Case report A 73-year-old caucasian male with a medical history of ulcerative proctitis (treated with mesalazine 3g/day) and gastroesophageal reflux disease (treated with omeprazol 20mg/day) was referred to our center due to epigastric discomfort. He was submitted to an upper endoscopy, which showed a peripapillary duodenal polypoid mass with approximately 30mm. Endoscopic biopsy showed a mixed inflammatory infiltrate and fibronecrotic tissue. A magnetic resonance cholangiopancreatography (MRCP) and an endoscopic examination with a duodenoscope were requested and were consistent with a subepithelial lesion located about 8mm from the papilla of Vater. New biopsies were taken, revealing the same findings. Apart from a mild lymphocytosis (3,66 x 109/L), laboratory tests were unremarkable (including CEA, CA 19.9, bilirubin, alkaline phosphatase and gama-glutamyl transferase). An endoscopic ultrasound was carried out, which identified a 30mm homogeneous hypoechoic lesion in the second part of the duodenum, not related to the papilla, arising in the 4th duodenal wall layer (muscularis propria), without invasion of adjacent layers (Figure 1 A-C). Figure 1: Homogeneous and hypoechoic lesion in the second part of the duodenum, arising in the 4th wall layer, observed on radial (A) and linear (B) endoscopic ultrasonography (EUS); the ampulla of Vater was normal (C).   Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed (22G needle, 3 passes) providing samples for conventional smear, liquid-based cytology (ThinPrep CytoLyt®) and into a 10% formalin solution (Figure 2). Figure 2: EUS-FNA of the lesion.   Cytological analysis was compatible with a primary duodenal follicular lymphoma (Figure 3). Figure 3: Histopathological examination […]

Case Report A 56 year-old post-menopausal previously healthy woman was admitted with one week epigastric pain. Physical examination revealed an adequate general physical status and painful abdomen at deep epigastric palpation. Serum lipase was 3231 UI/L. Abdominal ultrasound (US) revealed two solid hypoecogenic hepatic nodules, in the V and VI segments, with well defined limits and “target” sign, suggestive of metastasis; in the pancreatic head, a nodular hypoechogenic 26x28mm lesion with poorly defined boundaries and several other hypoechogenic centimetric nodules dispersed in the pancreatic body and tail (Figure 1). The CT Scan confirmed the hepatic and pancreatic US findings and revealed a heterogeneous uterine cervix and isthmus with increased dimensions, with a 43x46x53mm lesion in the left side. Figure 1. A– Hepatic metastasis; B– Pancreatic head with a nodular hypoechogenic 26x28mm lesion; C– Hypoechogenic centimetric nodules dispersed in the pancreatic body; Wirsung not dilated.   Endoscopic ultrasound (EUS) identified multiple hypoechogenic well defined nodules throughout the pancreas, the largest with 19mm in the cephalic region, without dilatation of the Wirsung or common bile duct and without vascular invasion (Figure 2). Figure 2. A– Hypoechogenic 19mm lesion in the pancreatic head. B– Smaller (9 mm) nodule in the pancreatic tail.   Citology analysis from EUS-FNA of the cephalic and tail pancreatic nodules (25G needle, three passages), identified small cells, with scarce cytoplasm, nucleus with granular chromatin, without nucleoli. Endovaginal US and Pelvic Magnetic Resonance Imaging (MRI) identified a solid cervix lesion with invasion of the uterine body (Figure 3). Figure 3. […]

