Clinical Case Summary

Endoscopic ultrasound (EUS) is an essential tool in the diagnosis, staging, and treatment of various pathologies, playing an increasingly significant role in clinical practice.

We present the case of a 35-year-old patient with a history of hypertriglyceridemia and post-measles pneumopathy at 6 months of age. He was referred to the endocrinology clinic for hypoglycemia detected on routine blood tests. Upon exploration, the patient reported sudden episodes of hunger, sweating, and malaise, relieved by food intake for two years. A prolonged fasting test revealed glucose of 26mg/dL, insulin of 14.8 uUI/mL, and C-peptide of 2.4ng/mL. Initially, an abdominopelvic computed tomography (CT) scan showed an homogeneous pancreas without lesions. Due to persistent suspicion of insulinoma, magnetic resonance cholangiopancreatography was requested but without abnormalities. A chest CT scan also revealed no findings. Finally, the patient underwent EUS, revealing a hypoechoic nodule in the cephalopancreatic region of 10x8mm. Fine-needle aspiration biopsy confirmed a neuroendocrine tumor. After three years since the onset of symptoms, the patient underwent a cephalic duodenopancreatectomy, with histology confirmation of a well-differentiated G1 pT1 pN0 neuroendocrine tumor. One month later, the patient experienced intractable vomiting, fever, and elevated inflammatory markers. Imaging revealed a peri-pancreatic collection, leading to therapeutic EUS. An 85x60mm heterogeneous collection was observed and drained using a pigtail stent, allowing purulent content to flow into the gastric lumen. The patient showed substantial improvement after drainage and antibiotic. One month of follow-up showed no further complications.

Clinical suspicion of insulinoma can be confirmed by standard endocrinological tests, yet its identification remains challenging. This case illustrates how EUS not only enhanced diagnostic sensitivity but also played a key role in managing subsequent complications.

Introduction

EUS-guided Gallbladder Drainage (EUS-GBD) with Lumen Apposing Metal Stent (LAMS) is a standard treatment for management of acute cholecystitis (AC) in unfit-for-surgery patients. Gallbladder Perforation is standardly considered as a contraindication to EUS-GBD.

Aims & Methods

This series aims at exploring outcomes of EUS-GBD in patients with AC and contained perforation (cp-AC).
All consecutive patients undergoing EUS-GBD in a single tertiary institution between 2020 and 2024 were enrolled in a prospective registry (PROTECT, ClinicalTrials.gov NCT04813055). Patients with cp-AC were included in this series, when presenting gallbladder wall rupture with adjacent encapsulated fluid collections. Baseline demographics and technical details were registered together with Technical success, Clinical success, Adverse Events (AEs), Recurrence and Survival evaluated every 60 days.

Results

From a prospective cohort of 48 EUS-GBD, 19 patients presented with cp-AC (median age 71 [62-78], male 42.1%, Charlson Comorbidity Index of 8 [7-9.8]). Acute cholecystitis was iatrogenic in 79% of these cases (ERCP with metal stenting in 14 and TACE in 1). Reason to avoid surgery was underlying malignancy in 89.5% and comorbidities in 15.8%. Amongst underlying malignancies, the most frequent one was Pancreatic Adenocarcinoma.
Ascites was present in 26.3% of cases. All procedures were performed transduodenally, with an operative luminal space of 31 [25 – 36] mm and a median tract thickness of 6 [5-8] mm.
A 10 mm Hot Axios LAMS was used in 95% of cases, and the release was free-hand in 89% and over-the-wire after former distention in 11% of cases. Antibiotic prophylaxis and coaxial double-pigtail plastic stents were adopted in 95% of cases.
Technical success was 100%. Clinical success was 94.7%, with a statistically significant 7-days reduction of white blood cells (p=0.0017 ) and C Reactive Protein (p=0.0067) .
AEs were registered in 21% of cases, severe/fatal in 11%.
Of note, 2 AEs (1 fatal) were related to additional attempts of draining liver abscesses adjacent to the GBD.
Five patients (27%) underwent additional endoscopic procedures for peroral cholecystoscopy, GBD clearance and LAMS removal, while 2 (11%) patients experienced uneventful LAMS migration.
Median hospital stay was 8 [6-13] days and median time to chemotherapy was 26 [19-56] days for those who were candidate to oncological treatment (N=10).
After a median follow-up of 254 [56-454] days, no AC recurrence was registered.

Conclusion

In the context of AC, contained perforation with adjacent collections does not seem to represent a contraindication to EUS-GBD with LAMS, despite the additional complexity related to a thicker interluminal distance. Management of large adjacent abscesses should involve multidisciplinary management and might require percutaneous drainage.

