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US Quiz December 2018

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 […]


US Quiz November 2018

Case Report A 68-year-old man presented with weight loss (3kg in 5 months). His past medical history was remarkable for ART-controlled HIV infection (HIV viral load <20 and CD4+ lymphocyte count 692/uL). Review of systems revealed no other symptomatology. Chest X-ray showed a right-sided pleural effusion (Fig. 1). Figure 1. Chest x-ray (posterior-anterior view):right-sided pleural effusion. A diagnostic thoracentesis was then performed and revealed a very viscous yellow pleural fluid, which biochemical analysis was compatible with exudative effusion. Fluid cultures were negative. Cytological analysis of the pleural fluid showed morular papillary neoplastic cells with cytoplasmic vacuoles compatible with adenocarcinoma. However, cell block immunohistochemistry was positive for CK5/6 and negative for BerEP4, TTF1 and CDX2 favoring the diagnosis of mesothelioma. To assist the differential diagnosis a pleural biopsy was done but it was inconclusive due to insufficient material. A contrast-enhanced thoracic computed tomography (CT) was then performed and revealed a large right-sided pleural effusion and a 16x10x5cm hypodense non-enhancing posterior mediastinal mass, anterior to the vertebrae and causing esophageal and aortic artery axis deviation, without invasion or pleural thickening; no parenchymal lung masses or lymphadenopathies were seen (Fig. 2).   Figure 2. Thoracic CT (a – coronal view; b – axial view): large right-sided pleural effusion and 16x10x5cm hypodense posterior mediastinal mass. To further characterize this mediastinal mass an endoscopic ultrasound (EUS) was done and showed a very large well-defined rounded hypoechogenic mediastinal mass, located between 29 and 39cm from the incisors, adjacent to the esophagus and aorta, without invasion (Fig. […]


US Quiz October 2018

Case Report A 59-year-old woman with no relevant past medical history was referred to the Outpatient Clinic due to iron-deficiency anemia (minimum hemoglobin level of 6.8g/dL). Upper endoscopy showed a large smooth-surfaced polypoid lesion occupying most of the duodenal bulb (Figure 1). Ileocolonoscopy was normal. Figure 1. Upper endoscopy showed a large polypoid lesion covered with intact mucosa in the duodenal bulb. Endoscopic ultrasound (EUS) revealed a 36x24mm heterogeneous mixed echoic submucosal lesion with multiple cystic areas (Figure 2a), with a 14mm thick short pedicle (Figure 2b) and a feeding artery on color Doppler. Figure 2. EUS showed a larged mixed echoic submucosal lesion with cystic areas (Figure 2a), with a short pedicle (Figure 2b).   Quiz   Discussion Bite-on-bite biopsies were taken where Brunner’s glands hyperplasia was identified. Resection of the lesion with a hot snare after submucosal injection of diluted adrenaline was performed, without complications (Figure 3). Histopathologic diagnosis was Brunner’s gland hamartoma (Figure 4).Figure 3. Endoscopically ressected specimen. Figure 4. Photomicrograph of Brunner’s gland hamartoma. On 6-months follow-up, the patient has no anemia. Brunner’s gland hamartomas are rare and benign tumors that occur mainly in the bulb, with less than 200 cases reported in the literature1. Most cases have been reported between the ages of 50 and 60 years, with no gender predominance2. They consist of abnormal proliferation of Brunner’s glands embedded in a fibrous stroma with bundles of smooth muscle and cystic dilated ducts1. Hyperplasia is the designation for lesions smaller than 5mm, which can be diffuse […]


US Quiz of the Month

Instructions for Authors

US Quiz of the Month presents one or more striking ultrasound images in Gastroenterology that are meant to be a didactic challenge to readers. The clinical case is presented as unknown, with the diagnosis hinging on the correct interpretation and integration of the image and clinical data. Each month a new case is presented.
Manuscript must be sent as a Microsoft Word document to and must follow the instructions below:

Title: title cannot reveal diagnosis.
Authors: maximum 5 authors. provide authors’ name and filiation.
Structure: Case description; Multiple choice question (5 choices); Discussion; References.
Word Count: maximum 600 words, excluding figure and video legends and references.
Figures/Videos: maximum 4 images and/or 1 video. Figure and video legends are required. Figures must be submitted as separate attachments in JPEG or TIFF formats (minimum 150 PPI resolution) and videos must be submitted as separate attachments in MOV or MO4 formats.
References: maximum 6 references. References should be cited according to the Vancouver reference style.




Prémio Melhor “US Quiz of the Month


O Prémio “Melhor US Quiz of the Month”, da responsabilidade do GRUPUGE, destina-se a premiar o melhor US Quiz of the Month publicado, em cada ano, no site oficial do GRUPUGE (


Ao vencedor do prémio “Melhor US Quiz of the Month” será oferecida uma inscrição num congresso internacional de ecoendoscopia, designadamente no EURO EUS.


O Prémio “Melhor US Quiz of the Month” será entregue no decurso da Semana Digestiva de cada ano.


Serão candidatos ao Prémio “Melhor US Quiz of the Month”, os 12 US Quiz of the Month aceites para publicação no site do GRUPUGE nos meses de Maio do corrente ano a Abril do ano seguinte.


Os critérios a serem avaliados pelo júri incluem:
a) Originalidade;
b) Relevância Clínica;
c) Rigor Científico;
d) Qualidade Iconográfica.

Cada um dos critérios será classificado de 0-5 pontos, completando um total de 20 pontos


O Júri, formado por 4 elementos, é nomeado anualmente pela Direcção do GRUPUGE.


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