Introduction

Detective flow imaging (DFI) is a novel technology that enables the evaluation of low-speed blood flow signal that is difficult to visualize with conventional Doppler techniques^1)-3). This technique allows for evaluating microvascular signals within tumors in endoscopic ultrasound (EUS) without using contrast agents. In this study, we aimed to investigate the usefulness of DFI for the diagnosis of biliary tract lesions.

Aims & Methods

A retrospective study was conducted of patients who underwent DFI with EUS between September 2019 and December 2022 at our institution. Patients with biliary tract lesions diagnosed by either endoscopy or pathology were included. Malignant biliary tract lesions were defined as those with histopathological diagnoses of non-invasive or invasive carcinoma. To evaluate the diagnostic ability of DFI for malignant biliary tract lesions, we assessed the presence of tortuous or variable caliber vessels in DFI findings. Inter-observer agreement and the diagnostic ability of DFI in identifying malignant biliary tract lesions were also assessed. Additionally, the DFI findings of intraductal papillary neoplasms (IPNB) and cholangiocarcinoma in patients who underwent surgical resection.

Results

There were 17 cases of cholangiocarcinoma, 9 cases of IPNB, 3 cases of bile duct stone, and 3 other cases. The final diagnosis of biliary tract lesion was made by surgery in 20 cases and by EUS-FNA or biopsy in 9 cases. In the first analysis, the sensitivity and specificity for the presence of tortuous or variable caliber vessels for the diagnosis of malignancy were 80% and 43% for tortuous vessels and 68% and 100% for variable caliber vessels, respectively. Interobserver agreement was k=0.63 for tortuous vessels and k=0.75 for variable caliber vessels. In the second analysis, DFI identified stalk vessels in 7 of 8 cases (87.5%) of IPNB and in only 1 of 10 cases (10%) of invasive cholangiocarcinoma. The rate of concomitant stalk vessels was significantly higher in IPNB than in invasive cholangiocarcinoma (P<0.01).

Conclusion

DFI is a simple and easy-to-use technique that allows for the evaluation of blood flow in biliary tract lesions without the use of contrast agents. It has the potential to be a useful tool for the differential diagnosis of malignant biliary tract lesions.

References

1. Yamashita Y, Yoshikawa T, Yamazaki H et al. A novel endoscopic ultrasonography imaging technique for depicting microcirculation in pancreatobiliary lesions without the need for contrast-enhancement: a prospective exploratory study. Diagnostics (Basel) 2021; 11: 2018.
2. Yamashita Y, Yoshikawa T, Kawaji Y et al. Novel endoscopic ultrasonography imaging technique for visualizing microcirculation without contrast enhancement in subepithelial lesions: prospective study. Dig Endosc 2021; 33: 955–961.
3. Miwa H, Sugimori K, Maeda S. Vessel images of gallbladder polypoid lesions on detective flow imaging endoscopic ultrasonography. Dig Endosc 2023. doi: 10.1111/den.14530 [Online ahead of print].

Clinical Case Summary

For decompensated advanced chronic liver disease (dACLD) individuals, the onset of refractory ascites (RA) represents a dramatic event (6-month survival rate < 50%). In this setting, a relevant proportion of RA patients develop Hepatorenal Syndrome-Acute Kidney Injury (HRS-AKI) with limited therapeutic and survival chances.
An 81-year-old female dACLD RA patient was admitted to our department to receive large-volume paracentesis (LVP). Eradicated HCV infection, type II diabetes, and chronic obstructive pulmonary disease were her comorbidities.
The AKI onset imposed the intravenous (i.v.) human albumin (HA) (1 g/kg/die) administration, followed by the proper dosage of terlipressin (for HRS-AKI) within the first 72 hours (h), subsequently discontinued due to the persistence of anuria and the worsening of respiratory failure.
To simultaneously address uremic symptoms and facilitate ascites drainage, a Tenckhoff catheter was placed, and peritoneal dialysis (PD) started with a single icodextrin dwell, resulting in the removal of 14 L of ascites and an improvement in AKI within the subsequent 72h. After one week, she was discharged, receiving a specific PD schedule. After the readmission due to the difficulties in administering i.v. HA, we proposed administering HA via the intraperitoneal route, creating an HA-enriched PD (PD+HA) home-performable schedule by adding two vials of 100 ml of HA 20% to 800 ml of icodextrin solution (40 g in 1000 ml/die; lasting: 12 hours; frequency: every other day) (Figure 1).
The patient has been performing this PD schedule for 12 months (~0.5 L of ascites is discharged every other day before performing PD+HA dwell). During the follow-up, no PD-related complications (e.g., peritonitis) and liver-related events requiring hospitalization have been observed.
We report the first successful use of PD+HA, highlighting the cruciality of a multidisciplinary (hepatologists-nephrologists) approach in the management of dACLD-RA HRS-AKI patients.

