Case Report We present the case of a 54-year-old female, with a previous history of cervical squamous cell carcinoma treated with radical hysterectomy, Piver type III (pT1b N1 R0). On a follow-up pelvic computer tomography (CT) scan, multiple iliac lymphadenopathies (9-13 mm) were detected. The patient was proposed to adjuvant radiotherapy and chemotherapy with cisplatin. One year later, a thoraco-abdominopelvic CT scan was performed, and two periceliac lymph nodes conglomerates with 44 x 29 mm and 27 x 26 mm, suggestive of recurrence of the previous neoplasia, were identified (Fig. 1). Fig. 1 – Endoscopic ultrasound imaging showing a hypoechoic solid mass with central anechoic areas, suggestive of a lymphadenopathy with central necrotic areas.   An endoscopic ultrasound (EUS) was performed using a linear scope, which confirmed the presence of a hypoechoic solid mass with central anechoic areas, with 45 mm of greater diameter, surrounding the celiac trunk and in close contact with the spleno-portal confluence and the splenic artery but, without signs of invasion (Fig. 2). Fig. 2 – Thoraco-abdominopelvic CT scan imaging showing, two periceliac conglomerate of lymph nodes, suggestive of recurrence of the cervival neoplasia.   Other, smaller (10-12mm), periceliac lesions with similar ultrasonographic features, were also found. EUS-guided fine-needle aspiration (FNA) of the major lesion was performed (25G needle – Expect™ Slimline Boston Scientific® – 2 passes) providing samples for rapid on-site evaluation (ROSE). The cytological diagnosis was of granulomatous lymphadenitis (Fig. 3). Material collected for polymerase chain reaction testing, confirmed tuberculous aetiology. Fig. 3 – Cytologic […]

Case Report An 81-years-old female presented to our department with obstructive jaundice (dark urine, pale stools) and a non-specific clinical picture of nausea and appetite loss. Laboratory tests demonstrated a mild leukocytosis with neutrophilia (13.000 cell/mm3; 86%), conjugated hyperbilirrubinemia (7.7 mg/dL), increased aspartate aminotransferase and alanine aminotransferase (10xULN and 8xULN, respectively), slightly increased alkaline phosphatase (2xULN), increased lactate dehydrogenase (10xULN) and serum lipase (3xULN). CA 19.9 was 342 U/mL (Ref value < 37 U/mL). On physical examination, there was no evidence of peripheral lymphadenopathy or hepatosplenomegaly. Abdominal ultrasound (Figure 1-A) revealed a diffuse enlargement of the pancreatic gland. The pancreatic parenchyma was hipoechoic and surrounded by an enhanced peripancreatic fat layer. Also the extra-hepatic and intra-hepatic bile ducts were dilated. The examiner did not notice any dilation of the main pancreatic duct. Contrast-enhanced abdominal computerized tomography (CT, Figure 1-B) revealed a marked homogeneous enlargement of the pancreas. The cephalic portion measured 7cm (antero-posterior diameter), more marked in the uncinate process, without any clear well-defined mass/lesion. There was a dilation of the extra-hepatic and intra-hepatic bile ducts. There was a moderate amount of ascites, especially peri-hepatic, peri-splenic, peri-pancreatic and in the parieto-colic gutter. In addition, there was a significant edema of the subcutaneous tissue of the abdominal wall and, bilaterally pleural effusions were noted. Endoscopic ultrasound (EUS) (Figure 1-C and 1-D) identified an enlarged homogeneous hypoechoic pancreas, without any well-defined lesion, no dilation of the main pancreatic duct, no peripancreatic or celiac enlarged lymph nodes. Using a 19C EchoTip Pro-Core@ HD […]

Case Report A 38 year-old female patient, with no relevant previous medical history, was referred to our unit for evaluation of recurrent left iliac fossa pain, without associated symptoms. No blood test abnormalities were found. Physical examination, pelvic and abdomen ultrasound were normal. Colonoscopy was then performed identifying, at 15 cm from the anal verge, a 3cm bulge in the lumen covered by normal mucosa. These findings were suggestive of a subepithelial lesion (Figure 1). Figure 1. Colonoscopy: 3cm subepithelial lesion, at 15 cm from the anal verge.   Endoscopic ultrasonography (EUS) showed a 30mm hypoechoic heterogeneous mass, with no precise limits and with all layers involved (Figure 2). Figure 2. EUS: 30mm hypoechoic heterogeneous mass, with no precise limits and with all layers involved.   FNA (22G needle) of the lesion was performed and cytologic examination revealed the combination of endometrial glands and stroma. These findings were compatible with endometriosis. Pelvic MRI (Figure 3) and endovaginal ultrasound found no other endometriotic lesions in the pelvis. According to patient preference, hormonal therapy was started and symptoms remission was achieved. Figure 3. Pelvic MRI: coronal (left) and transverse (right) planes. Rectosigmoid endometriosis, with no other endometriotic lesions in the pelvis.   Commentary Subepithelial lesions of the gastrointestinal tract are commonly incidentally discovered during routine upper endoscopy and colonoscopy. In the colon, subepithelial lesions mostly occur in the rectum and cecum, but lipomas (the most frequent colonic subepithelial lesion) may be seen in any part of the colon.1 Lipomas are usually yellowish, […]

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 […]