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Case Report A 31-year-old Indian patient, living in Europe for the last 7 years, was admitted in the emergency department for jaundice, epigastric and right upper quadrant abdominal pain for the last 3 days, loss of 4.5Kg in the previous month, without fever or other remarkable symptoms. Physical examination showed tenderness on the right upper quadrant and icteric sclera. Laboratory studies revealed normal blood cell counts and C-reactive protein levels (3.5 mg/L), elevated total serum bilirubin levels (5.9 mg/dL), mainly due to direct bilirubin (4.4mg/dL), AST of 107U/L, ALT of 132 U/L, ALP of 354 U/L and GGT of 152 U/L.  Computed tomography (CT) showed a hypodense, multiloculated lesion with cystic areas and calcifications, measuring 7×4.5x7cm, in the pancreatic head, isthmus and body, involving the portal vein and extending to the hepatic hilum, including the main bile duct, without significant upstream dilation (Fig. 1 and 2). Endoscopic ultrasound (EUS) revealed a hypoechoic retroperitoneal heterogenous lesion, >58mm, with dispersed calcifications, involving the portal vein and distal portion of the bile duct. The lesion contacted the head, isthmus and corpus of the pancreas; the remaining parenchyma and main pancreatic duct appeared normal (Fig. 3 and 4). Fine needle biopsy (22G Cook® ProCore®) was performed with core tissue acquisition. Quiz Discussion Citologic analysis revealed several epithelioid granulomas with caseous necrosis and the presence of giant Langhans cells. Acid-alcohol-resistant bacilli were detected and nucleic acid amplification test positive for Micobacterium tuberculosis complex. The patient was started on tuberculostatic treatment. Thoracic CT did not show typical signs […]


GRUPUGE Perspective: Interventional Endoscopic Ultrasound in Biliopancreatic Diseases

Assistimos nos últimos 5 anos a importantes progressos na área da endoscopia de intervenção na patologia bilio-pancreática, com a disponibilização de novos acessórios e com a publicação de um número crescente de estudos a avaliar a aplicabilidade clínica de diferentes terapêuticas em ecoendoscopia. O GRUPUGE considerou pertinente sistematizar o estado da arte, privilegiando a publicação de recomendações no formato de “perspectiva do GRUPUGE” sobre 5 temas em patologia bilio-pancreática, em que a ecoendoscopia tem assumido um papel crescente na abordagem terapêutica. 1. Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections 2. Endoscopic Ultrasound-Guided Biliary Drainage 3. Endoscopic Ultrasound-Guided Celiac Plexus Interventions 4. Endoscopic Ultrasound-Guided Ablation of Focal Pancreatic Lesions 5. Endoscopic Ultrasound-Guided Fine-Needle Tattooing and Fiducial Placement in Pancreatic Cancer


US Quiz February 2020

Case Report A 74-year old female patient presented with abrupt epigastric pain, vomiting and jaundice. Laboratory tests revealed an elevated total bilirubin of 4.85 mg/dL (direct 4.12 mg/dL). Abdominal ultrasound showed several calculi in the gallbladder and an increased diameter of intra-hepatic and common biliary duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) was not possible due to failed cannulation (Fig. 1), even using a pre-cut technique, however duodenoscopy identified a large periampullary duodenal diverticulum, with food debris.  An endoscopic ultrasound (EUS) was performed (Fig. 2 and 3).  Quiz Discussion Endoscopic ultrasound showed a compressed distal CBD by a periampullary diverticulum. The diagnosis of Lemmel syndrome was assumed. Considering the resolution of symptoms and laboratorial normalization after food removal, no other treatment was performed. After 8 months no recurrence was observed. Periampullary diverticula (PAD) are not uncommon findings in patients undergoing ERCP. Although many of PAD are asymptomatic, some may be associated with pancreatobiliary disease [1,2]. Lemmel syndrome, originally described by Gerhard Lemmel, is a symptom complex defined by the presence of obstructive jaundice caused by a periampullary duodenal diverticulum [3]. Although it is a rare condition, it should be considered as a differential diagnosis in the absence of choledocholithiasis, strictures or tumors [3,4,5]. References Zoepf T, Zoepf D, Arnold J, Benz C, Riemann J. The relationship between juxtapapillary duodenal diverticula and disorders of the biliopancreatic system: analysis of 350 patients. Gastrointest Endosc 2001;54:56–61. Egawa N, Anjiki H, Takuma K, Kamisawa T. Juxtapapillary duodenal diverticula and pancreatobiliary disease. Dig Surg. 2010;27(2):105-9. Lemmel G. The clinical significance of the duodenal diverticulum (Die […]