Case Report A 64-year-old female was referred for general surgery department for common bile duct (CBD) abnormal dilatation. Her previous medical history included dyslipidemia and depression and she was currently medicated with propranolol, lorazepam and sertraline. Previous surgeries included cholecystectomy, appendectomy and thyroidectomy. Magnetic resonance cholangiopancreatography (MRCP) revealed CBD dilation with a maximal diameter of 14 mm and mild dilation of intra-hepatic bile ducts. Although there were no intraluminal lesions, the dilation appeared to end abruptly at the junction with main pancreatic duct (Fig. 1). Therefore, she undergone endoscopic ultrasound (EUS) that confirmed CBD dilation and hyperechogenic contents were apparent at its distal portion suggestive of biliary sludge. Prompt endoscopic retrograde cholangiopancreatography (ERCP) was performed, but no calculi were identified at cholangiogram or after Fogarty balloon exploration. There were no immediate adverse events. At the following day, the patient complained of abdominal pain and performed an abdominal computerized tomography (CT) where moderate ascites was noted. Laboratory studies revealed leukocytosis and elevated C-reactive protein. Diagnostic paracentesis was consistent with biliary peritonitis and she started intravenous antibiotic therapy with ceftriaxone and metronidazole. Considering a possible biliary perforation, ERCP was repeated. There was no evidence of contrast leakage. Nevertheless, considering biliary ascites, a fully-covered self-expandable metal stent was placed (Fig. 2). She maintained antibiotic therapy for 14 days with clinical and biochemical improvement and undergone repeat abdominal CT which revealed three abdominal fluid collections: one with 14.9×6.9×7.8 cm at retroperitoneal location, one with 6.6×3.4 cm adjacent to gastric posterior wall and one with […]

Case Report A 40-year-old woman with rectal bleeding underwent a colonoscopy. Her past medical history included dysmenorrhea controlled with a hormonal intrauterine device. Colonoscopy revealed a 15 mm polypoid lesion covered by eroded mucosa and luminal narrowing at 20 cm from the anal verge (Fig. 1A and 1B).  Histopathologic assessment of standard biopsy specimens was inconclusive. A pelvic magnetic resonance imaging demonstrated a 20 mm neoplastic lesion at sigmoid colon with endophytic growth. An endoscopic ultrasound (EUS) showed a 19×8 mm hypoechoic, round, well-demarcated lesion arising from the muscularis propria and involving superficial layers (Fig. 2). A EUS-guided fine-needle biopsy (EUS-FNB) was performed (Acquire 22 G needle, Boston ScientificTM, 2 passes) (Fig. 3).  Quiz Discussion Histopathological and cytological examination showed endometrial glands and stroma (Fig. 4), a pattern compatible with endometriosis. The patient is receiving treatment with monthly subcutaneous injection of gonadotropin-releasing hormone agonists. The most common location of extragenital endometriosis is the bowel. Rectosigmoid colon is involved in up to 93% of these cases. Patients may be asymptomatic or may present with dysmenorrhea, hematochezia, lower abdominal pain, constipation, diarrhea, tenesmus, and even bowel obstruction. An association of symptoms with the menstrual cycle is an important diagnostic clue (1). Endoscopically, bowel endometriosis may mimic subepithelial and neoplastic lesions as well as inflammatory, infectious or ischemic disease (2). Standard biopsies obtained during endoscopy are rarely sufficient for the diagnosis and imaging tests are not sensitive for the diagnosis. EUS features of rectosigmoid endometriosis have been reported as including a hypoechoic deep pelvic mass with an irregular or unclear margin infiltrating the anterior wall of the rectosigmoid colon (3). However, to confirm a diagnosis of rectosigmoid endometriosis, histologic identification of […]

