Background and aim: The utility of endoscopic ultrasound (EUS) for the evaluation and management of gastrointestinal disorders among adults has been established. Data on efficacy of EUS in pediatric population (under 18 years of age) is limited. The aim of the work is to share the pediatric EUS experience at a single tertiary center. We describe the indications, findings, safety, success rate, and utility.

Patients and methods: All patients 18 years of age or younger referred for EUS between January 2016 and Jan 2018 were identified from our electronic medical record databases. Retrospective review of demographics data, procedure indications, EUS findings, and the clinical impact of EUS on the subsequent management of the patients was conducted.

Results: A total of 5 pediatric EUS were identified from 265 attempted procedures. The median age of the patients was 15.4 years (range 12–18 years), and 100% were females (5/5). The indications of EUS were: tracheal mass relation to esophagus before surgery (n=1), pancreatic head mass (n=1), retroperitoneal mass (n=1), ampullary mass (n=1), and localization of suspected insulinoma (n=1). EUS-FNA was done in 2 patients using 22G & 19G needles without any complications. The clinical impact of EUS on the subsequent management of the patients was as the following: the tracheal mass was separable from the esophagus and referred to surgery, the pancreatic head mass was diagnosed by FNA as carcinoid tumor confirmed by positive CD56 and Ki67 <2%, the retroperitoneal mass was diagnosed by FNA as Solid pseudopapillary neoplasm (SPN) and referred to surgery, the ampullary mass was duplication cyst and endoscopic deroofing was attempted without complication, and the suspected inslunioma was excluded in the last patient. 

Conclusion: EUS in pediatric population appears safe, feasible and impact the clinical decision of the subsequent management of the patients.  Increase in EUS awareness among pediatric gastroenterologists is expected in the next years and offering dedicated EUS training is indicated to some pediatric gastroenterologists. 

Case: A 46 years man with Situs inversus totalis (SIT) was referred to our facility for endoscopic ultrasound (EUS) examination and fine needle aspiration (EUS-FNA) of pancreatic head mass with multiple liver focal lesions. With the patient in left lateral position; challenging EUS examination of the whole pancreas from the stomach starting from the pancreatic tail to the head, with anticlockwise rotation 90^o  & a reversed orientation,  showed a hypoechoic pancreatic head mass 3.2x2.7 cm with multiple peri-pancreatic lymph nodes and multiple hyperechoic hepatic focal lesions. EUS-FNA was done from both pancreatic and hepatic masses by fanning technique using a 22G needle. Cytopathological examination revealed moderately differentiated adenocarcinoma with positive IHC for CK7 & CK19 consistent with metastatic tumor of pancreatic origin. Finally, patient started neoadjuvant therapy.     

Discussion: SIT is a rare congenital condition characterized by a mirror-image transposition of both the abdominal and thoracic viscera, its incidence accounts for 1/25,000 of the normal population [1]. This condition may cause difficulties in the diagnosis and therapeutic management of abdominal pathology [2,3]. The association of SIT and neoplasia is a rare coincidence; only sporadic cases have been reported. The first case was published by Maekawa in 1927; it was an autopsy case of gastric carcinoma in a 43-year-old man with SIT [4]. 

Conclusion: Herein, we describe a rare association of SIT and metastatic pancreatic adenocarcinoma. To the best of our knowledge, this is the first reported case of full EUS pancreatic examination and EUS-FNA in a patient with SIT.

References:

1. 1. Lee SE, Kim HY, Jung SE, Lee SC, Park KW, Kim WK: Situs anomalies and gastrointestinal abnormalities. J Pediatr Surg 2006, 41(7):1237-1242. 
2. 2. Uemura S, Maeda H, Munekage M, Yoshioka R, Okabayashi T, Hanazaki K: Hepatic resection for metastatic colon cancer in patients with situs inversus totalis complicated by multiple anomalies of the hepatobiliary system: the first case report. J Gastrointest Surg 2009, 13(9):1724-1727.
3. 3. Blegen HM: Surgery in situs inversus. Ann Surg 1949, 129:244-259.
4. 4. Maekawa T: Dextrocardia, report of five autopsy cases, with special reference to hereditary. Aichi Igakkai Zasshi 1927, 34:481–493.

