Clinical Case Summary

Gastric neuroendocrine tumors (NETs) are classified into three types based on their pathogenesis. Type 3 NETs are sporadic, not hypergastrinemia associated , and typically present as solitary, aggressive lesions with a higher metastatic potential. Current ENETS guidelines recommend surgical resection for lesions larger than 20 mm, particularly for Type 3 NETs, to minimize the risk of metastasis. We present the case of a 54-year-old male admitted for syncopal episodes and anemia (Hb 10.5 g/dL). After treatment with acetylsalicylic acid and enoxaparin for suspected myocardial ischemia, he developed a pre-syncopal event and a drop in hemoglobin to 6.8 g/dL. Urgent esophagogastroduodenoscopy (EGDS) revealed a 20 mm pedunculated polyp in the gastric body (Fig 1-2-3). Biopsies confirmed a neuroendocrine tumor (NET) with a Ki67 index of 1%. Systematic gastric mucosal mapping showed no other histological abnormalities, supporting the diagnosis of a sporadic Type 3 NET. Staging with contrast-enhanced CT, 68Gallium PET (68Ga-DOTATOC), and endoscopic ultrasound (EUS) excluded local invasion, nodal involvement, and distant metastases. Given the 0-Ip morphology according to the Paris classification, an endoscopic resection was performed using a hot snare technique with endoloop placement at the base of the peduncle. Histology confirmed a 21 mm NET G2 (Ki67 8%) with submucosal infiltration but no vascular or lymphatic invasion (Fig 4-5). Resection margins were clear. At six months, EGDS and 68Ga-PET showed no evidence of recurrence or residual disease. This case underlines how, even in Type 3 NETs larger than 20 mm, the pedunculated morphology can allow for complete and safe endoscopic resection, similarly to what is observed in the management of colonic polyps. Further studies are needed to better define the role of morphology in therapeutic strategies for gastric NETs. This is the only reported case of a pedunculated Type 3 NET of this size successfully treated endoscopically.

References

Figure 1. Upper gastrointestinal endoscopy revealed a 20 mm pedunculated polyp in the gastric body, corresponding to a Paris 0-Ip lesion. The surface appeared smooth, with signs of erosion and ulceration.

Figure 2. Linked Color Imaging (LCI) enhanced the vascular and mucosal pattern, showing a well-circumscribed lesion with preserved pit pattern, suggestive of a subepithelial neoplasm suitable for endoscopic resection.

Figure 3. Endoscopic view of the resection using a hot snare technique and prophylactic endoloop placement at the stalk base. Complete resection was achieved without complications.

Figure 4. Hematoxylin and eosin staining, 10x. The tumor arises from histologically normal oxyntic mucosa, without adjacent endocrine hyperplasia, consistent with a sporadic Type 3 gastric neuroendocrine tumor.

Figure 5. Immunohistochemistry panel of the resected specimen. The tumor shows diffuse positivity for Chromogranin A, Synaptophysin, and Somatostatin Receptor 2 (SSTR2). The Ki67 (MIB-1) proliferation index was 8%, consistent with a Grade 2 NET. No lymphovascular invasion was identified, and resection margins were clear.

Clinical Case Summary

Background: Enteric duplication cysts are one of the rarest lesions detected in the pancreas. Pancreatic duplication cysts can be challenging to distinguish from neoplastic lesions, particularly in symptomatic patients. Radiologic imaging, such as Computed Topography (CT) and Magnetic Resonance Imaging (MRI), may not always provide a clear differentiation, leading to potential misdiagnosis.
Case presentation: We present the case of a Fifty-seven male patient with a history of long-standing epigastric pain, dyspepsia, and weight loss. Upper and lower endoscopy showed only mild gastritis. Abdominal CECT abdomen showed a well-circumscribed pancreatic lesion of about 20x25 mm with no vascular invasions. Endoscopic ultrasound showed a well-circumscribed pancreatic neck lesion about 20x22 mm, anechoic, negative color flow doppler, soft on elastography, free surrounded vessels with no posterior acoustic enhancement. EUS suggested a cystic lesion versus a vascular NET. EUS fine-needle aspiration (FNA) was done with aspiration of gelatinous material and onsite cytopathology suggested a benign cystic lesion. Further pathological interpretation confirms the diagnosis of a duplication cyst leading to appropriate management without avoidance of major invasive surgical intervention.
Conclusion: EUS and EUS-guided biopsy have a crucial role in differentiating benign pancreatic conditions from malignancies, particularly in patients presenting with nonspecific symptoms and ambiguous radiologic findings. EUS should be considered early in the diagnostic process to avoid misdiagnosis and unnecessary surgical procedures.

Disclosure

Nothing to disclose

Clinical Case Summary

A 54-year-old man was referred to a Gastroenterology appointment due to weight loss and abnormal pancreatic findings on a CT scan, which revealed massive pancreatic enlargement. He had no relevant medical history. Endoscopic ultrasound demonstrated a globular pancreas with a hypoechoic but highly heterogeneous echotexture, multiple subcentimetric nodular formations and numerous millimetric hyperechoic foci, consistent with calcifications. Chromogranin A level was elevated at 143.2 ng/mL.
A 22G fine-needle aspiration of the pancreatic parenchyma was performed, but the result was inconclusive. Subsequently, PET/CT with 68Ga-peptides revealed a focal area of markedly increased uptake in the pancreatic tail (SUV max 47.8), highly suggestive of a neuroendocrine neoplasm, with increased radiotracer uptake throughout the pancreas. As a result, a percutaneous biopsy of the neoplasm and surrounding parenchyma (tail and body) was performed, confirming a well-differentiated (G1) pancreatic neuroendocrine tumor with amyloid stroma. Treatment was initiated with octreotide, later transitioned to lanreotide.
The patient underwent genetic evaluation, which revealed likely pathogenic variants c.1176+1_1176+7del p.? and c.361T>C p.(Cys121Arg) in the GCGR gene (heterozygous), confirming a diagnosis of Mahvash disease.
Two years later, during follow-up, abnormal liver function tests prompted abdominal magnetic resonance imaging, revealing liver nodules with characteristics of hypervascular metastases and signs of portal hypertension. An upper endoscopy was performed, revealing large esophageal varices with red spots, which were treated with two prophylactic elastic band ligations.
This case illustrates the development of portal hypertension arising from an extremely rare genetic disorder, with only about 15 confirmed cases of Mahvash disease reported to date. It is comprehensively documented through CT, PET imaging, histology, endoscopic ultrasound and upper endoscopy iconography.

