Introduction

Pancreatic cyst prevalence is about 2% to 3% in the general population(1,2). It is important to classify them accurately, given the fact that in premalignant lesions surgery could be curative. On the other hand, unnecessary pancreatic surgery could be associated with significant morbidity. The mucinous cysts are considered the premalignant types, traditionally the carcinoembryonic antigen (CEA) has been described as the analysis of cyst fluid to discern them from the non-mucinous. Recently, the cyst glucose value has been described as a better discriminant, however, there are different cut-off levels founds across the studies(3). The distribution of glucose in the body is almost uniform (4), a higher metabolic rate within a cyst translates into lower intracystic glucose, which correlates with high-grade injury (3). Therefore, we decided to explore the diagnostic performance of the glucometry-to-glucometry cyst ratio.

Aims & Methods

We conducted a prospective cohort from January 2021 to October 2022 at the endoscopy department at the National Institute of Medical Sciences and Nutrition “Salvador Zubiran” (INCMNSZ) in Mexico City. We included patients older than 18 years who underwent endoscopic ultrasound with FNA of a pancreatic cyst and had a fluid analysis of glucose, CEA, and amylase. We performed glucometry on-site on the patient and the cyst fluid with a FreeStyle Optium Neo glucometer. Glucometry to glucometry cyst ratio (glucometry patient/glucometry cyst) was calculated for each patient. Follow-up was performed and a final diagnosis was established by a multidisciplinary team, biopsy or surgical specimen. Finally, we performed a 2x2 table and a ROC curve with Youden index to establish the best cut off for diagnostic performance of glucometry-to-glucometry cyst ratio.

Results

24 patients were included 14 with mucinous cyst diagnosis and 10 with non-mucinous diagnosis, the median age was 58.5 (25-84), and 83% were female. CEA mean was 2331.7± 3359.3 ng/mL for mucinous vs 23.8± 62.6 ng/mL for non-mucinous (p= <0.001). The on-site cyst glucometry was 39.3± 22.1mgdL vs 112± 42.9 for the mucinous and non-mucinous respectively (p= 0.001). The glucometry/cyst glucometry relation was 3.30± 0.84 (mucinous) vs 1.13± 0.69 (non-mucinous), p= 0.001. The AUC was 0.971 (0.915 -1.000), 0.948 (0.853 – 1.00), and 0.964 (0.900 – 1.000) for glucose relation, glucometry, and CEA respectively. The sensitivity, specificity, PPV, NPV, and precision for CEA (192ng/dL) was 70%, 92.8%, 87.5%, 81.2%, and 83.3% while glucometry (<50mg/dL) was 80%, 85.7%, 83.3%, 85.7%, and 83.3%. Notably, the glucometry relation (>2.45) found a 90%, 92.8%, 90%, 92.8%, and 91.6% for the same parameters.

Conclusion

The glucometry-to-glucometry cyst relation is a novel, cheap, accessible, and superior diagnostic approach for the classification of mucinous and non-mucinous pancreatic cysts. Further studies with bigger sample sizes are needed to confirm these findings.

References

1. Laffan TA, Horton KM, Klein AP, et al. Prevalence of unsuspected pancreatic cysts on MDCT. AJR Am J Roentgenol 2008;191:802-7.
2. de Jong K, Nio CY, Hermans JJ, et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol 2010;8:806-11
3. Guzman-Calderon E, Md BM, Casellas JA, Aparicio JR. Intracystic Glucose Levels Appear Useful for Diagnosis of Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis. Dig Dis Sci 2021
4. Zierler K. Whole body glucose metabolism. Am J Physiol 1999;276:E409-26

Clinical Case Summary

Biliary pathology is a frequent motive for consultation in hospitals, and abdominal ultrasound is the first line-imaging test for its study. The genetic syndrome LPAC (Low Phospholipid-Associated Cholelithiasis) leads to the development of intrahepatic lithiasis. In this syndrome, there is a decrease in biliary phospholipids secretion caused by a mutation in the ABCB4 gene, responsible for a dysfunction of the MDR3 transporter. Despite being considered a rare entity, it accounts for 1-5% admissions for biliary pathology, affecting young women more frequently.
Two of three clinical criteria must be met for its diagnosis: symptoms onset before the age of 40, recurrence after cholecystectomy and compatible ultrasound appearance (presence of intrahepatic hyperechogenic spots, &quot;comet tail&quot; images or intrahepatic lithiasis with acoustic shadowing). Identification of the ABCB4 gene mutation is not a diagnostic criterion since it only appears in 50% of patients. Medical treatment with ursodeoxycholic acid is effective and cholecystectomy can be avoided.
We present a 23-year-old male who consulted for epigastric pain associated with vomiting. Laboratory tests showed elevation of amylase greater than three times above the upper limit of normal, which allowed the diagnosis of acute pancreatitis. Liver profile, calcium and triglycerides were within normal limits. The patient had no previous alcoholic intake. Abdominal ultrasound ruled out cholelithiasis but identified multiple intrahepatic hyperechogenic spots and &quot;comet tail&quot; signs. The patient was diagnosed with LPAC syndrome and treatment with ursodeoxycholic acid was initiated. During follow-up he did not present new episodes of biliary symptomatology.
The detection of the typical ultrasound signs of LPAC syndrome is the main tool for its suspicion. This disease is not as uncommon as it may seem, so it is essential to think about it in order to make a correct diagnosis and treatment of these patients.