Pancreatic lymphangiomas are very rare benign neoplasms that should be differentiated from pseudocysts,  congenital cysts, cystic neoplasms especially mucinous and serous cystadenomas, solid pseudopapillary tumors, IPMN, acinar cell cyst adenocarcinoma and other retroperitoneal cystic tumours.  EUS and EUS-FNA with macroscopic examination of aspirated fluid, biochemical and cytological evaluation of the sample can accurately diagnose cystic lymphangiomas, hence avoid unnecessary workup or surgery. Here, we report a rare case of pancreatic lymphangioma in a 55 years old female complaining of persistent epigastric pain. Multi slice CT abdomen showed a multicystic pancreatic body lesion 3 x 4 cm with anechoic contents and thin delicate septa crisscrossing the lesion that were confirmed by endosonographic examination.  EUS-FNA revealed a milky white thick aspirate. The cyst fluid showed normal amylase, CEA and CA-19.9 but markedly elevated triglycerides, 3158 mg/dl. Cytopathological examination showed proteinaceous background with many epithelial cells and lymphocytes, no malignant cells. Based on EUS picture combined with high triglycerides level in cyst fluid, a diagnosis of pancreatic lymphangioma could be achieved with certainty. So, unnecessary workup or surgery can be avoided.

Background and aims: Carcinoid tumors are rare tumors, 1.5% of gastrointestinal tumors. Digestive Location represents 74% cases. They are tumors that grow slowly and remain localized for a long time (especially in the differentiated tumors). The clinical manifestations vary depending on tumor location and secretory character.

The aim of our study is to report 17 cases of Gastric Carcinoids (GCs) and describe the management procedures for patients with GCs.

Materials and Methods: 17 patients (7 males and 10 females) were diagnosed with gastric neuroendocrine tumors at our Center

The mean age was 47 years.

Results: for the clinical signs: abdominal pain was predominant: 64,7% of cases (Gastrointestinal bleeding: 11,7% of cases,  Melena: 10% of cases, Search for a primary cancer: 5,8% of cases and Anemia in 7,6% of cases). The type I was founded in 58,8% of cases and the type III in 32,2% cases. Multiple small polypoid fundic lesions represented 58,8% of the endoscopic appearance, 35% of ulcerative process, and 5,8% of cerebral fundic folds. The anatomo-pathological findings were consistent with carcinoid tumor of the stomach. Treatment consisted in endoscopic resection for the type I, total gastrectomy for the type II, and the metastatic spread was observed in 5.8% who received systemic chemotherapy.

Conclusions: The clinical approach to Gastric Carcinoids is largely dependent upon type and size of lesions, a lot of controversies still exist about the optimal treatment of GC tumors.

Autoimmune pancreatitis (AIP) is a rare disease, accounting for less than 2% of the causes of chronic pancreatitis. It is histologically characterized by the presence of lympho-plasmocytic infiltrate and diffuse pancreatic fibrosis. And divided into two forms: the type 1 so-called lympho-plasmocytic sclerosing AIP and the so-called ductocentric type 2 AIP.

Materials and methods:

This is a case of auto-immune pancreatitis pseudo-tumor, collected in our service in 2016.

Result:

A young man of 28 years, having presented for 10 days cholestatic jaundice rapidly progressive, evolving in a context of apyrexia and conservation of the general condition. Biology found significant cholestasis and cytolysis with normal IgG4 levels. Imaging showed significant dilatation of VBIH and VBP on diffuse hypertrophy of pseudo-tumoral pancreas without dilation of Wirsung. The diagnosis of AIP type 2 was retained, and the patient was put on corticotherapy based on 40 mg / day of prednisolone with progressive degeneration for a total duration of 14 weeks. The evolution was marked by a regression of jaundice and pruritus with complete normalization of the biological assessment at 3 weeks of treatment (13-month follow-up).

Conclusion:

Autoimmune pancreatitis remains a rare entity, whose diagnosis is difficult especially in its pseudo-tumoral form, and the response to corticosteroids is an integral part of the diagnostic criteria.

The recto-colic tumors are frequent and have an important place in the digestive tumoral pathology, imposing their early detection at the polyp stage, especially that the adenoma-cancer filiation is well established. The aim of this work is to specify the epidemiological, clinical, endoscopic and histological characteristics of these polyps.

