Clinical Case Summary

Percutaneous endoscopic gastrostomy (PEG) tube has been frequently placed for various indications in order to provide long term enteral nutrition support[i],[ii],[iii]. Approximately 160,000 to 200,000 PEG tubes are placed each year in United States[iv]. Advancements in surgical interventions of gastrointestinal tract has resulted in increased number of anatomically altered stomachs, and so anatomically changed on endoscopic examination as well; which makes endoscopic interventions a little different[v]. Multiple case series have been reported for PEG tube placement in patients with subtotal gastrectomy [vi], however, there is scarce data available for PEG tube placement in patients with history of sleeve gastrectomy. The case that is presented here is regarding 64 years old lady with history of sleeve gastrectomy and now referred for PEG tube placement as she was advised for radiotherapy for squamous cell carcinoma of right buccal mucosa. PEG tube was successfully placed and follow up to a month showed effectively functional PEG tube with no major complications.

References

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[ii] Richards DM, Tanikella R, Arora G, Guha S, Dekovich AA. Percutaneous endoscopic gastrostomy in cancer patients: predictors of 30-day complications, 30-day mortality, and overall mortality. Dig Dis Sci. 2013;58:768–776. doi: 10.1007/s10620-012-2397-8.
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[iv] Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis. 2021 Aug;13(8):5277-5296. doi: 10.21037/jtd-19-3728. PMID: 34527366; PMCID: PMC8411178.
[v] Morrell D, Pauli E, Juza R. Endoscopy in surgically altered anatomy. Annals of Laparoscopic and Endoscopic Surgery. 2019 Apr 24;4.
[vi] Singh P, Kahn D, Greenberg R, Indaram A, Pooran N, Bank S. Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy. Endoscopy. 2003 Apr;35(4):311-4. doi: 10.1055/s-2003-38156. PMID: 12664387.

Introduction

Managing biliopancreatic disease in elderly patients is a growing challenge, where the balance between benefit and risk becomes increasingly delicate. ERCP remains a fundamental tool, but its application in older adults requires individualized technical and clinical considerations. The aim of our study was to evaluate the characteristics of elderly patients who underwent ERCP.

Aims & Methods

We conducted a retrospective descriptive study from January 2019 to January 2025, including all patients aged ≥65 years who underwent ERCP. Collected data encompassed demographic characteristics, clinical presentation, procedural indications, technical success, therapeutic approaches, and procedure-related complications.

Results

We recorded 186 patients : 62.36% women (n=116) and 37.6% men (n=70), with a median age of 75 years [IQR: 71–80]. The most frequent presenting symptoms were biliary colic (43.4%, n=79), acute cholangitis (23.6%, n=43), cholestatic jaundice (11.8%, n=22), and acute pancreatitis (10.8%, n=20).
ERCP was indicated for benign pathology in the majority of cases, primarily for choledocholithiasis (56.5%, n=104). Other benign etiologies (11%, n=12) included post-cholecystectomy syndrome, biliary pancreatitis, bile duct injury, and Sump syndrome.
Malignant indications included pancreatic head tumors (20.7%, n=38), hilar cholangiocarcinoma (7.1%, n=13), ampullary carcinoma (6.5%, n=12), and gallbladder carcinoma (3.8%, n=7).
The technical success rate for benign pathology was 97.4% (n=113), with a failure rate of 2.6% (n=3). In malignant indications, the success rate was 90% (n=63), with failures (10%, n=7) primarily due to duodenal obstruction or an intradiverticular papilla.
Stenting strategies included uncovered self-expandable metal stents (33.2%, n=43), covered metal stents (3.8%, n=7), and plastic stents (7.6%, n=14).
Intra-procedural bleeding following sphincterotomy occurred in 2.7% of cases (n=3); two were managed with epinephrine injection and one with hemostatic clipping. No delayed post-procedural complications were reported.

Conclusion

ERCP appears to be a safe, effective, and well-tolerated procedure in elderly patients. When guided by appropriate indications and expert technique, age does not represent a limitation but rather a parameter requiring adapted procedural planning.

Clinical Case Summary

Duodenal-Type Follicular Lymphoma (DTFL) is a rare form of non-Hodgkin’s lymphoma, accounting for <4% of gastrointestinal lymphomas. Though generally indolent, misdiagnosis can lead to delayed diagnosis in progressive cases. We present a case highlighting the importance of awareness for early detection. A 53-year-old woman with persistent epigastralgia underwent esophagogastroduodenoscopy (EGD) three times over five years at different hospitals. Only the latest EGD revealed multiple whitish nodular lesions in the first portion of the duodenum. Biopsies showed follicular proliferation confined to the mucosa, composed of small cleaved lymphoid cells. Immunohistochemistry confirmed a B-cell phenotype (CD20+, CD79a+, CD3-, CD5-), a germinal center phenotype (CD10+, Bcl6+), Bcl2 expression and low Ki-67. Blood tests were unremarkable, and viral serology was negative. CT scans revealed only reactive submandibular lymph nodes, with a normal bone marrow biopsy. PET scan showed uptake limited to the duodenum, confirming stage I disease (Lugano classification). Given its indolent course, a watch-and-wait strategy was adopted, with stable findings at a six-month follow-up EGD. DTFL is often incidentally detected during endoscopy and can be mistaken for benign conditions. Although typically localized, it may spread beyond the duodenum. Awareness is crucial to avoid unnecessary interventions and ensure timely diagnosis. Immunohistochemistry is key to distinguishing DTFL from reactive lymphoid hyperplasia and other low-grade lymphomas. While treatment options vary, active surveillance remains the most common approach due to its favorable prognosis. This case highlights DTFL as a rare but clinically significant entity that is frequently misdiagnosed, leading to unnecessary procedures. Recognizing its endoscopic and histologic features is essential for early diagnosis and appropriate management.

References

Figure 1: Upper endoscopy shows nodularity with whitish spots in the second portion of the duodenum (D2)
Figure 2: Endoscopic view showing a whitish polypoid lesion approximately 3 cm from the papilla
Figure 3: Duodenal mucosa with nodular lymphoid infiltrate, suggestive of duodenal-type follicular lymphoma

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