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Case Report A 65-year old female was referred to our Gastroenterology Department due to persistent upper abdominal pain and significant weight loss (20Kg) over the previous year. CT revealed a large retroperitoneal hypodense mass, in contiguity with the pancreatic body and tail, with encasement of the celiac trunk and superior mesenteric artery. Endoscopic ultrasonography (EUS) documented an extensive retroperitoneal hypoechoic lesion encasing the aorta, celiac trunk, common hepatic artery (Figure 1) and superior mesenteric artery (Figure 2), without vascular invasion (hyperechoic vascular wall interface was preserved), causing minimal compression of the pancreas. Figure 1. Endoscopic ultrasonography (transduodenal view): retroperitoneal hypoechoic lesion encasing the common hepatic artery, causing minimal compression of the pancreas. Figure 2. Endoscopic ultrasonography (transgastric view): retroperitoneal hypoechoic lesion encasing the superior mesenteric artery (AMS), without vascular invasion (hyperechoic vascular wall interface was preserved). Transgastric EUS-guided FNB (22G, Acquire, Boston Scientific) of the retroperitoneal mass was performed, coursing anterior to the aorta between the celiac trunk and the superior mesenteric artery (Figure 3). Figure 3. Transgastric EUS-guided FNB (22G, Acquire, Boston Scientific) of the retroperitoneal mass. Quiz Discussion Biopsy revealed spindle-shaped tumor cells and clusters of ganglion cells, with an eccentric large round vesicular nucleus and prominent macro nucleoli, consistent with ganglioneuroma (Figure 4). Figure 4. Cytology (Magnification: 400x; scale bar corresponds to 50 µm): Spindle-shaped tumor cells and clusters of ganglion cells, with an eccentric large round vesicular nucleus and prominent macro nucleoli (arrows). The retroperitoneum can host a wide spectrum of pathologies, including a […]
Case Report A 39-year-old female with no significant past medical history presented with intense epigastric, colic pain for the three previous days. Laboratory studies showed mild and isolated C-reactive protein (CRP) elevation (1.9 mg/dL); liver function tests and pancreatic enzymes were within normal range. An abdominal computed tomography (CT) was performed and revealed a duodenal (D2/D3) endophytic polypoid, high density, heterogeneous lesion, with 26 mm; biliary tree and pancreas were normal (Figure 1). Figure 1. Abdominal CT, coronal view: duodenal (D2/D3) endophytic polypoid, high density, heterogeneous lesion, with 26 mm. Upper endoscopy (Figure 2A) and duodenoscopy (Figure 2B) identified a 25 mm large subepithelial lesion, distal to the duodenal papilla (black circle in Figure 2A), with ulcerated top. Endoscopic ultrasound (EUS) examination confirmed a peripapillary subepithelial lesion with 22 mm and massively calcified, with posterior acoustic shadowing (transitionzone undefined)(Figure 3); the common bile duct was normal. Figure 2. A) Upper endoscopy; B) Duodenoscopy: 25 mm large subepithelial lesion, distal to the duodenal papilla (black circle in Figure 2A), with ulcerated top. Figure 3. EUS, D2 position: peripapillary subepithelial lesion with 22 mm and massively calcified, with posterior acoustic shadowing. Quiz Discussion In this patient, EUS findings raised the diagnostic suspicion of a gallstone impacted in the duodenal wall through a peripapillary bilioenteric fistula. Therefore duodenoscopy was repeated at day 6 but instead of the lesion previously seen there was now a large peripappilary orifice, suggestive of a bilioenteric fistula (40 mm large after contrast injection and guide-wire exploration) (Figure 4). There […]
