Saurabh Jindal

EUS imaging of dead Ascaris

Figure 2. Linear EUS view showing rounded hyperechoic structure in dilated common bile duct. CBD, common bile duct. A 4-year-old Indian boy presented because of recurrent biliary colic and jaundice for the previous 2 weeks. There was no history of fever. Laboratory investigations revealed alanine aminotransferase, 156 U/L (normal, 0-30 U/L); aspartate aminotransferase, 204 U/L (normal, 0-30 U/L); serum alkaline phosphatase, 920 U/L (normal, 30-120 U/L); and serum bilirubin, 8.4 mg/dL (normal, 0.2-1.2 mg/dL). Abdominal US revealed a normal gallbladder, dilation of the intrahepatic biliary radicles, and a dilated common bile duct (CBD) of 14 mm, with an ill-defined rounded echogenic shadow inside the lower end of the CBD. The possible differential diagnoses of CBD polyp, choledochal cyst with sludge, CBD stone, and a dead coiled worm were considered. EUS was performed with a linear echoendoscope (Pentax EG 3830 UT; Pentax, Tokyo, Japan) by use of a Hitachi Avius processor (Hitachi, Tokyo, Japan) before ERCP to determine the cause of the dilated CBD and further characterize the echogenic shadow seen on US. Linear EUS from the stomach revealed dilatation of the CBD to 14 mm, with a rounded hyperechoic structure without acoustic shadowing in the lower CBD (Figs. 1 and 2; Video 1, available online at www.VideoGIE.org). Linear EUS from the duodenal bulb with color Doppler imaging showed a hyperechoic avascular structure with a central anechoic area inside the CBD (Figs. 3 and 4; Video 1). This structure was without acoustic shadow,

Management of a Dieulafoy ulcer bleed with an over-the-scope clip

re 1. A, Small ulcer over a submucosal bulge in anterior wall of first part of duodenum. B, EUS color Doppler view showing submucosal vessel feeding perforator. C, EUS pulse Doppler view showing feeding artery of submucosal arteriole. D, Hemoclips were deployed on the Dieulafoy and epinephrine was injected. E, Deploying over-the-scope clip (OTSC) over the lesion. F, OTSC over the Dieulafoy ulcer with no further ing. OTSC, over-the-scope clip.

An unusual cause of hemobilia diagnosed on EUS

re 1. A, Linear EUS from the duodenal bulb showing an 8-mm 7-mm cystic-appearing lesion in the head/neck region of the pancreas. B, Color-flow and ler image showing vascular flow in the anechoic area. C, Pulse Doppler image showing arterial wave pattern in the vascular lesion whose origin appears to e gastroduodenal artery. D, Radial EUS view from the duodenal bulb showing the vascular lesion to be originating from the gastroduodenal artery. E, Radial view revealing characteristic “yin-yang” flow with bidirectional waveform pattern on color Doppler US. CBD, common bile duct; PD, pancreatic duct. en transcript of the video audio is available online at www.VideoGIE.org.

EUS imaging of splenic artery pseudoaneurysm

re 1. A, Endoscopic image showing blood in duodenum. B, Linear EUS view showing a 27 mm 32 mm cystic-appearing lesion in the body of the reas. C, The cystic lesion has a thick outer hypoechoic wall and inner anechoic area, giving it a characteristic “donut” appearance. D, EUS view ing edematous pancreatic parenchyma with peripancreatic fluid collection consistent with an acute attack of pancreatitis. E, Color-flow and Doppler aging showing vascular flow in the central anechoic area. F, G, The digital subtraction images of the splenic artery arteriogram demonstrating extravn of contrast medium into a splenic artery pseudoaneurysm (arrow). The angiocatheter is also seen. H, Digital subtraction image depicting the ssfully embolized splenic artery pseudoaneurysm with detachable coils. The arteriogram confirms complete stasis of flow within the artery without ual filling of pseudoaneurysm.