Materials and methods :

This is a three-year extended retrospective study of 78 patients with colonic polyps out of a total of 452 colonoscopies performed during this period, for a hospital prevalence of 8.22%.

Results: The average age of patients is 50 years, with male predominance: 60 men for 18 women. The main indications are: rectorragies (36%), transit disorders (15%) and abdominal pain (20%). Polyps predominate in rectosigmoid in 63% of cases and in more than ¾ cases they are less than 10 mm in size. Resection of the polyps was performed in all cases, by the diathermic loop in 65 cases and by clamp in 13 cases.

Conclusion: In this study, the hospital prevalence of rectocolic polyps in Morocco is much lower than that reported in the literature for Western countries, but there is a similarity regarding the frequency of polyps in the recto-sigmoid. Endoscopic polypectomy and mucosectomy are the main therapeutic contributions of colonoscopy.

Ischemic colitis is the most common vascular pathology of the digestive tract. Its incidence is markedly increased, and is responsible for a significant morbidity and mortality, especially in the event of delayed diagnosis. The usual symptoms associating abdominal pain, diarrhea and rectal bleeding is very suggestive of the diagnosis, but atypical presentations are possible.Case: This is a case of ischemic colitis collected in our department.  A 53-year-old male with rheumatoid arthritis under methotrexate who had acute abdominal pain with rectal bleeding, colonoscopy showed non-gangrenous sigmoid involvement, the etiology of which was medicated (methotrexate). The clinical course was favorable after monitoring and the discontinuation of methotrexate.

Conclusion: Ischemic colitis is easily overlooked, any delay diagnosis increases the risk of mortality. Its clinical presentation is variable and the treatment depends on the severity of the lesions and the etiology.

Background and aims: Bleeding esophageal varices is the most serious complication of the portal hypertension, and the greater cause of dead (25% of the patients). The survival after esophageal varices bleeding depends in wide part from the swiftness and effectiveness of hemostasis and from the degree of functional liver reserve. The aim of our study is to report our experience about hemostasis bleeding esophageal varices with endoscopic rubber band ligation.

Methods: We assigned 50 patients (M: F ratio = 29:21; mean age was 47 years) with portal hypertension who were referred to our unit between April 2015 to April 2018 for endoscopic band ligation. Sessions of ligation were repeated every 4 to 6 weeks until the varices were eradicated

Results: Portal hypertension on cirrhosis was predominant (72% of cases with HVB/HCV-related cirrhosis, 4% alcoholic cirrhosis, 8 % primary biliary cirrhosis, and 16% cryptogenic cirrhosis). All patients received continuous intravenous drip of octreotide (250µg/h) during 3-5 days and non selective beta-blocker therapy after the episode. Primitive haemostasis was successfully achieved in 96% of patients. The varices have been obliterated in 68% of patients requiring a median of 3.8 (range 2-7) procedures, which is in good agreement with other published data. There was one case of death, following episodes of repetitive lightning haemorrhage.

Conclusions: Endoscopic rubber band ligation is currently considered the first-line treatment of proper multidisciplinary approach to the patient, both during the acute event than prevention of rebleeding, because it is an effective, safe and repeatable, in experienced hands.

Abstract

Introduction: EUS plays an important role in local staging of pancreatic and gastrointestinal (GI) malignancy and lymph node metastasis including second station lymphadenopathy that may change the plan of management. Elastography adds valuable information to EUS by providing a qualitative and quantitative evaluation of tissue stiffness, thus reflecting the malignant or benign nature of the disease. Also, it is clinically useful in selecting the most suspicious LNs for tissue sampling, especially in patients presenting multiple LNs, thus reduces the number of unnecessary biopsies and can also help in guiding the puncture in the non-necrotic part of the suspicious LN.

Aim of work: This study aimed at assessing whether endosonographic elastography and EUS-FNA are able to improve LN staging and change the plan of management in patients with pancreatic and GI malignancy.

Patients and Methods: This cross sectional prospective study included 454 patients with malignant GI (248 patients) and pancreatic (206 patients) lesions sent for EUS staging and EUS-FNA from suspicious second station LNs if needed (lymph nodes with elasticity score 3 or 4 and/or strain ratio more than 2.5).