Case Report: A 53 year-old female patient, with no relevant previous medical history was referred to our unit for studying a cholestatic pattern – ALP 1783 U/l, GGT 1783 U/l, total bilirubin 1mg/dl. No other significant blood test abnormalities were found. Physical examination revealed only peripheral edema. Abdominal ultrasound and abdominal CT scan showed hepatomegaly, a macrocystic formation in the pancreatic tail (46x45mm) and multiple lateral aortic lymphadenopathies (Figure 1). Figure 1. Abdominal CT scan showed hepatomegaly, periceliac lymphadenopathies and a macrocystic formation in the pancreatic tail.   Endoscopic ultrasonography (EUS) confirmed the presence of multiple oblong and echogenic lymphadenopathies in the celiac area, left gastric station and hepatic hilum, the larger with 22mm (Figures 2a and 2b). Figure 2. EUS: oblong and echogenic lymphadenopathies in the celiac area (Fig 2a, upper) and hepatic hilum (Fig 2b, bottom).   FNA (with a 22G needle) of the lymphadenopathies in the celiac area was performed and histologic examination revealed apple-green birefringence in polarized light after congo red staining, consistent with amyloid deposit (Figure 3).   Figure 3. Histologic examination revealing amorphous hyaline material with positive staining with Congo Red.   In the pancreatic tail a 46 mm multiloculated, septated cyst, with a thicken septum of 7mm, without any communication with the main pancreatic duct (MPD), suggestive of mucinous cystadenoma (Figures 4a and b). Pancreatic cyst FNA (with a 22G needle) was also performed. Cystic fluid cytology and biochemistry analysis were consistent with mucinous cystadenoma (CEA level 6165 ng/dL; amylase 21 U/L). Figure 4. […]

Case Report As radiologic examinations evolve, the detection of asymptomatic pancreatic cystic lesions is rising and, consequently, there is a growing challenge to decide the best approach to this type of lesions. We report the case of a 48-years-old female patient with a prior history of HIV and HCV co-infections, asymptomatic gallstones, active smoking and social alcohol intake, with no prior history of acute pancreatitis. In a routine ultrasound, an incidental pancreatic cystic lesion in the body/tail transition was found. This lesion was further characterized by magnetic resonance imaging and endoscopic ultrasound (EUS). It was a cystic lesion with a long axis of 17 mm, a regular but thick wall and thin internal septations, apparently communicating with the main pancreatic duct (Figure 1). Figure 1 – Ultrasonographic aspects of the pancreatic lesion.   Due to the characteristics of the lesion, with the presence of one worrisome feature, we decided to perform EUS-guided fine needle aspiration (EUS-FNA) (Figure 2). Figure 2 – EUS-FNA of the lesion.   The cytologic examination with immunochemistry demonstrated small cells with scarce eosinophilic cytoplasm, eccentric round nucleus, with immunoreactivity to synaptophysin and chromogranin. These finding were suggesive of the diagnosis of a pancreatic neuroendocrine tumour (NET).   Commentary Pancreatic NETS represent 1-2% of pancreatic neoplasms and are typically solid lesions. Their presentation as cystic lesions is rare, and it’s assumed that it is the consequence of tumour necrosis. The decision to proceed to EUS-FNA of a pancreatic cystic lesion is still a question of debate, and the existent […]

Case Report A 79-year-old caucasian female was admitted due to painless jaundice, choluria, acholia and generalized pruritus for the previous week. On physical examination, an epigastric mass was documented. Abdominal ultrasonography showed dilation of common bile duct (CBD) and intrahepatic biliary tree, with an apparent stricture on CBD middle third. Laboratory findings included microcytic anaemia (Hb 6.5 g/dL), normal inflammatory markers and high levels of serum bilirubin (6.0 mg/dL), elevated transaminases (AST 262 IU/L; ALT 492 IU/L) and cholestasis parameters (GGT 426 IU/L; AF 519 IU/L). An endoscopic ultrasonography (EUS) was performed and showed, on the gastric cardia, an irregular and ulcerated lesion with 4-5cm, extending to the lesser curvature (Figure 1) and involving all gastric wall layers, splenic vessels and pancreas (T4) (Figure 2). Malignant perigastric adenopathies were identified (N+). Pancreas had no other parenchymal or ductal abnormalities. Ampullary area and distal common bile duct were normal. However, on the middle third of the common bile duct, a hypoecogenic, heterogeneous, irregular, infiltrative and stenotic lesion was identified (Figure 3). This lesion caused marked dilation of the proximal common bile duct and intra-hepatic biliary ducts and presented a hard pattern on elastography (Figure 4). Figure 1 – Irregular and ulcerated lesion with 4-5cm on gastric cardia, extending to the lesser curvature. Figure 2 – Gastric lesion involving all gastric wall layers, splenic vessels and pancreas (T4). Figure 3 – Hypoecogenic, heterogeneous, irregular, infiltrative and stenotic lesion on the middle third of the common bile duct. Figure 4 – Hard (blue) elastographic pattern of […]

