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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 September 2018

Case Report An 81 year-old anticoagulated male patient, with a medical history of atrial fibrillation and valvular cardiomyopathy, performed a total colonoscopy due to intermittent hematochezia, which revealed in the distal rectum a well-defined and regular protruded sessile lesion with 16 mm (T0 Is) (Figure 1). Figure 1. Protruded sessile lesion (T0 Is) with 16 mm, in the distal rectum. Endoscopic ultrasound examination (EUS) identified a hypoechoic lesion with clear margins arising from the second layer, without lymph node or muscular layer involvement (Figure 2). Figure 2. Hypoechoic lesion arising from the second layer.   Quiz   Discussion Abdomino-pelvic computerized tomography (CT) and PET-TC DOTA NOC showed no distant metastasis. Multidisciplinary evaluation was carried out and excision of the tumor by endoscopic submucosal dissection (ESD) was planned. The procedure was performed with no complications reported (Figure 3). Figure 3. A to F – Endoscopic excision of a rectal neuroendocrine tumor by endoscopic submucosal dissection (circumferential mucosal cutting and submucosal dissection performed with the Dual-Knife, Olympus®). Pathological analysis confirmed the diagnosis of a totally resected well differentiated neuroendocrine tumor (G1) with a low mitotic index (Ki67 < 2%) and no lymphovascular invasion. No distant metastasis were identified during the follow up period (2 years). The incidence of rectal neuroendocrine tumors has been rising largely due to an increased number of screening colonoscopies, allowing for identification of smaller lesions amenable to endoscopic treatment1. Indeed, endoscopic therapy of neuroendocrine tumours may be considered in lesions below 2 cm, without muscularis invasion according to the European Neuroendocrine […]


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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