Results: We found suspicious second station lymphadenopathy in 25 out of 454 patients (5.5%) with GI and pancreatic malignant lesions, EUS-FNA proved metastatic lymphadenopathy in 16 out of them (64%), so we changed the plan of therapy in 3.5% of all examined patients (16/454). Out of 16 patients with metastatic second station lymphadenopathy, 4 patients with pancreatic adenocarcinoma became inoperable and referred for possible radio chemotherapy, and 12 patients with GI malignancy were referred for neoadjuvant chemotherapy to downstage the tumor for possible surgical intervention later on.

Conclusion: Careful EUS stating of pancreatic and GI malignant lesions especially second station lymphadenopathy with EUS-FNA of suspicious lymph nodes is mandatory as it defiantly changed the plan of management. 

Intraductal papillary mucinous neoplasms (IPMNs) are mucin-producing papillary neoplasms of the pancreatic or biliary tract (BT-IPMN) that exhibit variable cellular atypia and cause ductal dilation. There are few reported cases of BT-IPMN in the literature. It has a higher propensity to undergo malignant transformation compared to pancreatic IPMN. We present an 80-year-old male complaining of painless jaundice. Abdominal CT revealed a 3.6 × 4.3 cm CHD soft tissue mass with diffuse dilatation of the left intrahepatic biliary ductal system and mild prominence of the right intrahepatic ductal system. EUS-FNA showed white viscous fluid with positive string sign, Histopathological examination revealed intraductal adenocarcinoma with positive mucin stain.  ERCP failed twice by two experts Endoscopist due to difficult papillary cannulation. Trial for biliary drainage by EUS was unsuccessful, due to difficulty to advance the wire through the left intrahepatic biliary ductal system distal to the CHD. A percutaneous rendezvous procedure enabled placement of guide wire through the left ductal system down to the papilla and deploying 10 French, 12 cm plastic stent.  

Heterotopic pancreas (HP) is relatively common (autoptic incidence up to 13.7%), mostly located within 3-4 cm on both sides of the pylorus. It can be affected by any pancreatic disorder, including malignancy.

A 47 year-old man was referred for thickening of the gastric wall as documented on abdominal ultrasound. Upper endoscopy (EGD) described a broad based, apically ulcerated submucosal lesion of the antrum(a).

Endosonography (EUS-FNB) with fine needle biopsy (Procore 20G needle) confirmed the submucosal origin of a 30x40 mm hypoechoic not homogeneous lesion with irregular borders, involving both submucosal and muscularis propria, with invasion of perigastric tissues (Fig1a).

After EUS-FNB obtained confirmatory neoplastic tissue (a tissue micro-core shows malignant cells with marked nuclear enlarment-b), the patient underwent Whipple surgery. The surgical specimen revealed a pancreatobiliary-type ductal adenocarcinoma (G3) arising from an HP.

Among submucosal lesions, differential diagnoses include gastrointestinal stromal tumour, carcinoid, lymphoma and schwannoma. On endoscopy, an aspecific umbilicated submucosal lesion is usually described. EUS represents a pivotal diagnostic tool for characterization of the lesion and for tissue acquisition [4].

Malignant transformation in HP may be a challenging diagnosis and must be considered when a submucosal antral lesion with EUS worrisome characteristics (irregular borders, invasiveness, abnormal nodes and an irregular shape) is found.

Introduction: Subepithelial lesions (SEL) are found incidentally during endoscopy. They are asymptomatic and often covered with normal mucosa. SEL is encountered in approximately 1 of every 500 endoscopy. Endosonography (EUS) is the most important diagnostic tool for optimal treatment and following for the SEL. In this study, we published the results of our clinic where patients underwent EUS and they were followed up for the SEL.

 Methods: The results of patients who underwent EUS procedure by using Olympus Linear / Radial echoendoscopy device are evaluated. All patients were recorded by sex, age, lesion site, size, layer, echo pattern, calcification, cystic cavities, and infiltration of serosa and lesion broad characteristics, EUS fine needle aspiration (FNA), and operations data found from medical records.