Case Report A 48-year-old man suffering from opioid refractory pain (recorded as 9 according to visual analog scale-VAS) due to an advanced stage IV histologically-proven pancreatic adenocarcinoma with liver metastases was referred to our center. As the tumor stage was beyond any possibility of surgical radical care and in order to relieve patient’s symptoms, EUS-guided CPN was performed. Under sedation with propofol, endoscopic ultrasound (EUS) was conducted with a Pentax® EG3870UTK ultrasound endoscope (Pentax Europe Ltd, Hamburg, Germany). EUS confirmed the nodular hypoechoic lesion in body of the pancreas . Figure 1: Tumoral nodule hypoechoic in body of the pancreas.   Ca 19-9 level was 1112 UI/mL. After colour Doppler assessment of vessel interposition, a 22 G needle (Cook Medical Inc, Bloomington, Indiana, USA) was introduced though the endoscope’s working channel to inject 15 mL bupivacaine 2.0% and 20 mL of ethylic alcohol 98% above the celiac axis. The endoscope is rotated to one side until the origin of the celiac axis was no longer seen and half of the entire solution was injected; the procedure was then repeated on the opposite side . During alcohol injection, a typical hyperechogenic shadow was observed . Figure 2: Celiac plexus neurolysis performed via the lateral approach. Figure 3: Typical hyperechogenic shadow was observed during alcohol injection.   No major or minor complications were experienced by the patient. Pain relief, namely VAS 2, was achieved 3 days after the CPN. The patient remained pain-free without need of opioid, was treated only with paracetamol for […]

Case Report We present the case of a 70-year-old woman with no relevant history to whom an upper endoscopy was performed due to dyspeptic complaints. During the examination, an apparent subepithelial lesion with approximately 30 mm located in the gastric fundus was observed. Figure 1. Nodular lesion with normal underlying mucosa in the gastric fundus.   For additional assessment, we performed a hydrogastric sonography (HGS). The examination was executed after the ingestion of 400 mL of water. HGS demonstrated a hyperechoic nodule located in the periphery of the left hepatic lobe with 27 mm of bigger axis, compatible with an hepatic hemangioma. As the lesion was exophytic, it compressed the stomach wall, mimicking a subepithelial lesion. Figure 2. HGS clearly demonstrating the liver hemangioma compressing the stomach wall. (F – liver; H – hemangioma; EST – stomach filled with water).   Commentary Hepatic hemangiomas are the most common liver benign tumors, typically presenting as a homogenous, hyperechoic nodule with well-defined margins on ultrasonography. Exophytic forms of hepatic hemangiomas are very rare . Endoscopic ultrasound (EUS) is currently the gold standard in the evaluation of subepithelial lesions of the gastrointestinal tract, allowing the differentiation of extramural compression from intramural growth, the determination of layer of origin, regional lymphadenopathy and the acquisition of tissue for anatomopathologic diagnosis . However, EUS is an invasive procedure with a risk of complications. HGS is a modification of transabdominal ultrasound, with the advantages of being widely available, non-invasive and with no major costs when compared with […]

Case Report We present the case of a 26-year-old who was referred to our centre due to the discovery of a focal liver lesion in an ambulatory ultrasonography. We repeated the abdominal ultrasonography, identifying an isoechoic nodule with approximately 30 mm of bigger axis located in segment V. Figure 1. Hepatic isoechoic nodule in segment V.   With the use of Doppler and 3-dimensional (3D) software, we were able to determine the existence of a central scar and radial distribution of the nodule vascularization. These findings taken together are characteristic of focal nodular hyperplasia (FNH).   Figure 2. A) Doppler mode; B) three dimensional reconstruction of the nodule vascularization, depicting the typical characteristics of focal nodular hyperplasia.   Commentary 3D ultrasonography represents a development in the ultrasonography field, with the advantage of creating ultrasound sections impossible to see on a routine scan. Additionally, it allows accurate volume measurements and interactive manipulation of volume data . In this case, the use of 3D ultrasonography associated with Doppler study allowed the clear demonstration of the typical characteristics of FNH, avoiding the need of more expensive exams.     References 1. Kupesic S, Kurjak A. Clinical Application of 3D Sonography: Taylor & Francis; 2000   Authors Paula Sousa1, Tiago Capela2, Ana Caldeira3, Eduardo Pereira3, António Banhudo3 1. Gastroenterology Department, Centro Hospitalar Tondela-Viseu 2. Gastroenterology Department, Centro Hospitalar Lisboa Central 3. Gastroenterology Department, Hospital Amato Lusitano