References

Ultrasound image of intrahepatic lithiasis

Introduction

Endoscopic ultrasound (EUS)-guided sampling is considered the gold standard for the cyto-histological diagnosis of solid pancreatic tumours. Development of new needles over the last years has improved the diagnostic accuracy of EUS-sampling.

Aims & Methods

Aim of our study was to evaluate the accuracy of EUS-sampling for the cyto-histological diagnosis of solid pancreatic tumours in clinical practice.
Methods: Patients who underwent EUS-sampling for the evaluation of solid pancreatic tumour over the last 13 years were identified from a prospectively collected EUS registry and included in the study. EUS was performed with linear Pentax echoendoscopes and Hitachi systems. Tissue acquisition was performed with standard cytology needles (19-gauge, 22-gauge, and 25-gauge) and core needles [ProcoreTM, Franseen and Fork-Tip] (19-gauge, 20-gauge, 22-gauge, and 25-gauge). Samples were collected in a cytological solution (Cytolit®) and processed for cyto-histological evaluation. Results are shown as mean ± standard deviation and percentages. Diagnostic accuracy for malignancy was analysed using the histopathological analysis of the surgical specimens, and the clinical and radiological long-term follow-up in non-operated patients, as gold standard.

Results

1072 patients were included in the study (mean age 67.6 years, range 17-92, 596 male). Size of solid pancreatic lesions was 33.4 ± 15.2 mm. 617 tumours were located in the head of the pancreas, 339 in the body, 83 in the tail and 33 in the uncinate process. Cytology needles were used in 543 patients (50.7%) and core needles in 529 (49.3%). Mean number of needles passes was 1.7 ± 0.8. On-site evaluation of samples was done in 224 (20.9%) cases. 916 (85.4%) masses were finally classified as malignant, whereas 156 (14.5%) were considered benign. Global sensitivity, specificity and overall accuracy for malignancy were 86.5%, 100% and 88.4%, respectively. Obtained sensitivity and overall accuracy were higher with core needles compared with cytology needles (89.4% vs 83.5%, and 90.7% vs 86.2%, respectively).

Conclusion

EUS-guided sampling is an accurate technique for the cyto-histological diagnosis of solid pancreatic tumours. Diagnostic yield reached in clinical practice is superior with core needles than with cytology needles.

Disclosure

Julio Iglesias-Garcia: Advisor Pentax, FujiFilm & Mediglobe

Introduction

Necrotizing pancreatitis with walled-off necrosis (WON) is associated with severe morbidity and substantial mortality. Vascular complications such as pseudoaneurysm, arterial erosion, and especially thrombosis of the splanchnic veins are all associated with acute pancreatitis (AP). However, the occurrence and clinical outcome of vascular manifestations in patients developing WON are poorly described. We aimed to describe vascular complications in a well-defined cohort of consecutive patients endoscopically treated for symptomatic WON.

Aims & Methods

Four hundred and nine patients treated endoscopically for their pancreatic fluid collection during a 10-year period were assessed for inclusion. Patients with pseudocysts, < 18 years, concomitant malignant disease and/or procedure-related bleeding were excluded. A total of 290 patients were eligible for analysis.
Vascular complications included bleeding and thromboembolic events. Thromboembolic complications were defined as confirmation of thrombus in one of the splanchnic veins on contrast-enhanced computed tomography scan (CECT). Bleeding complications were defined as clinical bleeding necessitating intervention, including embolization, surgery or transfusion.

Results

The median age was 59 years (range 18-84), and 57% were males. Gallstones were the etiology in 47%, alcohol in 20%, and post-ERCP pancreatitis in 14%. In 14% of the cases, the etiology was unknown. Infection was the main indication for intervention (92%), followed by gastric outlet obstruction (6%) and pain (2%). The average time from debut of symptoms to index procedure was 35 days (range 6-89). The average duration of hospital admission was 89 days (range 21-286). The overall in-hospital mortality was 14%, and need for admission to intensive care unit (ICU) was 35%.
In total, 87 (30%) patients developed vascular complications of which 53 (18%) were thromboembolic, 34 (12%) bleeding, and nine patients (3%) developed both thromboembolic and bleeding complications.
The portal vein was most affected (34%), followed by the splenic vein (28%) and the superior mesenteric vein (23%). Two or all three splanchnic veins were affected in 15%. The majority (81%) of thromboembolic complications occurred before the index procedure. Development of splanchnic venous thrombosis was not associated with in-hospital mortality (13% vs. 14%, p=1.0) or need for ICU admission (38% vs. 34%, p=0.64). None of the patients with splanchnic vein thrombosis developed variceal bleeding during follow-up.
The splenic artery was the most common cause of bleeding (32%), followed by the gastroduodenal artery (24%) and the left gastric artery (12%). In five cases, the source of the bleeding could not be identified. All patients received blood products, 23 patients were treated with arterial embolization and 4 patients with surgery. Seventy seven percent of the bleeding complications occurred after the index procedure. The need for ICU (59% vs. 32%, p=0.003) and in-hospital mortality (38% vs. 11%, p<0.0001) were significantly higher in patients with arterial bleedings as compared to patients without.