EUS-guided coiling of hepatic artery pseudoaneurysm in 2 stages

re 1. A, Contrast-enhanced CT view of the abdomen showing an aneurysm arising from the hepatic artery. B, EUS view showing a pseudoaneurysm g from the hepatic artery. C, EUS-guided coil embolization of hepatic pseudoaneurysm. D, Fluoroscopic image of coil embolization. E, US image of doaneurysm after first session of coil embolization. F, Fluoroscopic image of pseudoaneurysm after second session of coil embolization. G, EUS view ing complete obliteration of the pseudoaneurysm after a second session of coil embolization. H, Abdominal US view after the first week showing lete obliteration of the pseudoaneurysm. HA, hepatic artery; IVC, inferior vena cava; PV, portal vein; SA, splenic artery.

Management of luminal gossypiboma with endoscopy and laparoscopy

re 1. A, CT view of the abdomen showing a lesion with radiopaque marker in the first, second, and third parts of the duodenum. B, Upper GI scopic view showed a gauze piece with ulcer in the first part of the duodenum. C, Gauze piece was pulled into the antrum with rat-tooth forceps. mergence of gauze piece from the duodenum and impaction at midesophagus. E, Removal of gauze piece through laparoscopic gastrostomy. moval of gauze piece through laparoscopic gastrostomy. G, Postoperative upper GI endoscopic view showing a large excavated ulcer in the oinferior wall of the first part of the duodenum.

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

Biliary ascariasis: mimicker of biliary stent

Figure 2. US view of abdomen showing Ascaris lumbricoides mimicking stent within dilated common bile duct. A 50-year-old-man presented because of yellowish discoloration of the eyes, right upper-quadrant pain, and high-grade fever for 3 days. He had a history of common bile duct (CBD) stones and gallstones. He had undergone multiple ERCP procedures and biliary sphincterotomy with removal of stones and plastic biliary stent placement 1 year previously. Laboratory examination showed the following: white blood cell count of 20,000/mm with 88% neutrophils, aspartate transaminase 230 U/L (reference 0-32 U/L), alanine transaminase 380 U/L (reference 0-32 U/L), alkaline phosphatase 470 U/L (reference 0-120 U/L), and bilirubin 5 mg/dL (reference 0-2 mg/dL). A clinical diagnosis of acute cholangitis was established. Abdominal US showed dilation of intrahepatic biliary radicles, hepatomegaly, and dilated CBD (11 mm) with a linear echogenic structure (Figs. 1 and 2; Video 1, available online at www.VideoGIE.org). A possibility of cholangitis resulting from stent occlusion was considered. ERCP was planned for removal of the stent and clearance of the CBD. On ERCP, the papilla was patulous, with no stent in situ. The possibility of a migrated CBD stent was considered. A cholangiogram revealed dilated CBD with a linear echogenic filling structure inside the CBD, suggestive of Ascaris lumbricoides rather than a stent (Figs. 3 and 4). The CBD was cannulated with a stone extraction balloon (Fig. 5). A balloon sweep was performed, and a live creamy-white worm was removed from the papilla (Fig. 6). The worm was grasped with rat-tooth forceps (Fig. 7) and identified as A lumbricoides. The patient underwent therapy with albendazole and passed multiple roundworms in his stool. Repeated US after 2 weeks showed the CBD to be normal. To conclude, we present a case of cholangitis due to biliary ascariasis mimicking biliary stent on US. Biliary ascariasis should be considered in a patient presenting with acute cholangitis in endemic regions. A lumbricoides is the most common helminthic infection in the world. Although the duodenum and proximal jejunum are the normal habitats of an adult worm, occasionally these worms migrate to the CBD, the pancreatic duct (PD), or the gallbladder, leading to adverse events like biliary colic, cholecystitis, acute cholangitis, and pancreatitis. Biliary ascariasis is a common cause of pancreatobiliary disease in an endemic region. Migration of a worm to the CBD is more common than to the PD,