Clinical Case Summary

Although liver involvement is common in leukemia, acute hepatitis as its initial presentation is rare. This case highlights the diagnostic challenge of distinguishing reactive hematological changes from underlying malignancies in patients with unexplained hepatitis.
A 35-year-old woman presented in February 2024 with myalgias, fever with chills (38°C), jaundice, and right upper quadrant discomfort. Relevant history included recent intake of herbal supplements (vitamin C, zinc, echinacea, elderberry).
Initial laboratory findings showed leukocytosis, lymphocytosis (25%), monocytosis (12%), blasts (3%), thrombocytopenia (136×10⁹/L), and abnormal liver tests (AST 448 U/L, ALT 686 U/L, ALP 242 U/L, GGT 147 U/L, total bilirubin 4.14 mg/dL, direct bilirubin 2.9 mg/dL), with normal INR. Peripheral blood smear revealed mononuclear pleomorphism and lymphocytes with prominent nucleoli. Abdominal computed tomography showed moderate hepatomegaly without biliary or vascular abnormalities. Comprehensive testing for infeccious, autoimmune and metabolic causes was negative.
Liver tests improved and leukocytosis turned into leukopenia. Repeat blood smear was deemed reactive by Hematology. She was discharged and in early March re-evaluation, liver parameters normalized and leukopenia improved.
Later that month, she returned with fever, night sweats, and abdominal pain. Laboratory findings showed recurrent cytopenias and cytocholestasis. Blood smear revealed increasing blast count, and immunophenotyping suggested monoclonality. Bone marrow and liver biopsy confirmed B-cell acute lymphoblastic leukemia (ALL) with hepatic infiltration.
This case illustrates an unusual presentation of ALL as relapsing acute hepatitis. It reinforces the need to consider hematological malignancy in cryptogenic hepatitis, particularly when associated with evolving hematological changes. Serial blood smears, immunophenotyping, and timely bone marrow evaluation are essential to avoid diagnostic delay.

References

1. Hepatic biopsy: clusters of intermediate to large cells expressing TdT, CD20, PAX5, CD10, BCL6, CD43.
2. Bone marrow aspirate: 64% blasts, CD10+, CD20+ (strong homogeneous expression).
3. Bone marrow biopsy: increased cellularity due to diffuse interstitial infiltration by intermediate cells with blast-like morphology and lymphoid immunophenotype (TdT+, CD34+, MPO-, CD20+).

Introduction

The Maastricht V/ Florence Consensus has updated guidelines for the management of Helicobacter Pylori (HP) infection with special emphasis in high clarithromycin resistance settings as it is the case in our country. In line with the recommendations of the European Guidelines on surgery of severe obesity [1] and the recommendations of the American Society of Gastrointestinal Endoscopy on endoscopy of the bariatric patient [2) a policy of systematic HP screening and overtime updated eradication was implemented in obese patients undergoing Roux-en Y gastric bypass (RYGB) surgery.

Aims & Methods

Five year period (2020-2024) single center study. The aim was, in obese patients undergoing RYGB surgery, to assess the cumulative HP eradication rate by adopting, at first line, a 10 days bismuth quadruple therapy (BQT) - proton pump inhibitor (PPI) bid and three-in-one single capsule containing bismuth, metronidazole, and tetracycline qid - and, at second line, a 14 days levofloxacin based therapy ( LBT) – PPI bid, amoxicillin 1000 mg bid and levofloxacin 500mg bid. HP infection status was assessed, at baseline, by histology or urea breath test and post treatment, by urea breath test 4-6 weeks after the end of the therapy.

Results

One thousand four hundred and forty-nine consecutive HP‑positive patients completed BQT treatment: 1160 (80.1%) female, age 43.5 (±10.5) years, median age of 44 years), age range of 18-69 years. HP was eradicated in 1220 patients – 84.2% (95%CI: 82.2%-86.0%). In the remaining 229 patients, 87 patients withdrew and HP was eradicated in 118 patients out of 145 with LBT. The intention to treat (ITT) and per protocol (PP) cumulative eradication rates were, respectively, 92.3% (95%CI: 90.9%-93.6%). and 98.0% (95%CI: 97.1%-98.6%). Eradication rates were not significantly different by gender and age.

Conclusion

By adopting the Maastricht V/ Florence Consensus BQT first line therapy and second line LBT therapy, high ITT and PP cumulative HP eradication rates are achieved leaving only a residual number of obese patients undergoing RYGB in need of the culture and susceptibility testing prior to third line treatment.

References

1. Fried M, Hainer V, Basdevant A, et al. European Guidelines on surgery of severe obesity. . International Journal Of Obesity 2007;31:569-577.
2. ASGE Guidelines. Role of endoscopy in the bariatric patient. Gastrointest Endosc 2008; 68:1-10.