Case Report A 42-years-old Caucasian male, without relevant past medical history, was diagnosed with B-cell acute lymphoblastic leukemia. He completed the induction phase of the PETHEMA LAL Ph-2008 protocol, without complications. Later, the patient was readmitted to start the consolidation phase. However, it was noticed new-onset cytocholestasis and hyperbilirubinemia, without coagulopathy or encephalopathy. He had no personal or family history of liver disease. The metabolic, virological and autoimmune study was negative. Abdominal computed tomography scan revealed a liver with normal morphology and without hepatic metastasis or portal thrombosis. Magnetic resonance cholangiopancreatography showed normal intrahepatic and extrahepatic bile ducts. Endoscopic ultrasound (EUS) revealed no focal liver lesions. EUS-guided fine needle biopsy using a 22G needle was performed (2 passes; 22G Acquire, Boston Scientific) obtaining material that was sent for evaluation. The histological examination showed marked canalicular and hepatocytic cholestasis and ductopenia probably due to hepatic drug toxicity. Ten days after the liver biopsy, the patient presented sudden epigastric pain. He was hemodynamically stable. The abdomen was soft, with epigastric tenderness, without rebound tenderness. Hemoglobin and hepatic profile remained stable and there was no elevation of inflammatory markers. The abdominal ultrasound (US) revealed a heterogeneous lesion with 56 mm located in segment VIII of the liver (Fig. 1). Quiz Discussion The abdominal computed tomography scan revealed a hepatic pseudoaneurysm and an adjacent intrahepatic hematoma (Fig. 2). After the diagnosis, the patient underwent a transcatheter arterial embolization. Complete embolization of pseudoaneurysm was accomplished after 3 embolization sessions, performed during 1 week. During hospitalization, the patient maintained hemodynamic stability, without […]

Case Report The authors present the case of a 72-year-old male patient being studied at Gastroenterology Consult due to hyperbilirubinemia (Total bilirubin 2mg/dL). Gilbert syndrome and toxic, metabolic, virologic and auto-imune causes were excluded. Abdominal ultrasound showed gallbladder lithiasis. Abdominal magnetic resonance disclosed a pericentimetric periampullary nodularity.  An endoscopic ultrasonography (EUS) was performed and identified a hyperechoic thickening of the ampulla, with clearly defined regular borders, without intraductal infiltration, biliary or pancreatic duct dilation (Fig. 1). Quiz Discussion These findings were compatible with ampullary adenoma. Duodenoscopy showed a papilla with a polypoid appearance, with around 15mm, without ulceration. EUS evaluation showed signs of benign nature: the duodenal layers were preserved, there were no biliary or pancreatic duct dilatations and there was no evidence of intraductal polypoid infiltration. Multiple biopsies of the papilla of Vater were performed, that disclosed adenoma with low-grade dysplasia. The patient accepted and an endoscopic papillectomy was performed. Histologic assessment confirmed the adenomatous nature, with low-grade dysplasia. There were no signs of submucosal infiltration and resection margins were clear. Distal biliary duct biopsies were performed during the same session: bile duct type mucosa with fibrosis, without dysplasia or neoplastic tissue. Total bilirubin has normalized, and the patient is asymptomatic. Follow-up at three months with duodenoscopy and biopsies showed no signs of endoscopic or histologic recurrence.  Nowadays, ampullary tumors are being increasingly diagnosed, frequently during routine upper endoscopy performed for unrelated reasons [1,2]. The majority of benign and malignant ampullary tumors are sporadic and involve the major papilla; however, […]

Case Report The authors present the case of a 56-year-old female patient with a history of smoking, referred for upper endoscopy due to dyspepsia associated with vomits and weight loss (12Kg in 6 months). Laboratory study revealed no abnormalities. Upper endoscopy revealed erythema and thickening of the gastric folds, more apparent in the distal body, associated with atrophic gastropathy of the antrum (Figure 1). Biopsies of the body and antrum were performed.  Endoscopic ultrasound (EUS) was performed and revealed a diffuse and concentric wall thickening (10mm) of the gastric body, with loss of the pentalaminar structure, despite maintenance of cleavage plain with adjacent structures (Figure 2). The remaining gastric segments revealed no abnormalities in EUS. Neither abnormal peri gastric lymph nodes nor ascites were detected. Histology revealed fragments of gastric mucosa with chorion expansion, infiltrated by a population of small lymphocyte cells with irregular nucleus (Figure 3). Helicobacter pylori was found in the specimen. Immunohistochemistry revealed strong expression of CD20 and CD79a without expression of CD5 or cycline D1.  Quiz Discussion These findings are compatible with gastric MALT lymphoma IE2 (Ann Arbor staging system). Gastric MALT lymphoma comprises about 50% of primary gastric lymphomas (PGL) and up to 90% of PGL are either MALT or DLBCL [1]. Endoscopy combined with multiple biopsies is considered the gold standard in the diagnosis of gastric MALT lymphoma [2]. However, EUS is considered the method of choice for locoregional staging, including the detection of affected peri gastric lymph nodes [3]. This is of great importance since […]

