and identified as A. lumbricoides. The patient underwent deworming with albendazole. On follow up, EUS revealed normal pancreatic duct. A. lumbricoides is the most common helminthic infection in the world. Although the intestine is the normal habitat of the adult worm, occasionally these worms migrate to the bile duct or PD. PD ascariasis is a rare entity. In a study of 500 patients with hepatobiliary ascariasis, only seven had pancreatic ascariasis. Ascaris is a common cause of acute pancreatitis in developing countries. Mechanism of ascariasis-induced acute pancreatitis includes obstruction of Vater’s papilla, and invasion of the common bile duct or pancreatic duct. Ultrasonography is a sensitive test for biliary ascariasis; however, its sensitivity is low for PD ascariasis. EUS may be more sensitive for diagnosis of pancreatic ascariasis.

Endoscopic ultrasound/endobronchial ultrasound pierce the veil of precision medicine for lung cancer

The time has arrived for personalized medicine (1). Now each individual is recognized to be special. The medicines prescribed and treatment in general will soon be decided taking individual variability into account. Each one will be recognized by his own medical fingerprint and treatment catered according to that for that particular individual. Generalization will not be there anymore.

EUS-guided cyanoacrylate glue injection for treatment of anourethral fistula

Perianal fistulas are a frequent cause of morbidity. The causes of perianal fistula include cryptoglandular infection, Crohn’s disease, radiotherapy, and malignancy. Perianal fistula as an adverse event of anal canal surgery occurs infrequently. We report the EUS-guided management of a case of postsurgical perianal fistula with cyanoacrylate glue injection. A 35-year-old man presented with recurrent urinary tract infection requiring multiple courses of antibiotics for the past 15 years. He had undergone surgery for an imperforate anus at birth, and an anal stricture developed, which required repeated bougienage dilation until he was 4 years of age. After anal dilation, he had intermittent passing of urine through the anal opening and received a diagnosis of anourethral fistula. He underwent fistulectomy with urethral repair and anoplasty 1 year later and improved symptomatically, but he had recurrence of symptoms at 16 years of age and underwent fistulectomy again, with significant improvement. He became symptomatic again after

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.)

Imaging of spaces of neck and mediastinum by endoscopic ultrasound.

Endoscopic ultrasound (EUS) of the mediastinum was pioneered by gastroenterologists, and it was taken up by pulmonologists when the smaller-diameter endobronchial ultrasound (EBUS) scope was designed after a few years. The pulmonologists′ approach remained largely confined to entry from the trachea, but they soon realized that the esophagus was an alternative route of entry by the EBUS scope. The new generations of interventionists are facing the challenge of learning two techniques (EUS and EBUS) from two routes (esophagus and trachea). The International Association for the Study of Lung Cancer (IASLC) proposed a classification of mediastinal lymph nodes at different stations that lie within the boundaries of specific spaces. These interventionists need clear definitions of landmarks and clear techniques to identify the spaces. There are enough descriptions of spaces of the neck and the mediastinum in the literature, yet the topic mentioned above has never been discussed separately. The anatomical structures, landmarks, and boundaries of spaces will be important to interventionists in the near future during performances of endosonography. This article combines the baseline anatomy of the spaces with the actual imaging during EUS.

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).

Endoscopic ultrasonography of solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome (SRUS) is an uncommon poorly understood benign disorder of defecation. SRUS may simulate other disorders such as inflammatory bowel disease andneoplasms. Histopathological analysis forms the cornerstone of diagnosis for SRUS.Key histological features include fibromuscular obliteration of the lamina propria with splaying of the muscularis mucosae upward between the crypts, thickened mucosa, and glandular distortion [1]. Endoscopic ultrasonography (EUS) can be useful in the evaluation of SRUS. The characteristic findings are thick hyperechoic submucosa and thick hypoechoic muscularis propria with an intermediate hyperechoic layer. Linear EUS imaging shows a transition zone where the first interface layer and the muscularis mucosae disappear, and the submucosa gradually becomes thicker. The presence of an interface between the two muscular layers and between the muscular layer and the submucosa rules out malignant infiltration [2]. The hyperechoic band in the muscularis propria in SRUS has been attributed to a fibrous septum while the hyperechoic submucosa is due to a fibrotic lamina propria [3]. A 65-year-old man presented with a history of bleeding per rectum and straining at stool for 6 months. Sigmoidoscopy showed a large ulcer in the posterior rectal mucosa approximately 8cm above the anal verge (● Fig.1;● Video 1). Biopsies were sent for histopathological examination and a linear EUSwas performed. Linear EUS of the anal canal revealed normal thickness of the anal sphincters, but there was thickening of the submucosa as Fig.1 Sigmoidoscopic view showing a large ulcer in the posterior rectal mucosa. Fig.2 Linear endoscopic ultrasonography (EUS) images showing: a thickening of the submucosa and muscularis propria; b,c the solitary rectal ulcer in an otherwise normal rectum and the transition zone; d a hyperechoic layer in the thickened hypoechoic muscularis propria. Cases and Techniques Library (CTL) E76