References

1. Moreau, R.; Delègue, P.; Pessione, F.; Hillaire, S.; Durand, F.; Lebrec, D.; Valla, D.-C. Clinical Characteristics and Outcome of Patients with Cirrhosis and Refractory Ascites. Liver Int 2004, 24, 457–464, doi:10.1111/j.1478-3231.2004.0991.x.
2. Moore, K.P.; Wong, F.; Gines, P.; Bernardi, M.; Ochs, A.; Salerno, F.; Angeli, P.; Porayko, M.; Moreau, R.; Garcia-Tsao, G.; et al. The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club. Hepatology 2003, 38, 258–266, doi:10.1053/jhep.2003.50315.
3. Nadim, M.K.; Kellum, J.A.; Forni, L.; Francoz, C.; Asrani, S.K.; Ostermann, M.; Allegretti, A.S.; Neyra, J.A.; Olson, J.C.; Piano, S.; et al. Acute Kidney Injury in Patients with Cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) Joint Multidisciplinary Consensus Meeting. J Hepatol 2024, 81, 163–183, doi:10.1016/j.jhep.2024.03.031
4. Brown, E.A.; Blake, P.G.; Boudville, N.; Davies, S.; de Arteaga, J.; Dong, J.; Finkelstein, F.; Foo, M.; Hurst, H.; Johnson, D.W.; et al. International Society for Peritoneal Dialysis Practice Recommendations: Prescribing High-Quality Goal-Directed Peritoneal Dialysis. Perit Dial Int 2020, 40, 244–253, doi:10.1177/0896860819895364.

Clinical Case Summary

A 23-year-old female presented with epigastric pain, jaundice, and elevated liver enzymes. Imaging confirmed a mildly dilated common bile duct (CBD) with multiple filling defects. ERCP revealed a normal ampulla and a half-sphincterotomy was performed with three stones retrieved via balloon trawl. The procedure was uneventful, and she was discharged the same day.
Three days later, she re-presented with dizziness, melaena, and a haemoglobin drop from 127 g/L to 85 g/L. Gastroscopy demonstrated active oozing from the sphincterotomy site, managed successfully with placement of a fully covered metal stent (FCMS). She remained stable and was discharged with outpatient follow-up.
Three weeks later, she re-presented with partial stent blockage and underwent repeat ERCP for stent removal and duct clearance. Within 24 hours, she developed acute left shoulder tip and chest pain. Cardiac investigations were negative. CT imaging demonstrated a large haemoperitoneum and a bulging splenic haematoma without active bleeding, confirmed on a diagnostic laparoscopy .
She was managed conservatively in intensive care and follow up imaging confirmed complete resolution of the haematoma.
This case illustrates splenic haematoma as a rare yet significant complication of ERCP, with only a handful of cases described in the literature. Proposed mechanisms involve shear forces transmitted via the splenogastric ligament, typically in patients with known risk factors such as intra-abdominal adhesions, previous surgery, chronic pancreatitis, or cirrhosis. However, this case highlights its occurrence in a young, healthy patient with no risk factors, suggesting procedural technique or anatomical variation to be a potential trigger for injury. Symptoms such as shoulder or upper quadrant pain following ERCP should prompt consideration of splenic injury. Early recognition is key, as many cases resolve with conservative management but may carry a risk of life-threatening bleeding if unrecognised.