Case Report A 79-year-old woman, with no relevant past medical history was admitted due to an idiopathic acute pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) revealed a focal main pancreatic duct (MPD) stricture in the pancreatic head with moderate upstream dilatation (7 mm), as well as prominence of secondary branches. In the uncinate process, a 17 mm cystic lesion with no apparent communication with the MPD was also described. This acute episode had a good clinical course and the patient was discharged. One month later, she underwent another MRCP that showed no evidence of the aforementioned stricture but pointed a 9 mm dilatation of the MPD at the level of the pancreatic head. Serum CA 19.9 and CEA were normal. Four months later, she was admitted due to a new episode of mild acute pancreatitis. At that time, she was referred to our institution for endoscopic ultrasonography (EUS). This exam revealed a lesion in the pancreatic head along with an atrophic pancreatic parenchyma, with lobularity, hyperechoic foci and stranding. Elastography and contrast-enhanced harmonic EUS (SonoVue®) were performed. EUS revealed in the pancreatic head a cystic dilatation of the MPD (15×15 mm), with a hyperechogenic solid component and digitiform projections that conditioned almost complete occlusion of the duct (Figure 1). Figure 1. EUS: cystic dilatation of the MPD (15×15 mm) in the pancreatic head, with a hyperechogenic solid component and digitiform projections that conditioned almost complete occlusion of the duct. The solid component had a “hard” pattern on elastography (strain ration 18.79; Figure 2) and revealed an heterogenous […]
Ultrasound Imaging Prize Deadline: April 30 2019
Case Report A 65-year-old woman presented with new onset diabetes. Hes past medical history was remarkable for headache, anxiety and vasomotor symptoms for the last 3 years. Abdominal ultrasound followed by contrast-enhanced abdominal computed tomography (CT) revealed a 14-cm enhanced heterogeneous intra-abdominal mass, with cystic areas, in contact with the posterior wall of the gastric fundus (Figure 1). Figure 1. Abdominopelvic CT (axial and coronal view): a 14-cm enhanced heterogeneous intra-abdominal mass, with cystic areas, in contact with the posterior wall of the gastric fundus. Endoscopic ultrasound (EUS) was performed and showed a giant well-defined rounded hypoechogenic mass, without cleavage plane between the mass and the gastric wall. This was a very heterogeneous mass, with anechoic areas, suggestive of cystic transformation. Its size exceeded the endoscopic field (Figure 2-4). Figure 2. EUS (transgastric view): a giant well-defined rounded hypoechogenic and heterogeneous mass, with anechoic areas, suggestive of cystic transformation. Quiz Discussion EUS-fine needle biopsy (EUS-FNB) using a 25G needle with rapid on site cytological examination (ROSE) was performed. Cytological analysis performed on the cell block demonstrated irregular clusters of cells with finely eosinophilic granular cytoplasm and pronounced anisokaryosis with large and irregular nuclei (Figure 5). Immunohistochemistry was positive for vimentin and synaptophysin and negative for CD117, S100 and CD34; Ki67<3%. Figure 5. Cithology (Papanicolaou, 100x): irregular clusters of cells with finely eosinophilic granular cytoplasm and pronounced anisokaryosis with large and irregular nuclei. Toward these findings, 24-hour urine fractionated metanephrines were measured and were elevated (normetanephrine 5832pg/mL and metanephrine 11738pg/mL) and […]
Case Report A 38 year-old female patient, with no relevant previous medical history, was referred to our unit for evaluation of recurrent left iliac fossa pain, without associated symptoms. No blood test abnormalities were found. Physical examination, pelvic and abdomen ultrasound were normal. Colonoscopy was then performed identifying, at 15 cm from the anal verge, a 3cm bulge in the lumen covered by normal mucosa. These findings were suggestive of a subepithelial lesion (Figure 1). Figure 1. Colonoscopy: 3cm subepithelial lesion, at 15 cm from the anal verge. Endoscopic ultrasonography (EUS) showed a 30mm hypoechoic heterogeneous mass, with no precise limits and with all layers involved (Figure 2). Figure 2. EUS: 30mm hypoechoic heterogeneous mass, with no precise limits and with all layers involved. Quiz Discussion FNA (22G needle) of the lesion was performed and cytologic examination revealed the combination of endometrial glands and stroma. These findings were compatible with endometriosis. Pelvic MRI (Figure 3) and endovaginal ultrasound found no other endometriotic lesions in the pelvis. According to patient preference, hormonal therapy was started and symptoms remission was achieved. Figure 3. Pelvic MRI: coronal (left) and transverse (right) planes. Rectosigmoid endometriosis, with no other endometriotic lesions in the pelvis. Subepithelial lesions of the gastrointestinal tract are commonly incidentally discovered during routine upper endoscopy and colonoscopy. In the colon, subepithelial lesions mostly occur in the rectum and cecum, but lipomas (the most frequent colonic subepithelial lesion) may be seen in any part of the colon.1 Lipomas are usually yellowish, […]