Disclosure

NO CONFLICT OF INTEREST

Clinical Case Summary

We report a rare and fatal case of diffuse hepatic hemangiomatosis (DHH) in a 50-year-old male presented with acute painless jaundice of 10 days’ duration, dark urine, and hepatosplenomegaly. Laboratory workup revealed normocytic anemia, indirect hyperbilirubinemia, and elevated LDH levels, suggesting hemolysis, though the direct Coombs test was negative. Liver function tests showed cholestatic and hepatocellular injury patterns, while creatinine and coagulation profiles were initially normal. Abdominal ultrasound and triphasic computed tomography demonstrated hepatosplenomegaly and multiple hepatic focal lesions with peripheral nodular enhancement and centripetal fill-in. Liver biopsy revealed markedly dilated sinusoids without malignant infiltration. Unlikely, the patient developed acute kidney injury, hematemesis, and hepatic encephalopathy, culminating in death from liver failure within one month from the onset of his illness.

Clinical Case Summary

Introduction: Von Hippel-Lindau (VHL) syndrome is a rare hereditary neurocutaneous disorder distinguished by its propensity for the development of both benign and malignant tumors such as cerebellar hemangioblastomas, retinal angiomas, clear cell renal carcinomas, pancreatic neuroendocrine tumors, and others. Additionally, multiple pancreatic, renal, and urogenital cysts may also develop, potentially giving rise to localized symptoms and the risk of malignant transformations (1).
Case report: This case study centers on a 54-year-old male patient who was flagged for potential tumorous lesions in both kidneys upon undergoing a comprehensive health assessment. Following a multi-sliced computed tomography (MSCT)-guided biopsy, the presence of clear cell renal carcinoma was bilaterally confirmed. An abdominal MSCT delineated an enlarged pancreas featuring multiple cystic formations. Then, an Endoscopic Ultrasound (EUS) examination detailed the presence of multiple cysts in the pancreatic region, forming conglomerates with a collective dimension of up to 80 mm. Following an EUS-FNA (fine needle aspiration) procedure, cuboidal epithelium within the cyst was identified, and a biochemical analysis revealed normal levels of CEA, amylase, and glucose. The combination of these findings, along with the patient's medical history, raised suspicions of serous cystadenoma and prompted consideration of VHL syndrome. Finally, a heterozygous missense variant in the VHL gene was detected by sequencing genes included in the clinical exome panel.
Conclusion: Distinguishing cystic pancreatic lesions, which can give rise to endocrine and/or exocrine insufficiency or be asymptomatic, from potentially malignant lesions is of paramount importance. Therefore, diligent tumor surveillance associated with VHL syndrome is crucial for timely detection and treatment.

References

1. van Asselt SJ, de Vries EG, van Dullemen HM, Brouwers AH, Walenkamp AM, Giles RH, Links TP. Pancreatic cyst development: insights from von Hippel-Lindau disease. Cilia. 2013 Feb 5;2(1):3.

Introduction

Biliary and gastric outlet obstruction (GOO) are common complications in patients with pancreatic cancer, often delaying essential cancer treatments. While endoscopic ultrasound-guided
gastroenterostomy (EUS-GE) has been shown to be superior to duodenal self-expandable metal stents (dSEMS) for managing GOO, the optimal strategy for biliary drainage (BD) in this setting remains unclear. Specifically, there is no consensus on whether to prefer EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided hepaticogastrostomy (EUS-HGS).

Aims & Methods

We conducted a systematic review and meta-analysis to identify the optimal biliary drainage approach in patients undergoing EUS-GE for concomitant GOO and biliary obstruction. We searched Medline, Scopus, and EMBASE up to February 2025. Studies were included if they reported outcomes of EUS-CDS or EUS-HGS in patients with biliary obstruction and concomitant GOO
treated by EUS-GE. Pooled outcomes included technical and clinical success, stent dysfunction, and adverse events, analyzed using a random-effects model. Results were reported as relative risks (RRs) with 95% confidence intervals (CIs).

Results

Five studies met inclusion criteria, comprising 128 patients (female = 45.5%; mean age range 63.0–73.0 years), with 61 undergoing EUS-CDS and 67 undergoing EUS-HGS. Four studies were conducted in Europe and one in the United States; one study was prospective. Technical success rates were similar between groups (RR 0.96, 95% CI 0.83–1.11; I² = 0%; EUS-CDS 94.5% vs EUS-HGS 96.4%), as were clinical success rates (RR 1.04, 95% CI 0.92–1.19; I² = 0%; EUS-CDS 96.5% vs EUS-HGS 89.1%). However, the risk of stent dysfunction was significantly higher in the EUS-CDS group compared to EUS-HGS (RR 4.42, 95% CI 1.71–11.43; I² = 0%; EUS-CDS 45.1% vs EUS-HGS 10.9%). The incidence of procedure-related adverse events was comparable between the two approaches (RR 1.14, 95% CI 0.24–5.50; I² = 40.8%; EUS-CDS 10.7% vs EUS-HGS 16.0%).

Conclusion

This meta-analysis suggests that both EUS-CDS and EUS-HGS are similarly safe and effective for managing malignant biliary obstruction in the setting of concomitant GOO. However, EUS-CDS is associated with a more than four-fold increase in the risk of stent dysfunction, which may result in delays to critical cancer treatments.

Disclosure

None