Case Report An 81 year old woman presented to the emergency room with one week history of abdominal pain and general weakness. The abdominal CT scan showed a 30mm mass in the body of the pancreas, suggestive of a neoplastic process, so the patient was scheduled for an EUS for local staging and tissue sampling . The endoscopic ultrasound confirmed a 26 mm mass in the neck of the pancreas, c uT2N0 (Fig. 1). Fig. 1 – Pancreatic tumor. On withdrawal, during the posterior mediastinum scanning, we identified a hypo-echoic mass that occupied almost 90% of the left pulmonary artery (Fig. 2). An angioCT scan later confirmed the pulmonary embolism and the patient was started on anticoagulation therapy. Fig. 2 – Thrombus in left pulmonary artery (LPA)   Commentary As the number of EUS procedures increases, gastroenterologists will be expected to identify more incidental findings in structures beyond the GI tract that could have an impact on patient´s management and prognosis. Therefore, a methodic evaluation of all the surrounding systems, beyond the scope of the exam, is crucial.   Authors Irina Mocanu1, Rita Barosa2, Marta Patita2, Gonçalo Nunes2, Pedro Pinto Marques2 1. Gastroenterology Department, Hospital Espírito Santo, Évora 2. Gastroenterology Department, Hospital Garcia de Orta, Almada.

Case Report We present the case of a 69-year-old woman with past history of bilateral breast carcinoma, treated with surgery and radiotherapy in 2006 and 2012, in clinical remission for the past 4 years. She had no other recent symptoms or clinical diagnosis. Following hereditary neoplastic syndromes surveillance protocol, the patient was submitted to an upper GI endoscopy, where a small submucosal lesion of the gastric antrum was identified and the patient was subsequently scheduled for an upper GI endosonography (EUS). Cardiac examination, laboratory tests and electrocardiogram were performed and were normal. At EUS, a small lipoma in the submucosal layer of the antrum was diagnosed. At mediastinal observation, a 12mm, isoechoic mass bulging from the inter-auricular septum into the left atrium was identified. The mass had no relation with the valvar ring (Figure 1). Figure 1. Mediastinal EUS showing a bulging mass in the left atrium (LA). The patient was immediately admitted for further investigations. The transesophageal echocardiography confirmed the presence of a small mass of the auricular septum and excluded thrombi or cardiac failure. There were no changes on chest and abdominal CT scan. At this point, the most plausible diagnosis was a cardiac myxoma, although the presence of a cardiac breast cancer metastasis could not be excluded, given the patient´s history. The following week, she underwent complete surgical resection of the tumor (Figure 2), with a confirming histology of cardiac myxoma. The post-operatory recovery was uneventful. Figure 2. Ex-vivo atrial mixoma.   Commentary Primary tumors of the heart are extremely rare, with […]

Case Report A 51-year-old Caucasian female with a previous history of depressive disorder and non‐steroidal anti-inflammatory drugs (NSAID) use for chronic pain by orthopaedic trauma was referred to our center due to epigastric pain, nausea and occasional vomiting during last 3 months. Physical examination, laboratory parameters and plain abdominal X-ray were unremarkable. Upper gastrointestinal endoscopy with biopsies revealed chronic pangastritis without dysplasia and positivity to Helicobacter pylori (Hp). No clinical improvement was verified following successful Hp eradication therapy and NSAID withdrawal. Abdominal ultrasound pointed to a possible wall thickening at the descending colon (0.70 cm x 4.3 cm) (Figure 1). Figure 1 – Abdominal ultrasound showing a thickening of the bowel wall with loss of layering.   Then, a total colonoscopy was performed with no abnormalities. Abdominal ultrasound was repeated and continued to show the same findings, but a small bowel origin was admitted. Therefore, an abdominopelvic CT and CT enterography were done, but both were normal (Figure 2). Figure 2 – Abdominopelvic CT (A) and CT enterography (B) with no abnormalities.   A few months after the onset of symptoms, the patient had clinical worsening with weigh loss (>10%) requiring hospital admission to parenteral nutrition. Despite a normal analytical study, abdominal ultrasound continued to show a small bowel thickening (0.88 cm in thickness), loss of wall lawering and additionally, several local lymphadenopathies and mild interloop ascites (Figure 3). Figure 3 – Sequential abdominal ultrasound continued to show a persistent bowel thickening, loss of stratification, several local lymphadenopathies and mild interloop […]

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 […]