Conclusion

Vascular complications are common in WON patients. The timing of occurrence seems distinct, as the vast majority of thromboembolic complications occur before index endoscopic intervention, while bleeding complications mainly occur after. While arterial bleedings are linked to increased morbidity and in-hospital mortality, thromboembolic complications are not associated with a poor short- or long-term clinical outcome.

Clinical Case Summary

Introduction: Since the covid-19 pandemic, there has been a significant resurgence of tuberculosis in endemic countries. As a result, extremely rare localizations of tuberculosis have appeared. Stomach involvement is rarely seen in gastrointestinal tuberculosis. The clinical presentation can be either alarming symptoms (anorexia, weight loss...), or a complication (digestive hemorrhage, perforation). In front of the weight loss and the alteration of the general state, the diagnosis is often directed towards a neoplastic pathology, which represents a diagnostic challenge.

Clinical case: We received in our institution a 77-year-old woman, referred from the emergency room for hematemesis with epigastric pain. She had experienced important weight loss during the last month. The clinical examination was unremarkable, and blood tests was normal, despite an hemoglobin of 8,7 g/dl. An upper endoscopy was performed, which showed the existence of 3 ulcerations localized on the greater curvature of the stomach, the largest measuring 4 centimeters. Biopsies of the ulceration borders were performed. Histology revealed the presence of an epithelio-giganto-cellular granuloma with caseous necrosis.
The final diagnosis was gastric tuberculosis. We started an antituberculosis therapy, with a proton pump inhibitor, with significant improvement within one month.

Conclusion: In conclusion, gastric tuberculosis, even if it is a rare entity, should be considered when gastric signs are associated with signs of tuberculosis impregnation, especially in endemic countries. The endoscopic signs are not specific, only histology can establish a reassuring diagnosis. Our patient was successfully treated by Antitubercular drug despite the severity of his bleeding.

References

Endoscopic images showing tow small gastric ulcers and a large gastric ulcer of the greater curve of the stomach
Histological image showing epithelio-giganto-cellular granuloma with caseous necrosis

Clinical Case Summary

Pancreatic cystic lymphangioma is extremely rare, accounting for less than 5% of pancreatic cystic neoplasms and less than 1% of all lymphangiomas.¹
A 51-year-old female presented with complaints of recurrent abdominal pain for 4 weeks. She was previously misdiagnosed as acute pancreatitis complicated with pancreatic pseudocyst. There was no history of trauma. Dynamic MRI on the abdomen revealed a large, encysted collection at the pancreatic body suggesting a query pancreatic pseudocyst. EUS examination revealed a large cystic lesion at the body of the pancreas. The cyst was multilocular with characteristic multiple thin septa within the lesion (Figure 1). EUS-FNA with 22-G needle was done with aspiration of about 20 ml of cyst fluid, divided into two bottles, one for cytology examination and mucin stain while the second bottle for Amylase, CEA and TG levels. Aspiration fluid was serous yellowish in colour, with negative string sign. Also, a large focal lesion within the spleen was also seen.The biochemical evaluation of the aspirated cystic fluid revealed low amylase and CEA, and high TG levels. Cytopathological examination showed fairly cellular material featuring numerous predominantly small lymphocytes. There were no epithelial, atypical, or malignant cells. IHC staining was positive for CD-31 and CD2-40. Alcian blue mucin stain was negative. The diagnosis of pancreatic cystic lymphangioma was made based on EUS, cytological and biochemical examination with IHC features. Since, lymphangiomas are benign tumors without malignant potential, treatment depends on the symptoms. Lymphangioma can encroach on adjacent organs and need surgical resection. To relieve symptoms of abdominal, distal pancreatectomy and splenectomy was discussed, but patient refuse surgery. Multidisciplinary team decided a conservative management with a follow-up by dynamic MRI and EUS within 6 months.

References

1. Chen D, Feng X, Lv Z, Xu X, Ding C, Wu J. Cystic lymphangioma of pancreas: A rare case report and review of the literature. Medicine (Baltimore). 2018 Jul;97(28): e11238. doi: 10.1097/MD.0000000000011238.