Clinical Case Summary

An 80-year-old man, with no history of alcohol or tobacco use, presented with a six-month history of oral mucosal erosions, odynophagia, dysphagia, dysphonia, and a significant weight loss. Physical examination revealed an abdominal mass. A CT and MRI showed a normal sized liver with regular contours and a large nodular hepatic lesion suggestive of hepatocellular carcinoma (HCC), along with two small satellite nodules and one large lymphadenopathy at the hepatic hilum. Labs showed elevated -fetoprotein levels of 190 ng/mL. He was referred to Hepatic Oncology and underwent an ultrasound-guided biopsy of the liver lesion, confirming well-differentiated HCC. The patient also developed erythematous-brown scaly plaques on the trunk and limbs. A skin biopsy was performed, and along with clinical and serological findings, confirmed the diagnosis of paraneoplastic pemphigus. High-dose Prednisolone was started and led to partial improvement. Two cycles of IVIG followed, with significant remission of skin lesions. He also began Sorafenib for HCC. After six months, follow-up imaging showed progression of the hepatic lesion, as well as tumor seeding in the thoracic wall along the needle tract of the liver biopsy. Treatment was escalated to Regorafenib, which was discontinued after two months. He died 16 months after diagnosis ,from traumatic brain injury. Paraneoplastic pemphigus is a rare autoimmune disease typically linked to hematologic cancers, with only four cases of associations with HCC described in the literature. This rare combination limits treatment options, particularly immune checkpoint inhibitors. In this case, immunosuppression may have impaired antitumor immunity, contributing to rapid tumor progression and biopsy needle tract dissemination.

References

1. Hinterhuber, G., Drach, J., Riedl, E., Böhler, K., Ferenci, P., Wolff, K., & Foedinger, D. (2003). Paraneoplastic pemphigusin associationwith hepatocellular carcinoma. Journal of the American Academy of Dermatology, 49(3), 538–540.
2. Yokokura, H., Demitsu, T., Kakurai, M., Umemoto, N. et al (2006). Paraneoplastic pemphigus mimicking erosive mucosal lichen planus associatedwith primary hepatocellular carcinoma. The Journal of dermatology, 33(12), 842–845.
3. Jang, M., Lee, K., Han, S., Park, J., Lee, J., Suh, K. (2014). Paraneoplastic Pemphigus Associated with Hepatocellular Carcinoma. Korean Journal of Dermatology,34-39.
4. Muramatsu, T., Matsumoto, H., Yamashina, Y., Shirai, T., & Sakamoto, K. (1989). Pemphigus foliaceus associated with acanthosis nigricans-like lesions and hepatocellular carcinoma. International journal of dermatology, 28(7), 462–463.
5. Schaffler-Schaden, D., Birsak, T., Zintl, R., Lorber, B., & Schaffler, G. (2020). Risk of needle tract seeding after coaxial ultrasound-guided percutaneous biopsy for primary and metastatic tumors of the liver: report of a single institution. Abdominal radiology (New York), 45(10), 3301–3306.
7. Decaens, T., Roudot-Thoraval, F., Bresson-Hadni, S., Meyer, C. et al (2006). Role of immunosuppression and tumor differentiation in predicting recurrence after liver transplantation for hepatocellular carcinoma: a multicenter study of 412 patients. World journal of gastroenterology, 12(45), 7319–7325.

Introduction

Difficult biliary stones and complex bile duct anatomy often limit the efficacy of endoscopic sphincterotomy (EST) alone. Dilation-Assisted Stone Extraction (DASE), involving large balloon dilation following EST, has emerged as a complementary technique to improve stone clearance. This study aimed to evaluate the safety and effectiveness of DASE performed either after primary EST in patients with naïve papilla or as a rescue strategy following prior EST.

Aims & Methods

A retrospective review was conducted on all patients who underwent DASE between January 2018 and December 2024 at the Department of Gastroenterology and Digestive Endoscopy, Mohammed VI University Hospital, Marrakech, Morocco. Inclusion criteria comprised patients with naïve or previously treated papilla undergoing DASE for bile duct clearance. Technical success was defined as successful balloon placement across the papilla, full inflation to target diameter for >30 seconds, followed by complete stone extraction. Complications were categorized as intraprocedural, early (<24 hours), or delayed (>24 hours).