Case Report A 74-year-old man was referred to the Gastroenterology Department under suspicion of pancreatic cancer. He had a previous history of arterial hypertension, dyslipidaemia, prostatectomy for adenocarcinoma, vascular surgery for infra-renal aortic aneurysm repair and retroperitoneal fibrosis with ureteral stents placement. He also had a previous hospital admission, two months prior, for acute pancreatitis without an identified aetiology (without lithiasis or alcohol consumption). He underwent an abdominal computed tomography (CT) which showed a mass in the head of the pancreas (Figure 1). Figure 1. Abdominal CT with a 16mm mass in the head of the pancreas.   For further characterization, the patient underwent an endoscopic ultrasound (EUS), which revealed a diffusely hypoechoic pancreatic parenchyma on body and tail and a hypoechoic area with 24x16mm at the head of the pancreas, as well as a peri-pancreatic and hepatic hilum lymphadenopathy with inflammatory features (Figure 2). Fine-needle aspiration (FNA) with a 22-gauge needle through the duodenal bulb was performed. Figure 2. Linear EUS-FNA – A) diffusely hypoechoic pancreatic parenchyma; B) hypoechoic area with 24x16mm at the head of the pancreas; C) hepatic hilum lymphadenopathy with inflammatory features.   The cytological and histological examinations were consistent with chronic pancreatitis with infiltration of IgG4-bearing plasma cells (Figure 3), and, serum IgG4 assay was >6x the upper normal range (1330mg/dL – N: 3-201mg/dL), so the diagnose of type 1 autoimmune pancreatitis was established. The patient started treatment with prednisolone 40 mg/day, with gradual taper after 4 weeks, and clinical, analytical and radiological improvement was […]

Case Report An 81-years-old man with medical history of constipation and normocytic anemia presented in our department with severe weight loss over a 2 month period, without any evidence of gastrointestinal bleeding. Transabdominal ultrasound of the gastrointestinal tract was performed, without previous bowel preparation, revealing a large solid heterogeneous mass within the lumen of the descending colon, isoechogenic to the muscularis propria, measuring approximately 20 mm of longest diameter. On colour Doppler, the lesion showed predominantly central vascularity, compatible with a vascularized pedicle (Figure 1). Figure 1: Abdominal ultrasonography with Colour Doppler – A) celiac lymph node; B) heterogeneous mass, with approximately 20 mm of longest diameter, wihin the lumen of the descending colon; C and D) low vascularized lesion, with predominantly central vascularity, compatible with a vascularized pedicle   Additionally, celiac lymph node involvement was found. For further characterization, a hydrocolonic ultrassonografic evaluation was performed, showing a well-defined protruded intraluminal mass, with vascularized pedicle, consistent with a colonic polypoid lesion (Figure 2). Figure 2: Hydrocolonic ultrassonografic evaluation – well-defined protruded intraluminal mass, with vascularized pedicle, consistent with a colonic polypoid lesion.   A total colonoscopy revealed at the descending colon, with poor viewing area, an irregular and protruded sessile lesion with 25 mm (0-Is in Paris Classification), occupying two thirds of the circumference of the lumen (Figure 3). Biopsy confirmed tubulovillous adenoma with high-grade dysplasia. Figure 3: Colonoscopy with sessile polyp lesion in splenic flexure.   The patient had previously performed a computed tomography (CT) in an external institution which […]