Endoscopic ultrasound of duodenal heterotopic gastric mucosa

A 50-year-old woman presented with dyspepsia but no history of weight loss or gastrointestinal bleeding. Esophagogastroduodenoscopy (EGD) showed a sessile polypoidal submucosal lesion in the second part of the duodenum close to the ampulla with a central opening (fish-mouth appearance) (▶Fig. 1). The contour of this lesion was smooth and there was no disruption of the surrounding folds, nor ulceration or bleeding. Linear endoscopic ultrasound (EUS) was performed for evaluation of the lesion. This revealed that the lesion was arising from the mucosa/submucosa of the duodenum and had a cystic anechoic central core in the submucosa with no solid component and well-demarcated margins (▶Fig. 2; ▶Video1). On the basis of the EUS images, it was suspected that this was heterotopic gastric mucosa (HGM) and therefore the decision was made to resect the lesion endoscopically. The patient underwent polypectomy and the submucosal lesion was sent for histopathology. The histopathological examination confirmed the presence of HGM revealing fundal and pyloric glands covered by duodenal epithelium (▶Fig. 3). HGM is common in all organs of the gastrointestinal tract, particularly in the esophagus and duodenum [1]. A recent study found duodenal HGM appearing as solitary or multiple small nodules in 1.9% of 28210 patients who underwent EGD with duodenal biopsy [2]. EUS for the evaluation of submucosal lesions is a well-established entity, but literature with regard to the EUS description of duodenal HGM is rare. Hizawa et al. [3] described duodenal HGM presenting as a simple anechoic mass within the submucosa. In a recent series of six patients with duodenal HGM, the lesions appeared as solitary, sessile submucosal lesions with a depression at the top [1]. On EUS, these lesions had a heterogeneous pattern with or without an anechoic area and were located within the mucosa/submucosa. Although HGM is a benign entity, it may require laparoscopic or endoscopic resection if the lesion is large in size.

Endoscopic ultrasound appearance of dead Ascaris lumbricoides in the biliary tract

A 2-year-old Indian girl was referred with symptoms of biliary colic and obstructive jaundice of 3 weeks’ duration. Abdominal ultrasonography revealed dilation of intrahepatic biliary radicles, a distended gallbladder, and a dilated common bile duct (CBD) of 15mm (normal diameter up to 6mm) containing multiple ill-defined, oval, hyperechoic shadows near the lower end (▶Fig. 1). Magnetic resonance cholangiopancreatography (MRCP) showed multiple intraluminal curvilinear, hypointense areas in the lower CBD consistent with stones or worm (▶Fig. 2). Linear endoscopic ultrasound (EUS) was performed for evaluation of the CBD filling defects visualized on abdominal ultrasound and MRCP. Linear EUS from the stomach and duodenal bulb revealed a dilated CBD with multiple hyperechoic structures without acoustic shadowing. EUS showed curvilinear, disc-shaped short-segment echogenic structures, 2–6mm in size, with a central anechoic core and parallel and equidistant from each other; this was suggestive of recently broken down soft parallel fragments of roundworms (▶Fig. 3, ▶Video1). The central anechoic core represented the digestive tract of Ascaris lumbricoides. Cholangiography revealed a dilated CBD with tapering at the lower end showing multiple filling defects (▶Fig. 4). After multiple balloon sweeps on endoscopic retrograde cholangiopancreatography (ERCP), creamy white structures and yellow-colored material were removed that were suggestive of recently fragmented roundworm (▶Fig. 5, ▶Video1). The patient’s clinical condition improved significantly after ERCP, and repeat abdominal ultrasound after 1 week demonstrated decreased size of the CBD. The patient underwent deworming with albendazole, with the passage of multiple roundworms in stools further confirming the diagnosis of obstructive jaundice due to Ascaris. Pancreaticobiliary ascariasis is a common problem in tropical countries [1]. Dead Ascaris is a rare but an important cause of obstructive jaundice in the developing world [2]. In conclusion, we describe an unusual appearance of recently dead Ascaris lumbricoides on abdominal ultrasound, MRCP, and EUS. In endemic regions, biliary ascariasis should be considered in any child presenting with obstructive jaundice [3].