 Results: A total of 79 patients with preliminary SEL diagnosis were performed EUS. The mean age 52.9 ± 15.3, 38 (48.1%) were female and 41 (51.9%) were male patients were observed with an average of 16 months (3-22). Mean lesion size was 20.9 (6-90) mm. EUS-FNA was performed in 17(26.9%) of the patients. In the upper gastrointestinal system, the most common SEL encountered with EUS were first gastrointestinal stromal tumors (GIST) and second extraluminal compressions were seen in 16 (20.3%) of the patients (Table -1). When extraluminal compression is compared statistically according to the age and sex, there is not a significant difference (table-2). When divided according to the anatomical region, the most frequent lesions are in the esophagus leiomyoma (61.1%), GIST (58.5%) in the stomach and duodenum lipoma with 75% (table - 3).

 Conclusion: EUS for the description of layer, size, echo pattern and biopsy sampling in SEL is the most effective tool in the diagnosis and treatment decisions of SEL. According to the data we obtained from our clinic, the diagnosis and treatment is carried out effectively and easily when EUS/EUS FNA is effectively used for the patients who have SEL.

The usefulness of endoscopic ultrasound (EUS) elastography has been reported for the diagnosis of pancreatic lesions. EUS quantitative elastography strain ratio (SR) and strain histograms (SHs) are recently developed methods for non-invasive differentiation of pancreatic masses. SHs is a quantitative technique based on artificial network processing of EUS elastography digitalized videos obtaining average value with a special computer program.

Aim of the work: To investigate the accuracy of SR and SHs EUS-based methods for the diagnostic differentiation of patients with pancreatic masses.

Patients and Methods: This preliminary prospective study included 50 patients with focal pancreatic masses. Elastography images were recorded using Pentax EG-3870 UTK EUS linear probes in combination with Hitachi Avius ultrasound machine. After the final diagnosis was established, the patients were divided into two groups: a pancreatic cancer group with positive cytology achieved by fine needle aspiration puncture or histology after surgery (31 patients), and a mass forming pancreatitis group with negative cytology and follow up for at least one year (19 patients).

RESULTS: Results were obtained with software for strain histograms with reversed hue scale (0 represents the hardest tissue structure and 255 the softest). Based on the receiver operating characteristics (ROC) curve coordinates, the cut-off point for Mode 1 was set at the value of 94. Values under the cut-off point indicated the presence of pancreatic malignancy. Mode 1 reached 80% sensitivity and 47% specificity with overall accuracy of 64% (95%CI: 36%-64%) in detection of  pancreatic malignant tumors among the patients with pancreatic masses. The positive and negative predictive values were 71% and 60%, respectively. The cut-off for the strain ratio was set at the value 3.6 based on the ROC curve coordinates. Values equal or above the cut-off value were indicative of pancreatic malignancy. The strain ratio reached 100% sensitivity, 58% specificity and an overall accuracy of 80% (95%CI: 50%-80%). The positive and negative predictive values were 80% and 100%, respectively.

CONCLUSION: Mode-1 SHs showed considerable sensitivity in pancreatic

malignant tumor detection but disappointingly has low specificity, these results may be improved with sequentially incorporating larger number of patients in this work . Higher sensitivity, specificity and accuracy were achieved using the strain ratio.

Introduction:Acute lithiasis cholangitis is a bacterial infection of the bile ducts due to a lithiasic obstacle. This is a therapeutic emergency that can be life-threatening. The purpose of our work is to evaluate the results of endoscopic drainage in case of acute lithiasis cholangitis.Materials and methods:This is a retrospective study conducted in the Department of Gastroenterology II of the Military Hospital Mohammed V Instruction of Rabat between April 2002 and December 2016 including 105 patients who received ERCP for acute cholangitis. We analyzed the epidemiological data of the patients, the results of the ERCP, as well as the endoscopic amorphity and post-sphincterotomy mortality. Results and Discussion: The mean age of the patients was 58 years old with extremes ranging from 21 to 80 years old and a sex ratio of 0.06. Endoscopic biliary sphincterotomy was performed in 91.4% of cases. A naso-biliary drain was put in place in 16.1% of cases. The overall success rate of stone extraction was 95.2%. The cure rate at 7 days after ERCP was 8.5%. The mortality rate was zero. Conclusion: Endoscopic sphincterotomy has revolutionized the treatment of the lithiasis of the main bile duct and lithiasic cholangitis. It allows a good biliary drainage. Its results are satisfactory, with less morbidity and mortality compared to surgical treatment.