Gastrovision Case-2

7/22/2019 Gastrovision Case-2

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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: [email protected] |Telefax: 022 2404 4680

Case-2

Acute Pancreatitis- Leading Pancreatic Pseudocyst- Endoscopic Treatment

performed (EUS Guided Cystogastrostomy )

A 36 yrs/ Male referred to us for the favor of EUS ( Endoscopic Ultrasound) sos guided

drainage of Pancreatic pseudocyst secondary to an episode of severe acute pancreatitis (alcohol related) about 11 months back. The size of pseudocyst was around 11 cms x 10cms and there was no regression of size in the last 11 months and patient complained of

intermittent pain and vomiting and hence EUS was considered.

EUS showed a large pseudocyst with some compression on stomach without anyabnormal vessels or pseudoaneurysm. EUS guided cystogastrostomy was then performed

with a therapeutic EUS scope. After placement of double pigtail stent the pseudocystregressed immediately and patient was observed overnight and sent home the next day.

On follow up patient is symptomatic and stent has been removed, so far in 23 months offollow up there is no recurrence.

1.EUS showed large pseudocyst

without debris2. EUS guided transgastric puncture



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3. Puncture tract dilated with cystotome 4. Tract further dilated with a 6 mm

balloon

5. Double pigtail stent draining clearPseudocyst fluid into the stomach

6 Fluoroscopy shows double pigtail stent

Placed across the stomach wall into thePseudocyst. Echoendoscope seen.

Expert comments:

It is well known that after an episode of acute pancreatitis some patient may develop pseudocyst of pancreas. Almost 2/3

rd of them resolve spontaneously over a period of 6-8

months and about 1/3 of them may become symptomatic which requires treatment.Traditionally the treatment of Pancreatic Pseudocyst has been Surgical – either open

surgery or Laparoscopic.

However, with the advent of EUS guided drainage, in our experience for last 1 decadeeversince we pioneered the Interventional EUS in Mumbai and India, almost 95-97% of

symptomatic Pseudocysts at Endoscopy Asia can be managed with EUS guided drainage procedure. Published studies have shown similar conclusion that most patients with

Pancreatic pseudocyst either secondary to acute or chronic pancreatitis can be managedsuccessfully with EUS guided drainage, hence the role of Surgery is there only if EUS



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infrastructure and expertise are not available, especially if there is a non bulging pseudocyst..

Though large bulging pseudocysts can be drained even endoscopically, whenever

possible EUS guided drainage will provide a safer window of puncture across the gut

wall and thereby prevent complications such as bleeding and perforation that can occur.

Case 3

Bleeding per rectum- Endoscopic diagnosis and treatment

A 48yrs/ F was referred to us for the favor of colonoscopy to evaluate the exact etiologyof bleeding per rectum off and on for last 6 months leading to drop in Hb. Patient was

treated conservatively for colitis and piles by a family physician. However, patientcontinued to have symptoms despite several months of treatment and hence went to see a

Surgeon who asked for a colonoscopic evaluation.

Ileo-colonoscopic evaluation revealed a large 4 cms bilobed polyp with a thick stalk atthe recto-sigmoid junction. Rest of the colon upto the caecum and also the last 15 cms of

terminal ileum was normal. Polypectomy was then performed with a snare and cauteryafter injection of diluted saline adrenaline into the stalk. Complete resection of the polyp

was achieved and was sent for HPE, which revealed tubulovillous adenoma withoutdysplasia. Patient was sent home the same evening.

1. Large bilobed polyp with thick stalkseen in Recto-sigmoid region.

2. Diluted saline adrenaline injected in thestalk



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3. The stalk strangulated with a

polypectomy Snare

4. No evidence of bleeding from the

resected site

5. Polyp retrieved with a Roth net. 6. Bilobed resected polyp was sent for

histopathological examination

Expert comments

Patient above the age of 45 yrs with h/o bleeding per rectum should be investigated in

detail and empirical treatment without a definitive diagnosis should be avoided. In thiscase patient suffered for almost 6 months before getting the a definitive diagnosis and

effective endoscopic treatment in the same sedation and was cured of her symptoms.Pedunculated or even flat sessile colonic lesions can be successfully resected with

endoscopic techniques such as polypectomy as in this case or we can employ moresophisticated tools that can perform EMR ( Endosocpic Mucosal Resection ) or ESD (

Endoscopic Submucosal Dissection).

It is our policy at Endoscopy Asia to inspect 10-15 cms of terminal ileum in all patientsreferred to us for Colonoscopy and more so if we are looking for a lesion that could

bleed. It is also important to perform these procedures under one sedation at the pilot



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endoscopy, both the diagnostic and therapeutic aspects when we deal with bleeding perrectum in an infrastructure which is equipped enough with all the methods of endoscopic

haemostasis.

Gastrovision Case-2

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