Case Report A 79-year-old woman, with no relevant past medical history was admitted due to an idiopathic acute pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) revealed a focal main pancreatic duct (MPD) stricture in the pancreatic head with moderate upstream dilatation (7 mm), as well as prominence of secondary branches. In the uncinate process, a 17 mm cystic lesion with no apparent communication with the MPD was also described. This acute episode had a good clinical course and the patient was discharged. One month later, she underwent another MRCP that showed no evidence of the aforementioned stricture but pointed a 9 mm dilatation of the MPD at the level of the pancreatic head. Serum CA 19.9 and CEA were normal. Four months later, she was admitted due to a new episode of mild acute pancreatitis. At that time, she was referred to our institution for endoscopic ultrasonography (EUS). This exam revealed a lesion in the pancreatic head along with an atrophic pancreatic parenchyma, with lobularity, hyperechoic foci and stranding. Elastography and contrast-enhanced harmonic EUS (SonoVue®) were performed. EUS revealed in the pancreatic head a cystic dilatation of the MPD (15×15 mm), with a hyperechogenic solid component and digitiform projections that conditioned almost complete occlusion of the duct (Figure 1). Figure 1. EUS: cystic dilatation of the MPD (15×15 mm) in the pancreatic head, with a hyperechogenic solid component and digitiform projections that conditioned almost complete occlusion of the duct. The solid component had a “hard” pattern on elastography (strain ration 18.79; Figure 2) and revealed an heterogenous […]

Case Report A 65-year-old woman presented with new onset diabetes. Hes past medical history was remarkable for headache, anxiety and vasomotor symptoms for the last 3 years. Abdominal ultrasound followed by contrast-enhanced abdominal computed tomography (CT) revealed a 14-cm enhanced heterogeneous intra-abdominal mass, with cystic areas, in contact with the posterior wall of the gastric fundus (Figure 1).  Figure 1. Abdominopelvic CT (axial and coronal view): a 14-cm enhanced heterogeneous intra-abdominal mass, with cystic areas, in contact with the posterior wall of the gastric fundus. Endoscopic ultrasound (EUS) was performed and showed a giant well-defined rounded hypoechogenic mass, without cleavage plane between the mass and the gastric wall. This was a very heterogeneous mass, with anechoic areas, suggestive of cystic transformation. Its size exceeded the endoscopic field (Figure 2-4). Figure 2. EUS (transgastric view): a giant well-defined rounded hypoechogenic and heterogeneous mass, with anechoic areas, suggestive of cystic transformation.   Quiz   Discussion EUS-fine needle biopsy (EUS-FNB) using a 25G needle with rapid on site cytological examination (ROSE) was performed. Cytological analysis  performed on the cell block demonstrated irregular clusters of  cells with finely eosinophilic granular cytoplasm and pronounced anisokaryosis with large and irregular nuclei (Figure 5). Immunohistochemistry was positive for vimentin and synaptophysin and negative for CD117, S100 and CD34; Ki67<3%. Figure 5. Cithology (Papanicolaou, 100x): irregular clusters of  cells with finely eosinophilic granular cytoplasm and pronounced anisokaryosis with large and irregular nuclei. Toward these findings, 24-hour urine fractionated metanephrines were measured and were elevated (normetanephrine 5832pg/mL and metanephrine 11738pg/mL) and […]

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.   Quiz   Discussion 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. 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 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 26-year-old male with history of sleeve gastrectomy (4 years ago) was referred to the Gastroenterology outpatient clinic due to abdominal discomfort. On physical examination a hard, nontender, large abdominal mass was found. Abdominal CT scan revealed a 210×117 mm contrast-enhanced solid mass centered in the mesentery (Fig. 1a and 1b). There were no signs of bowel obstruction or evidence of lymphadenopathy. Figure 1. Abdominal CT (a – coronal view; b – axial view): contrast-enhanced solid mass centered in the mesentery. After multidisciplinary discussion, endoscopic ultrasound (EUS) with tissue acquisition was performed. The cranial portion of the abdominal mass was observed through the distal second portion of the duodenum. EUS demonstrated a hypoechoic heterogeneous mass with ill-defined borders (Fig. 2a). Real-time EUS elastography revealed a heterogeneous, predominantly blue (hard) pattern (Fig. 2b). Through the duodenum we performed EUS-guided fine needle core biopsy (EUS-FNB) using a 25G needle (Acquire™, Boston Scientific®). Figure 2. EUS (transduodenal view): hypoechoic heterogeneous mass with ill-defined borders; a –  EUS – elastography: predominantly blue (hard) pattern; b – EUS-FNB.   Quiz   Discussion The histology specimen showed the presence of fusiform cells, without atypia (Fig. 3a and 3b). Imunohistochemical staining was positive for β-catenin (Fig. 3c) and negative for c-KIT, DOG-1, AE1/AE3, CD34, S100 protein, alfa-actin and MDM2.  Figure 3.  Patholohy: a and b – Presence of fusiform cells, without atypia (4x and 20x, respectively); c – imunohistochemical staining was positive for β-catenin (20x). The patient underwent surgical resection of the tumor that included segmental enterectomy […]

