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Electronic Clinical Challenges and Images in GI
Electronic Clinical Challenges and Images in GI David A. Katzka and David L. Jaffe, Section Editors
Image 1 Question: A 35-year-old pregnant woman (estimated gestational age of 30 weeks) was admitted to our clinic with jaundice. She described biliary colic and dark urine in the last 2 days. Physical examination revealed right upper quadrant tenderness. Transabdominal ultrasonography revealed thickened gallbladder wall (6 mm) with fine granular echogenic masses in the lumen. The common bile duct (CBD) diameter was 20 mm without any signs of stone or mass. Intrahepatic bile ducts were dilated. Laboratory investigations revealed increased white blood cells (14,000/mL), serum alkaline phosphatase (670 IU/L), alanine aminotransferase (78 IU/L), aspartate aminotransferase (70 IU/L), ␥-glutamyl transferase (450 IU/L), total bilirubin (5.6 mg/dL), and conjugated bilirubin (4.1 mg/dL). Because the patient was pregnant, we decided to perform endosonography (EUS)-assisted CBD cannulation without exposing the patient to radiation. CBD was imaged using Lineer EUS probe (Pentax EG-3630UR, Pentax Europe, Hamburg, Germany). The CBD was visualized from second portion of duodenum and the diameter of CBD was 20 mm. There was fine– granular echogenic material without echogenic shadow in the CBD. We had no idea about the nature of the material seen in CBD, but it did not resemble a CBD stone. Then we decided perform endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy.
A standard ERCP catheter was inserted into CBD. After successful selective cannulation of the CBD, a guidewire was inserted and ERCP catheter was retracted. EUS was slowly withdrawn avoiding the dislodgment of guidewire. After insertion of the guidewire into the working channel of a duodenoscope in a retrograde manner, the duodenoscope (ED-3480TK, Pentax) was advanced toward the papilla and a standard, tapered-tip sphincterotome was inserted using the guidewire. Endoscopic sphincterotomy and balloon sweeping of the CBD were performed. The obstructing lesion was an unexpected one. What is the most likely diagnosis in this patient? See the GASTROENTEROLOGY web site (www. gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. TARKAN KARAKAN, MD MEHMET CINDORUK, MD Gazi University Faculty of Medicine Department of Gastroenterology Ankara, Turkey
© 2009 by the AGA Institute
0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.07.080
GASTROENTEROLOGY 2009;136:e1– e2
e2
GASTROENTEROLOGY Vol. 136, No. 3
Answer to the Clinical Challenges and Images in GI Question: Image 1: Unusual Cause of Obstructive Jaundice in a Pregnant Woman Video shows the sweeping of the CBD after sphincterotomy. The daughter cysts of Echinococcus granulosus (hydatid disease) were drained spontaneously after sphincterotomy and clearly seen as grey, gelly-like material with a whitish hydatid fluid. The Echinococcus granulosus antibody (ELISA) is measured and was positive in the serum of this patient. After CBD clearance, blood chemistry (including bilirubin) normalized and CBD diameter decreased to 13 mm on abdominal ultrasound imaging in a few days. Patient gave birth at 38 weeks gestation without complication. After 3 months of follow-up, the patient had no signs or symptoms of hydatid disease. Hydatid disease is a zoonotic parasitic disease predominantly affecting the liver, lung, and other vital organs. The most frequent causative agent is Echinococcus granulosus (the “dog tape worm”) and to a lesser extent, E multilocularis. Despite a plethora of publications on echinococcosis, little is known about the disease in pregnant women because the incidence in pregnancy is as low as 1 in 20,000 to 30,000.1 Pregnancy can exacerbate the present hydatid cyst or enhance its recurrence. Although rupture into the biliary system is a common complication of hydatid disease,2 this is the first pregnant patient with obstructive jaundice reported in the literature. Many different methods are reported for performing ERCP during pregnancy; however, there is no established safe method.3 We have used a novel technique using EUS-guided CBD cannulation. This method should be investigated in further trials. References 1. Rodrigues G, Seetharam P. Management of hydatid disease (echinococcosis) in pregnancy. Obstet Gynecol Surv 2008;63:116 –123. 2. Goumas K, Poulou A, Dandakis D, et al. Role of endoscopic intervention in biliary complications of hepatic hydatid cyst disease. Scand J Gastroenterol 2007;42:1113–1119. 3. Shelton J, Linder JD, Rivera-Alsina ME, et al. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos). Gastrointest Endosc 2008;67:364 –368. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Image 1 Question: A 35-year-old pregnant woman (estimated gestational age of 30 weeks) was admitted to our clinic with jaundice. She described biliary colic and dark urine in the last 2 days. Physical examination revealed right upper quadrant tenderness. Transabdominal ultrasonography revealed thickened gallbladder wall (6 mm) with fine granular echogenic masses in the lumen. The common bile duct (CBD) diameter was 20 mm without any signs of stone or mass. Intrahepatic bile ducts were dilated. Laboratory investigations revealed increased white blood cells (14,000/mL), serum alkaline phosphatase (670 IU/L), alanine aminotransferase (78 IU/L), aspartate aminotransferase (70 IU/L), ␥-glutamyl transferase (450 IU/L), total bilirubin (5.6 mg/dL), and conjugated bilirubin (4.1 mg/dL). Because the patient was pregnant, we decided to perform endosonography (EUS)-assisted CBD cannulation without exposing the patient to radiation. CBD was imaged using Lineer EUS probe (Pentax EG-3630UR, Pentax Europe, Hamburg, Germany). The CBD was visualized from second portion of duodenum and the diameter of CBD was 20 mm. There was fine– granular echogenic material without echogenic shadow in the CBD. We had no idea about the nature of the material seen in CBD, but it did not resemble a CBD stone. Then we decided perform endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy.
A standard ERCP catheter was inserted into CBD. After successful selective cannulation of the CBD, a guidewire was inserted and ERCP catheter was retracted. EUS was slowly withdrawn avoiding the dislodgment of guidewire. After insertion of the guidewire into the working channel of a duodenoscope in a retrograde manner, the duodenoscope (ED-3480TK, Pentax) was advanced toward the papilla and a standard, tapered-tip sphincterotome was inserted using the guidewire. Endoscopic sphincterotomy and balloon sweeping of the CBD were performed. The obstructing lesion was an unexpected one. What is the most likely diagnosis in this patient? See the GASTROENTEROLOGY web site (www. gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. TARKAN KARAKAN, MD MEHMET CINDORUK, MD Gazi University Faculty of Medicine Department of Gastroenterology Ankara, Turkey
© 2009 by the AGA Institute
0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.07.080
GASTROENTEROLOGY 2009;136:e1– e2
e2
GASTROENTEROLOGY Vol. 136, No. 3
Answer to the Clinical Challenges and Images in GI Question: Image 1: Unusual Cause of Obstructive Jaundice in a Pregnant Woman Video shows the sweeping of the CBD after sphincterotomy. The daughter cysts of Echinococcus granulosus (hydatid disease) were drained spontaneously after sphincterotomy and clearly seen as grey, gelly-like material with a whitish hydatid fluid. The Echinococcus granulosus antibody (ELISA) is measured and was positive in the serum of this patient. After CBD clearance, blood chemistry (including bilirubin) normalized and CBD diameter decreased to 13 mm on abdominal ultrasound imaging in a few days. Patient gave birth at 38 weeks gestation without complication. After 3 months of follow-up, the patient had no signs or symptoms of hydatid disease. Hydatid disease is a zoonotic parasitic disease predominantly affecting the liver, lung, and other vital organs. The most frequent causative agent is Echinococcus granulosus (the “dog tape worm”) and to a lesser extent, E multilocularis. Despite a plethora of publications on echinococcosis, little is known about the disease in pregnant women because the incidence in pregnancy is as low as 1 in 20,000 to 30,000.1 Pregnancy can exacerbate the present hydatid cyst or enhance its recurrence. Although rupture into the biliary system is a common complication of hydatid disease,2 this is the first pregnant patient with obstructive jaundice reported in the literature. Many different methods are reported for performing ERCP during pregnancy; however, there is no established safe method.3 We have used a novel technique using EUS-guided CBD cannulation. This method should be investigated in further trials. References 1. Rodrigues G, Seetharam P. Management of hydatid disease (echinococcosis) in pregnancy. Obstet Gynecol Surv 2008;63:116 –123. 2. Goumas K, Poulou A, Dandakis D, et al. Role of endoscopic intervention in biliary complications of hepatic hydatid cyst disease. Scand J Gastroenterol 2007;42:1113–1119. 3. Shelton J, Linder JD, Rivera-Alsina ME, et al. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos). Gastrointest Endosc 2008;67:364 –368. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).