Case Report An 81-years-old female presented to our department with obstructive jaundice (dark urine, pale stools) and a non-specific clinical picture of nausea and appetite loss. Laboratory tests demonstrated a mild leukocytosis with neutrophilia (13.000 cell/mm3; 86%), conjugated hyperbilirrubinemia (7.7 mg/dL), increased aspartate aminotransferase and alanine aminotransferase (10xULN and 8xULN, respectively), slightly increased alkaline phosphatase (2xULN), increased lactate dehydrogenase (10xULN) and serum lipase (3xULN). CA 19.9 was 342 U/mL (Ref value < 37 U/mL). On physical examination, there was no evidence of peripheral lymphadenopathy or hepatosplenomegaly. Abdominal ultrasound (Figure 1-A) revealed a diffuse enlargement of the pancreatic gland. The pancreatic parenchyma was hipoechoic and surrounded by an enhanced peripancreatic fat layer. Also the extra-hepatic and intra-hepatic bile ducts were dilated. The examiner did not notice any dilation of the main pancreatic duct. Contrast-enhanced abdominal computerized tomography (CT, Figure 1-B) revealed a marked homogeneous enlargement of the pancreas. The cephalic portion measured 7cm (antero-posterior diameter), more marked in the uncinate process, without any clear well-defined mass/lesion. There was a dilation of the extra-hepatic and intra-hepatic bile ducts. There was a moderate amount of ascites, especially peri-hepatic, peri-splenic, peri-pancreatic and in the parieto-colic gutter. In addition, there was a significant edema of the subcutaneous tissue of the abdominal wall and, bilaterally pleural effusions were noted. Endoscopic ultrasound (EUS) (Figure 1-C and 1-D) identified an enlarged homogeneous hypoechoic pancreas, without any well-defined lesion, no dilation of the main pancreatic duct, no peripancreatic or celiac enlarged lymph nodes. Using a 19C EchoTip Pro-Core@ HD […]
Realizou-se nos dias 6 e 7 de dezembro o 15º Curso Teórico Prático de Ultrassonografia para Gastrenterologistas no Hospital Amato Lusitano, em Castelo Branco sob a coordenação da Dra. Ana Caldeira e Dr. Eduardo Pereira. Veja algumas fotografias do curso.
Case Report A 26-year-old male with history of sleeve gastrectomy (4 years ago) was referred to the Gastroenterology outpatient clinic due to abdominal discomfort. On physical examination a hard, nontender, large abdominal mass was found. Abdominal CT scan revealed a 210×117 mm contrast-enhanced solid mass centered in the mesentery (Fig. 1a and 1b). There were no signs of bowel obstruction or evidence of lymphadenopathy. Figure 1. Abdominal CT (a – coronal view; b – axial view): contrast-enhanced solid mass centered in the mesentery. After multidisciplinary discussion, endoscopic ultrasound (EUS) with tissue acquisition was performed. The cranial portion of the abdominal mass was observed through the distal second portion of the duodenum. EUS demonstrated a hypoechoic heterogeneous mass with ill-defined borders (Fig. 2a). Real-time EUS elastography revealed a heterogeneous, predominantly blue (hard) pattern (Fig. 2b). Through the duodenum we performed EUS-guided fine needle core biopsy (EUS-FNB) using a 25G needle (Acquire™, Boston Scientific®). Figure 2. EUS (transduodenal view): hypoechoic heterogeneous mass with ill-defined borders; a – EUS – elastography: predominantly blue (hard) pattern; b – EUS-FNB. Quiz Discussion The histology specimen showed the presence of fusiform cells, without atypia (Fig. 3a and 3b). Imunohistochemical staining was positive for β-catenin (Fig. 3c) and negative for c-KIT, DOG-1, AE1/AE3, CD34, S100 protein, alfa-actin and MDM2. Figure 3. Patholohy: a and b – Presence of fusiform cells, without atypia (4x and 20x, respectively); c – imunohistochemical staining was positive for β-catenin (20x). The patient underwent surgical resection of the tumor that included segmental enterectomy […]