Case Report A 68-year-old man presented with weight loss (3kg in 5 months). His past medical history was remarkable for ART-controlled HIV infection (HIV viral load <20 and CD4+ lymphocyte count 692/uL). Review of systems revealed no other symptomatology. Chest X-ray showed a right-sided pleural effusion (Fig. 1). Figure 1. Chest x-ray (posterior-anterior view):right-sided pleural effusion. A diagnostic thoracentesis was then performed and revealed a very viscous yellow pleural fluid, which biochemical analysis was compatible with exudative effusion. Fluid cultures were negative. Cytological analysis of the pleural fluid showed morular papillary neoplastic cells with cytoplasmic vacuoles compatible with adenocarcinoma. However, cell block immunohistochemistry was positive for CK5/6 and negative for BerEP4, TTF1 and CDX2 favoring the diagnosis of mesothelioma. To assist the differential diagnosis a pleural biopsy was done but it was inconclusive due to insufficient material. A contrast-enhanced thoracic computed tomography (CT) was then performed and revealed a large right-sided pleural effusion and a 16x10x5cm hypodense non-enhancing posterior mediastinal mass, anterior to the vertebrae and causing esophageal and aortic artery axis deviation, without invasion or pleural thickening; no parenchymal lung masses or lymphadenopathies were seen (Fig. 2).   Figure 2. Thoracic CT (a – coronal view; b – axial view): large right-sided pleural effusion and 16x10x5cm hypodense posterior mediastinal mass. To further characterize this mediastinal mass an endoscopic ultrasound (EUS) was done and showed a very large well-defined rounded hypoechogenic mediastinal mass, located between 29 and 39cm from the incisors, adjacent to the esophagus and aorta, without invasion (Fig. […]

Case Report A 59-year-old woman with no relevant past medical history was referred to the Outpatient Clinic due to iron-deficiency anemia (minimum hemoglobin level of 6.8g/dL). Upper endoscopy showed a large smooth-surfaced polypoid lesion occupying most of the duodenal bulb (Figure 1). Ileocolonoscopy was normal. Figure 1. Upper endoscopy showed a large polypoid lesion covered with intact mucosa in the duodenal bulb. Endoscopic ultrasound (EUS) revealed a 36x24mm heterogeneous mixed echoic submucosal lesion with multiple cystic areas (Figure 2a), with a 14mm thick short pedicle (Figure 2b) and a feeding artery on color Doppler. Figure 2. EUS showed a larged mixed echoic submucosal lesion with cystic areas (Figure 2a), with a short pedicle (Figure 2b).   Quiz   Discussion Bite-on-bite biopsies were taken where Brunner’s glands hyperplasia was identified. Resection of the lesion with a hot snare after submucosal injection of diluted adrenaline was performed, without complications (Figure 3). Histopathologic diagnosis was Brunner’s gland hamartoma (Figure 4).Figure 3. Endoscopically ressected specimen. Figure 4. Photomicrograph of Brunner’s gland hamartoma. On 6-months follow-up, the patient has no anemia. Brunner’s gland hamartomas are rare and benign tumors that occur mainly in the bulb, with less than 200 cases reported in the literature1. Most cases have been reported between the ages of 50 and 60 years, with no gender predominance2. They consist of abnormal proliferation of Brunner’s glands embedded in a fibrous stroma with bundles of smooth muscle and cystic dilated ducts1. Hyperplasia is the designation for lesions smaller than 5mm, which can be diffuse […]

Case Report An 81 year-old anticoagulated male patient, with a medical history of atrial fibrillation and valvular cardiomyopathy, performed a total colonoscopy due to intermittent hematochezia, which revealed in the distal rectum a well-defined and regular protruded sessile lesion with 16 mm (T0 Is) (Figure 1). Figure 1. Protruded sessile lesion (T0 Is) with 16 mm, in the distal rectum. Endoscopic ultrasound examination (EUS) identified a hypoechoic lesion with clear margins arising from the second layer, without lymph node or muscular layer involvement (Figure 2). Figure 2. Hypoechoic lesion arising from the second layer.   Quiz   Discussion Abdomino-pelvic computerized tomography (CT) and PET-TC DOTA NOC showed no distant metastasis. Multidisciplinary evaluation was carried out and excision of the tumor by endoscopic submucosal dissection (ESD) was planned. The procedure was performed with no complications reported (Figure 3). Figure 3. A to F – Endoscopic excision of a rectal neuroendocrine tumor by endoscopic submucosal dissection (circumferential mucosal cutting and submucosal dissection performed with the Dual-Knife, Olympus®). Pathological analysis confirmed the diagnosis of a totally resected well differentiated neuroendocrine tumor (G1) with a low mitotic index (Ki67 < 2%) and no lymphovascular invasion. No distant metastasis were identified during the follow up period (2 years). The incidence of rectal neuroendocrine tumors has been rising largely due to an increased number of screening colonoscopies, allowing for identification of smaller lesions amenable to endoscopic treatment1. Indeed, endoscopic therapy of neuroendocrine tumours may be considered in lesions below 2 cm, without muscularis invasion according to the European Neuroendocrine […]