Clinical Case Summary

- Colorectal endometriosis is a particular form of deep endometriosis. Diagnosis is suspected on the basis of clinical signs, and confirmed by non-invasive imaging. The combined use of pelvic MRI and rectal endoscopy, when concordant, confirms the diagnosis at 100%.
We report the case of a patient admitted to the gastroenterology department for recto sigmoid endoscopic ultra sound (EUS) following suspicion of recto sigmoidal endometriosis.
- Case report: Mrs S.F, aged 39, has been treated for diffuse endometriosis for 2 years.
Following the onset of pelvic pain and cyclic rectal discharge, the patient underwent pelvic MRI, which showed invasion of the recto-sigmoid junction. Recto sigmoidoscopy was performed, with no particular findings.
Complementary radial recto sigmoid endoscopic ultra sound revealed invasion of the anterior sigmoid wall, extending from 15 to 23 cm from the anal margin, from a focus of pelvic endometriosis, involving the sigmoid muscularis, and respecting the mucosa, internal sphincter, external sphinter and muscularis of the other segments of the rectum.
The patient was referred back to gynecology for further management.
- Ultrasound rectal endoscopy is useful for diagnosing colorectal endometriosis, with a VPN of 97.7%, and is now part of the preoperative work-up.
*** (Included Images: Fig 1 : endoscopic ultrasound image showing sigmoid muscularis and hourglass-shaped endometriosis, Fig 2: endoscopic ultrasound image showing an endometriosis nodule, Fig 3: endoscopic ultrasound image showing normal rectal wall)

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

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

Helicobacter pylori is a common cause of peptic ulcers and gastritis. Standard triple therapy includes a PPI with amoxicillin and either clarithromycin or levofloxacin. Rising antibiotic resistance has reduced its effectiveness. Sequential therapy offers a phased alternative with better outcomes in resistant cases.

Aims & Methods

To evaluate and compare the efficacy of clarithromycin and levofloxacin-based triple and sequential therapies for Helicobacter pylori (H. pylori) eradication in a resource-limited setting, in the context of emerging antibiotic resistance.
A prospective, randomized study was conducted at a tertiary care center from January 1, 2022, to January 1, 2025. A total of 300 treatment-naïve patients aged 18–60 years, diagnosed with H. pylori infection through stool antigen, urea breath test, or histology, were included. Patients with prior eradication therapy or recent antibiotic use were excluded. Participants were randomized into four equal groups (n=75 each):

• Clarithromycin-based triple therapy (amoxicillin, clarithromycin, PPI)
• Levofloxacin-based triple therapy (amoxicillin, levofloxacin, PPI)
• Clarithromycin-based sequential therapy (amoxicillin + PPI for 5 days, followed by clarithromycin + tinidazole + PPI for 5 days)
• Levofloxacin-based sequential therapy (amoxicillin + PPI for 5 days, followed by levofloxacin + tinidazole + PPI for 5 days) Therapeutic response was assessed post-treatment for eradication.
  

Results

Out of 300 patients (180 males, 120 females), eradication was achieved in:

• 48/75 (64%) in clarithromycin-based triple therapy
• 53/75 (70.7%) in levofloxacin-based triple therapy
• 51/75 (68%) in clarithromycin-based sequential therapy
• 61/75 (81.3%) in levofloxacin-based sequential therapy

All patients completed therapy without notable adverse events or compliance issues. Lower eradication rates in clarithromycin-based regimens suggest rising resistance.

Conclusion

Levofloxacin-based sequential therapy demonstrated the highest eradication rate, highlighting its potential as a preferred regimen in settings with rising clarithromycin resistance. Clarithromycin-based treatments showed suboptimal outcomes, emphasizing the need for region-specific antibiotic stewardship and resistance surveillance.

References

1. Kim JS, Kim BW, Hong SJ, Kim JI, Shim KN, Kim JH, Baik GH, Kim SW, Song HJ, Kim JH. Sequential Therapy versus Triple Therapy for the First Line Treatment of Helicobacter pylori in Korea: A Nationwide Randomized Trial. Gut Liver. 2016 Jul 15;10(4):556-61. doi: 10.5009/gnl15470. PMID: 27114421; PMCID: PMC4933415.
2. Chang, J.Y., Shim, KN., Tae, C.H. et al. Triple therapy versus sequential therapy for the first-line Helicobacter pylori eradication. BMC Gastroenterol 17, 16 (2017). https://doi.org/10.1186/s12876-017-0579-8

Clinical Case Summary

Intra-ampullary papillary tubular neoplasms (IAPNs) are rare neoplastic intraepithelial lesions that occur within the ampulla. Given their well-documented malignant potential, early recognition and intervention are paramount to prevent malignant transformation. We present a case of IAPN successfully managed via endoscopic papillectomy.
A 58-year-old male was incidentally found to have a bulky-appearing ampulla of vater during esophagogastroduodenoscopy as part of routine health screening. Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla, with histopathological evaluation demonstrating low-grade dysplasia (indeterminate for neoplasia). Laboratory investigations, including hematological parameters, biochemical profiles, and tumor markers, were within normal limits. Contrast-enhanced abdominal CT demonstrated a well-defined, homogeneously enhancing 20-mm lesion at the ampullary region without biliary/pancreatic duct dilation.
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application. Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%). The postoperative course was uncomplicated, with discharge achieved on the sixth postoperative day. At six-month follow-up evaluation, surveillance endoscopic ultrasonography showed no evidence of recurrence.
IAPN represents a distinct neoplastic ampullary entity within the spectrum of ampullary tumors. While endoscopic resection demonstrates therapeutic efficacy, its implementation requires advanced endoscopic expertise in specialized centers.

