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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 […]


US Quiz January 2020

Case Report A 65-year old asymptomatic male was referred to our Gastroenterology Department following incidental detection on abdominal ultrasound of a pancreatic head tumour, strongly hypoechoic, with 35mm in diameter, just above the confluence of the superior mesenteric and splenic veins. Magnetic resonance cholangiography (MRI) suggested a solid lesion measuring 30mm adjacent to the splenic-mesenteric-portal venous confluence and above the pancreatic isthmus; an identic lesion measuring 16mm was detected adjacent to the pancreatic tail (Fig. 1. and 2.). Endoscopic ultrasonography (EUS) documented an anechoic structure with thin well-defined walls adjacent to the portal confluent and continuing with the splenic vein, 30mm in diameter, with positive colour Doppler and monophasic waveform in pulse wave Doppler study; this lesion was adjacent to the pancreas but with a clear interface with it (Fig. 3.). Adjacent to the pancreatic tail another lesion was identified, mildly hypoechoic, homogenous, well defined regular walls, 14mm in diameter, again with a clear interface with the pancreas and the spleen (Fig 4.).  Quiz Discussion A wide range of anatomic variants and pathologic conditions in and around the pancreas may simulate primary pancreatic neoplasia at different imaging modalities. Based on EUS appearance of the lesion and its relation to the splenic vein, the diagnosis of splenic vein aneurysm was easily made. The smaller lesion had very different US characteristics suggesting an accessory spleen, due to its location and US features (namely similar echostructure to the adjacent spleen). Venous system aneurysms are uncommon and splenic vein aneurysms are exceedingly rare. Lowenthal and Jacob described the first case of splenic vein aneurysm in […]