References

MRCP Image Demonstrating CBD Filling Defects
Coronal MRCP showing a mildly dilated common bile duct with multiple signal voids consistent with choledocholithiasis.
ERCP Image Showing Duct Clearance
Fluoroscopic image during ERCP showing balloon trawl and retrieval of multiple CBD stones following half-sphincterotomy.
Blood Results Demonstrating Haemoglobin Drop
Laboratory panel showing haemoglobin decline from 127 g/L to 85 g/L following gastrointestinal bleeding.
Gastroscopy Image Demonstrating Oozing and FCMS Placement
Endoscopic image showing active oozing at the sphincterotomy site and successful placement of a fully covered metal stent.
CT Image of Splenic Haematoma
Axial CT abdomen showing extensive haemoperitoneum and a bulging splenic haematoma in the left upper quadrant.
Follow-up CT Confirming Resolution
Interval CT imaging showing complete resolution of the previously identified splenic haematoma.

Clinical Case Summary

Introduction: Acute pancreatitis (AP) is an acute inflammatory disease characterized by severe abdominal pain and the development of local-systemic complications. In its etiology, drugs, especially gallstones and alcohol, can also cause AP (1). Drug-related acute pancreatitis constitutes 2-5% of the etiology of all acute pancreatitis (2). Here, we planned to present a patient diagnosed with Multiple Myeloma who developed AP after daratumumab.
Case: A 75-year-old male patient diagnosed with multiple myeloma complained of abdominal pain in the epigastric region radiating to the back on the 13th day of chemotherapy after starting the daratumumab, bortezomib and dexamethasone (DVd) protocol. There was no history of jaundice, abdominal pain, alcoholism, trauma, hyperparathyroidism. The patient, who did not use any medication other than DVd, increased serum amylase to 1601 U/L (28-100) and lipase to 1807 U/L (13-66) within seven days after the second dose of daratumumab treatment and was diagnosed with acute pancreatitis. The patient's abdominal computed tomography was compatible with AP and no stones or sludge were observed in the gallbladder. Other causes of pancreatitis were excluded. Since the patient who had previously received bortezomib treatment, had no complaints of abdominal pain, daratumamab was suspected as the etiology. The drug was discontinued and the patient received symptomatic medical treatment. After the treatment, the symptoms regressed and serum amylase and lipase returned to normal.
Conclusion: In order to say that any drug causes pancreatitis, other causes that may cause pancreatitis must be excluded, there must be findings such as regression of pancreatitis after discontinuation of the accused drug and recurrence of the pancreatitis attack when the drug is used again. We aimed to draw attention to drug use, which is a rare cause in the etiology of pancreatitis, by presenting a case of acute pancreatitis due to daratumumab use.

References

1. Jin DX, Lacson R, et al. A clinical model for early diagnosis of acute pancreatitis in the emergency department. Pancreas. 2018;47:871-79.
2. Lowe ME. Pancreatitis. In: Wyllie R, Hyams JS, Kay M, eds. 5th ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Elsevier; 2016. p.1016-26

Clinical Case Summary

Introduction: Cirrhosis complicated by portal hypertension often leads to gastrointestinal bleeding, predominantly from esophageal varices. However, the occurrence of lower GI bleeding from rectal varices and angiodysplasias represents a rarer and more complex clinical scenario. We report the case of a 62-year-old man with cirrhosis and multiple vascular anomalies requiring multidisciplinary management.
Patient observation: The patient, with a history of Type 2 diabetes, coronary artery disease, and prior cholecystectomy, was diagnosed with cirrhosis of presumed autoimmune origin, despite non-confirmatory liver biopsy. He experienced recurrent upper GI bleeding from esophageal varices, managed with beta-blocker therapy. More recently, a massive lower GI bleed led to endoscopic assessment revealing gigantic rectal varices and diffuse colonic angiodysplasias. Stabilisation was achieved by treating the angioddysplasias endoscopically with APC.
Figure 1&2: endoscopic images
Discussion: This case illustrates the difficulty of managing complex portal hypertension complications. While beta-blockers reduce bleeding risk from esophageal varices, rectal varices and angiodysplasias pose additional therapeutic challenges. Endoscopic sclerotherapy, band ligation, or embolization may be required, but their efficacy in diffuse vascular anomalies remains limited. The presence of multiple bleeding sources demands vigilant surveillance and individualized management strategies. Moreover, coexisting comorbidities like diabetes and cardiovascular disease complicate procedural risks and therapeutic decisions.
Conclusion: Managing cirrhosis complicated by giant rectal varices and angiodysplasias requires a multidisciplinary and tailored approach. This case highlights the importance of ongoing surveillance, optimized medical therapy, and readiness for endoscopic or interventional radiology techniques to prevent further decompensations and preserve quality of life.