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Endoscopy Case Capsule 9 Endoscopic Ultrasound Diagnosis & Endotherapy of Recurrent Acute Pancreatitis leading to Calculous Chronic Pancreatitis A 22 yrs male patient was referred to us for the favor of EUS sos Endotherapy for recurrent acute pancreatitis. Patient has been suffering for multiple episodes of acute pancreatitis over the last 2 years and had more than 7 episodes of hospitalization. Unfortunately he was advised by his treating doctors that nothing can be done for recurrent acute pancreatitis and he has to live with it. Fortunately, he was then seen by a Surgeon and evaluated and found to have changes of chronic pancreatitis on other imaging studies and was then advised to come and see us. Patient was then subjected to EUS which revealed a soft stone in the prepapillary portion of MPD with dilated MPD and possibility of pancreatic ductal anomaly. There was no evidence of any parenchymal disease and no calcification. In view of these findings in the same sedation, pancreatic Endotherapy was then performed. ERCP followed by pancreatic sphincterotomy, stone extraction and pancreatic stenting was performed. Immediately after pancreatic Endotherapy patient started having complete relief in symptoms and he is asymptomatic on follow up over the last few months. Patient was admitted only for a day for observation and was sent home the next day with uneventful recovery. Endoscopy Asia’s Comments As we can see here, accurate EUS Pancreatic evaluation of both the pancreatic duct and parenchyma allows us to offer the most optimal treatment option for this young patient. In our experience at Endoscopy Asia of over several hundred patients diagnosed and treated for recurrent acute pancreatitis and chronic pancreatitis, we have observed that a combined protocol of EUS sos Pancreatic Endotherapy has emerged as the most patient friendly approach in decision making regarding the long-term outcomes of these patients. Published studies have shown that around 65-70% patients with chronic pancreatitis can --------------------------------------------------------------------------------------------------------------------Endoscopy Asia 2nd Floor, Lion Tarachand Bapa Hospital Marg,Jain Society, Sion (West),Mumbai 400 022, India. Contact No (09:30 - 20:30) 022 2404 3522 / 2404 4680, 3208 8827 / 8 / 9 | Emergency (08:30 - 23:30) +91 93200 91763 / 98200 91763 | Email: enquiry@endoscopyasia.com |Telefax: 022 2404 4680


be successfully treated with Endotherapy with reasonable long-term outcomes, however, patient selection in the chronic pancreatitis group is vital to success. Take Home Message This patient was suggested by his treating doctors that nothing can be done for recurrent acute pancreatitis and as you can see here that an appropriate approach with EUS evaluation of the etiology of pancreatitis, the ductal and parenchymal study allowed effective endoscopic treatment for this young patient, who is now relieved of his suffering. Hence, it is my appeal to all clinicians, that any patient who has suffered more than 2 episodes of acute pancreatitis should be evaluated thoroughly. In this event, EUS evaluation is considered as the most important imaging modality worldwide and we have been practicing this protocol for over 14 years now.

1. EUS shows normal CBD and Gall bladder

2. After selective cannulation of MPD pancreatic sphincterotomy was performed

3. Pancreatogram showed changes of chronic pancreatitis on ERP with a stone in MPD

4. Soft stone from the Pancreatic duct was extracted with stone extraction balloon catheter

--------------------------------------------------------------------------------------------------------------------Endoscopy Asia 2nd Floor, Lion Tarachand Bapa Hospital Marg,Jain Society, Sion (West),Mumbai 400 022, India. Contact No (09:30 - 20:30) 022 2404 3522 / 2404 4680, 3208 8827 / 8 / 9 | Emergency (08:30 - 23:30) +91 93200 91763 / 98200 91763 | Email: enquiry@endoscopyasia.com |Telefax: 022 2404 4680


5. After stone extraction and complete pancreatic ductal clearance, a 5 fr stent was placed to ensure effective ductal decompression

Endoscopy Asia Photo Journal Case Capsule-9 A 49 yrs old female patient was referred to us for the favor of EUS sos EUS guided FNA for diagnosed large nodes in the peripancreatic and perigastric region detected on USG abdomen and CT Scan on a routine health check up. The only symptoms patient had was of some dyspepsia off and on without anorexia or weight loss. EUS showed large conglomerate of nodes measuring 4.0 cms x 3.0 cms. EUS guided FNA was then performed and aspirated material was sent for cytological , histopathological examination along with AFB culture and sensitivity. The examination revealed tubercular lymphadenitis and diagnosis was clinched. The whole EUS FNA procedure took us 10 minutes at Endoscopy Asia on an OPD basis and patient was sent home the same day. Take Home Message: As we have seen in this case that any lymph node mass detected on either USG abdomen or CT scan can have accurate tissue diagnosis with the help of EUS-FNA and therefore all the leading Institutes of world are moving away from CT guided FNA / Biopsy. The advantage of EUS-FNA is that if there are periportal or perigastric nodes we can approach them and while coming out if there any Mediastinal nodes we can approach that too for tissue acquisition and in this case. I am glad to share with you that we have experience of over 1500 patients with periluminal nodal mass sent to us for EUS guided FNA with a diagnostic accuracy at our unit close to 92%

--------------------------------------------------------------------------------------------------------------------Endoscopy Asia 2nd Floor, Lion Tarachand Bapa Hospital Marg,Jain Society, Sion (West),Mumbai 400 022, India. Contact No (09:30 - 20:30) 022 2404 3522 / 2404 4680, 3208 8827 / 8 / 9 | Emergency (08:30 - 23:30) +91 93200 91763 / 98200 91763 | Email: enquiry@endoscopyasia.com |Telefax: 022 2404 4680


1. A large hypoechoic nodal mass seen in the porta with anechoic and microcalcific areas

2. EUS guided FNA being performed from the porta nodal mass. EUS allows targeted real time approach

3. A large conglomerate of nodal mass was seen in the subcarinal periesophageal region in the posterior mediastinum.

4. EUS guided FNAB was performed with a Core biopsy needle and specimen was acquired For histopathological examination sos IHC studies

--------------------------------------------------------------------------------------------------------------------Endoscopy Asia 2nd Floor, Lion Tarachand Bapa Hospital Marg,Jain Society, Sion (West),Mumbai 400 022, India. Contact No (09:30 - 20:30) 022 2404 3522 / 2404 4680, 3208 8827 / 8 / 9 | Emergency (08:30 - 23:30) +91 93200 91763 / 98200 91763 | Email: enquiry@endoscopyasia.com |Telefax: 022 2404 4680


Gastrovision september 2012 contents  
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