References

Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application.
Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%).

Clinical Case Summary

Infectious esophagitis occurs most commonly in immunocompromised patients. Candida is the most common cause, followed by Herpes simplex virus. While HSV is known to cause esophagitis in immunocompromised patients, its occurrence in immunocompetent patients is rare.
We present the case of a 23 year-old male patient who was admitted to the emergency room with retrosternal chest pain, odynophagia, dysphagia, fever and hematemesis. Blood results showed leukocytosis and C-reactive protein of 93.5 mg/L.
An esophagogastroduodenostomy revealed multiple round and coalescing white plaques in the entire esophagus. The distal esophagus was severely affected and highly friable. Biopsies were taken.
A diagnosis of severe infectious esophagitis was assumed with an endoscopic appearance suggestive of esophageal candidiasis. He started treatment with fluconazole 400mg daily. Considering the medical history and clinical findings, intravenous acyclovir 5mg/Kg every 8 hours was added.
The patient denied drug and alcohol abuse but confirmed unprotected sexual intercourse with two women. HIV-1/2, HBV and HCV were negative. Serological results revealed positive HSV 1/2 IgM and negative IgG.
Clinical improvement allowed discharge on day 3 with oral fluconazole and acyclovir treatment.
Biopsies later confirmed herpetic esophagitis.
On follow-up, the patient was asymptomatic and with complete endoscopic resolution. Serological tests revealed HSV-1 seroconversion, confirming a diagnosis of HSV-1 primo-infection esophagitis.
Herpetic esophagitis in immunocompetent hosts is usually related to a primo-infection and the patient is often a young healthy male. It is an endoscopic and histopathological diagnosis with multiple, discrete, volcano-shaped or coalescent small ulcers. In some cases, the endoscopic appearance may mimic Candida esophagitis. While most cases in immunocompetent patients require no specific treatment, evidence indicates that acyclovir may shorten the duration of the disease.

Clinical Case Summary

Background: Pancreatic Adenocarcinoma (PA) represents an aggressive disease affected by very poor prognosis worldwide. In the early phases, PA remains asymptomatic favoring delayed diagnosis and affecting the disease prognosis. Recently, Acute Pancreatitis (AP) has been described by some anecdotical cases as a potential early manifestation of PA, in particular if case of pancreatic head development.
Case presentation: An 80-year-old female patient affected by diabetes mellitus type 2 complaining of acute epigastric pain was admitted to the emergency room receiving an AP diagnosis. After 2 days she was hospitalized at Gastroenterology Department to receive medical treatment. On admission, the patient presented hyper-neutrophilia, elevated levels of pancreatic enzymes, cholestasis indexes, and phlogosis markers. Abdominal ultrasound revealed a hypoechoic nodular lesion of 40 mm located at the pancreas body, associated with ectasia of the upstream Wirsung duct. The contrast enhancement US (CEUS), evidenced a hypoenhancement pattern in the arterial phase suggesting the need for a second-level imaging examination. The abdominal CT scan revealed the lesion ventral to the splenic-portal confluence without signs of vascular infiltration, presenting a late contrast enhancement suggestive of a hetero-primitive lesion of the pancreatic body. Echo-endoscopy-guided sampling confirmed the adenocarcinoma diagnosis. After this, the patient received a distal pancreatectomy to achieve surgical radicality. No progression of disease was observed after surgery, and she is currently on stable oncological follow-up.
Conclusion: Even when the neoplasm is not located in the head of the organ, AP has herein been reported as a rare exordial manifestation of PA whose onset can help clinicians to achieve early diagnosis of this aggressive tumor.

References

1. Saluja A, Maitra A. Pancreatitis and Pancreatic Cancer. Gastroenterology. 2019 May;156(7):1937-1940. doi: 10.1053/j.gastro.2019.03.050. Epub 2019 Mar 30. PMID: 30940522.
2. Bezuidenhout AF, Wei PK, Burstein D, Brook A, Brook OR, Freedman SD, Tsai LL. Unexplained Acute Distal Pancreatitis: Association With Subsequent Diagnosis of Pancreatic Cancer. AJR Am J Roentgenol. 2023 Aug;221(2):196-205. doi: 10.2214/AJR.23.28999. Epub 2023 Mar 22. PMID: 36946899.
3. Walling A, Freelove R. Pancreatitis and Pancreatic Cancer. Prim Care. 2017 Dec;44(4):609-620. doi: 10.1016/j.pop.2017.07.004. Epub 2017 Oct 5. PMID: 29132523.