Case Report The authors present the case of a 68-year-old male patient with a history of smoking and chronic cough. A thoracic CT scan was performed and revealed a mass with mediastinal invasion in the left upper lobe and a nodule in the right lung. An abdominal CT scan documented a mass of 40×35 mm in the transition between the body and tail of the pancreatic gland, as well as a nodule in the right adrenal gland, three small liver nodules and a nodule in the right kidney. An endoscopic ultrasonography (EUS) was performed and identified a heterogeneous, hypoechoic solid lesion, with a clearly defined irregular borders, measuring 17.8 x 20.5 mm. Fine needle biopsy (FNB) was performed (Acquire 22 G, Boston Scientific). Figure 1. EUS (transgastric view): A heterogeneous hypoechoic solid lesion, with a clearly defined irregular borders, measuring 17.8 x 20.5 mm, located between the body and tail of the pancreatic gland. FNB was performed. Quiz Discussion These findings were compatible with pancreatic metastasis of lung cancer. Histopathological analysis revealed small cell high grade neuroendocrine carcinoma, positive for cytokeratin AE1/AE3, CAM 5.2, TTF1, CD56 and synaptophysin and negative for p40 and chromogranin; Ki67 antibody was positive in 40-50% of neoplastic cells. Positivity for TTF1 suggested it was a primary tumor of the lung – small cell lung carcinoma. A final diagnosis of metastatic small cell lung carcinoma was made. Metastatic tumors of the pancreas are responsible for 1-2% of all pancreatic solid lesions [1]. On EUS they show […]

Case Report The authors present the case of an 81-year-old male patient with a history of smoking and hypertension, referred for an endoscopic ultrasound (EUS) due to the appearance of obstructive jaundice. The patient previously performed abdominal CT scan that revealed a pancreatic head mass, measuring 40x40mm and multiple bone lesions in the sternum and ribs. Laboratory study revealed hyperbilirubinemia (total bilirubin 4.3 mg/dL, direct bilirubin 3.2 mg/dL) and cholestasis (alkaline phosphatase 341U/I, gamma-glutamyl transferase 641 U/I). CA 19.9 and carcinoembryonic antigen were normal. EUS revealed in the cephalopancreatic region a vaguely nodular area, heterogeneous, hypoechogenic, and with ill-defined limits and contours, with approximately 36x37mm (Figure 1). The elastography study of the lesion revealed a heterogeneous green pattern with a strain-ratio of 6.8 (Figure 2). The main pancreatic duct had a normal caliber in the body and tail, with mild ectasia in the cephalic/periampullary region. Tissue sampling was obtained through fine needle biopsy (FNB), 2 passages, using an AcquireTM 22G needle (Boston Scientific). Histopathological analysis identified an infiltration of the pancreatic parenchyma with intermediate size anaplastic cells, some of which with plasmacytoid phenotype. Immunohistologically there was positivity of CD138; proliferative activity assessed by Ki67 was 80%, and CD20 and cytokeratins were negative. Quiz Discussion The histopathological analysis was compatible with a pancreatic plasmacytoma. About 5% of plasma cell tumors form an isolated solitary lesion, called plasmacytoma.1 Extramedullary plasmacytoma is a very rare tumor derived from plasma cells and found outside the bone marrow. Only 10% of extramedullary plasmacytomas occur in the gastrointestinal tract, where […]

Case Report The authors present the case of a 73-year-old male patient with a history of smoking and chronic obstructive pulmonary disease. A thoracic CT scan was performed and revealed multiple esophageal nodules in all segments (Fig. 1). The patient was asymptomatic, with no dysphagia, thoracic or epigastric pain or weight loss. An esophagogastroscopy was performed and documented multiple bulges covered by normal mucosa, non-pulsatile, of hard consistency without pillow sign (Fig. 2). Endoscopic ultrasonography (EUS) revealed hypoechoic nodules arising from the fourth layer of the esophageal wall, the largest with 25×18 mm (Fig. 3). Fine needle biopsies (FNB) were performed (Acquire 22 G, Boston Scientific). Quiz Discussion These findings were compatible with multiple leiomyomas. Histopathological analysis revealed benign leiomyomatous cellular proliferation, positive for muscle specific actin and negative for CD117 and S100. A final diagnosis of multiple leiomyomas was made. Primary intramural benign tumors of the esophagus are responsible for 2% of all esophageal tumors [1]. Leiomyoma is the most common solid benign tumor of the esophagus, and comprises of around 70% of esophageal subepithelial lesions [2,3]. It occurs more often in male patients (2:1) at a median age of 30-35 years and rarely presents as multiple lesions, with few cases reported [1]. By EUS, leiomyomas present as well-defined hypoechoic nodules in the muscularis propria or the muscularis mucosae (fourth and second EUS layers, respectively) [4]. Histology demonstrates well-differentiated smooth muscle cells with immunohistochemical findings positive for muscle actin and negative for CD117 and S100. CD117 corresponds to c-Kit […]