Results

A total of 57 patients were included (mean age 72.5 ± 12.1 years; 30 females [52.6%], 27 males [47.4%]). Thirty-five patients (61.4%) had a naïve papilla, and 22 (38.6%) had prior EST. Main indications for DASE included large or impacted CBD stones (63.2%), periampullary diverticulum (15.8%), difficult cannulation (12.3%), altered anatomy (5.3%), and other causes (3.5%).
Technical success was achieved in 55 patients (96.5%). Thirteen patients (22.8%) experienced complications: 7 (53.8%) intraprocedural, 4 (30.8%) early, and 2 (15.4%) delayed.
Adverse events included:

• Bleeding in 8 patients (61.5% of all complications): 4 self-limited (50%), 3 endoscopically managed (37.5%), and 1 required radiological embolization (12.5%).
• Post-ERCP pancreatitis (PEP) in 4 patients (30.8%): all mild, resolved with conservative management.
• Perforation in 1 patient (7.7%): managed successfully with endoscopic clipping and supportive care.

Conclusion

DASE following EST is a highly effective and relatively safe approach for managing difficult CBD stones, with a high technical success rate and acceptable complication profile. The results support its routine use in therapeutic endoscopy, particularly for cases refractory to EST alone. Prior EST may be associated with a higher risk of adverse events and should prompt careful intra- and post-procedural monitoring.

References

- Zhang Q, Shen H, Zhang Y, Ding Y, Zhang X, Wang L.
Dilation-assisted stone extraction versus mechanical lithotripsy for large bile duct stones: a systematic review and meta-analysis. Endoscopy. 2021;53(5):454–463.
- Liao WC, Angsuwatcharakon P, Isayama H, Dhir V, Devereaux B, Khor CJL, et al.
International consensus recommendations for difficult biliary access.
Gastrointest Endosc. 2017;85(2):295–304.
- Tringali A, Familiari P, Perri V, Boskoski I, Mutignani M, Costamagna G.
Endoscopic papillary large balloon dilation with sphincterotomy for the treatment of difficult common bile duct stones: outcomes, complications, and rates of stone recurrence.
Surg Endosc. 2020;34(11):4912–4920.

Clinical Case Summary

A 50-year-old man with known hypertension and hypothyroidism was recently diagnosed with AML. He presented with high-grade fever for one month. There were no gastrointestinal complaints, weight loss, or night sweats. Physical examination was unremarkable aside from fever (38.7°C); he was hemodynamically stable.
Initial labs revealed pancytopenia: hemoglobin 8.4 g/dL, WBC 1.2 × 10⁹/L, platelets 42 × 10⁹/L, and ANC 200/µL. Peripheral smear confirmed febrile neutropenia. He was started on intravenous broad-spectrum antibiotics. Due to persistent fever, a workup for occult infections was initiated. Blood and urine cultures were negative. Serum and BAL galactomannan were positive, suggesting possible invasive aspergillosis; liposomal amphotericin B was commenced.
Abdominal ultrasound revealed a bulky pancreas with heterogeneous echotexture. Contrast-enhanced CT showed a 2×3 cm heterogeneously enhancing lesion in the pancreatic tail. CA 19-9 was normal. EUS identified a hypoechoic.The main differentials considered included: Leukemic infiltration: due to AML background, Primary pancreatic malignancy: suggested by the imaging appearance, Invasive fungal infection: supported by positive galactomannan assays,Pancreatic tuberculosis: rare, but considered due to an endemic background.
FNAC showed granulomatous inflammation with caseation. GeneXpert MTB/RIF was positive for M. tuberculosis.
He was started on anti-tubercular therapy. Fever resolved within 10 days. Imaging at 3 months showed resolution of the mass. He completed a 6-month course uneventfully.
The presence of a discrete mass and lack of gastrointestinal symptoms complicated the diagnosis. FNAC with GeneXpert was key in confirming TB and ruling out other causes.

References

Pancreatic TB is a rare form of extrapulmonary tuberculosis, accounting for less than 5% of abdominal TB cases. It typically affects younger individuals and may be more prevalent in immunocompromised patients, including those with HIV or malignancy.

Clinically, pancreatic TB is a great mimicker. Common symptoms include fever, abdominal pain, weight loss, and night sweats. Jaundice may be seen if there is biliary involvement. Radiologically, it is difficult to distinguish from pancreatic cancer or pancreatitis. Masses may be solid or cystic and can involve any part of the pancreas.

EUS has emerged as a critical tool in evaluating pancreatic lesions. It allows for high-resolution imaging and real-time sampling via FNAC. Cytological examination may reveal granulomatous inflammation, although this is not pathognomonic. A definitive diagnosis often hinges on demonstration of acid-fast bacilli, culture, or PCR-based methods such as GeneXpert.

Our case highlights the importance of considering TB in the differential diagnosis of pancreatic masses, especially in endemic areas or immunocompromised patients. Early diagnosis via EUS-FNA and initiation of ATT can result in complete clinical and radiological recovery, sparing the patient from unnecessary surgical intervention.