References

- Yu, Run. “Plea to radiologists: Please consider Mahvash disease when encountering an enlarged pancreas.” World journal of radiology vol. 16,8 (2024): 371-374. doi:10.4329/wjr.v16.i8.371
- Robbins, Justin et al. “Liver Transplantation in a Woman with Mahvash Disease.” The New England journal of medicine vol. 389,21 (2023): 1972-1978. doi:10.1056/NEJMoa2303226

Clinical Case Summary

Background: Endoscopic ultrasound (EUS)-guided cystogastrostomy with lumen-apposing metal stents (LAMS) is a widely accepted treatment for symptomatic pancreatic pseudocysts, particularly in cases of walled-off necrosis (WON). While the procedure is generally safe, delayed bleeding can occur. This report presents a novel approach to managing massive upper gastrointestinal bleeding following LAMS placement when interventional radiology (IR) embolization is not feasible.
Case presentation: A 51-year-old male with a history of pancreatitis and a large pancreatic pseudocyst underwent successful EUS-guided placement of an Axios stent. The patient was discharged on the second day of the procedure with no adverse events. Three days later, the patient developed significant melena, pallor, and a dramatic drop in hemoglobin levels, necessitating urgent blood transfusions. Diagnostic upper endoscopy revealed active pulsatile bleeding from the cyst wall behind the stent edge, which is inaccessible to conventional endoscopic methods. Two attempts of angiography by two different IR consultants failed to locate the bleeding source.
Given the critical situation and after resuscitation with IV blood transfusion, a multidisciplinary team proposed a novel technique: injection of Purastat, a hemostatic agent, into the cyst through the stent, followed by stent removal and additional application of glue over the cyst orifice. This approach successfully controlled the bleeding, stabilized the patient’s condition, and eliminated the need for surgery. Follow-up imaging revealed a small splenic artery aneurysm without active bleeding.
Conclusion: This case highlights the potential of Purastat as an effective tool for managing life-threatening gastrointestinal bleeding following LAMS placement. The successful use of this technique in sealing the cyst and stopping the bleeding suggests it could be a definitive management option in similar cases.

References

1. Shamah S, et al. Delayed bleeding after lumen-apposing metal stent placement for pancreatic fluid collections: Incidence, risk factors, and management. *Endoscopy International Open*. 2023;11(2):E158-E163.
2. Varadarajulu S, et al. Hemostasis in gastrointestinal endoscopy: Emerging techniques and devices. *Gastrointestinal Endoscopy Clinics of North America*. 2022;32(3):421-439.

Clinical Case Summary

An 82-year-old man with Child B alcoholic cirrhosis, complicated by portal hypertension, underwent surveillance upper digestive endoscopy (UDE), revealing large esophageal varices and a 20 mm exophytic lesion, 40 cm from the dental arch, with an infiltrative and ulcerated appearance. Biopsies were inconclusive. Endoscopic ultrasound identified a heterogeneous, amorphous lesion with poorly defined borders and disruption of all wall layers, complicated by numerous large varices, preventing biopsy due to hemorrhagic risk. Computed tomography revealed parietal thickening in the distal esophagus and multiple varices, complicating lesion delineation. An oncology consultation recommended clinical surveillance, considering the patient's age, comorbidities, indeterminate nature of the esophageal lesion, and low suspicion for adenocarcinoma on ultrasound. One year later, surveillance UDE showed regression of the lesion.Histological samples were reviewed, revealing changes consistent with pyogenic granuloma. Pyogenic granuloma is a rapidly growing capillary hemangioma that may occur within the lumen of a pre-existing vessel (intravascular variant). The case is supported by appropriate iconography.

This case is presented with imaging, highlighting the challenge due to the macroscopic appearance suggestive of a neoplastic lesion and the pyogenic granuloma's growth within esophageal varices, limiting diagnostic and therapeutic management.

References

Introduction

Studies report that almost 50% of Large Non-Pedunculated Colorectal Polyps (LNPCP) have been subjected to heavy manipulation in form of prior attempts at resection or extensive biopsy sampling prior to referral to an expert centre. This significantly impacts several critical outcomes of endoscopic resection (ER). However, understanding of standardised classifications of LNPCP, endoscopic diagnosis and indications for ER has increased in general endoscopy practice which may have improved decision making prior to referral. We aimed to compare trends in patterns of prior injudicious manipulation and the significance of biopsy sampling over sequential time periods in a large cohort of patients referred to a tertiary referral centre for ER.

Aims & Methods

Referral documentation, including clinic and referral letters, endoscopy reports, and histopathology result, were reviewed for evidence of prior resection attempts or biopsy sampling. Data included the number of biopsy samples taken and corresponding histological results. Patients referred between January 2011 and August 2024 were categorised into five time periods. Heavy manipulation was defined as either a prior resection attempt or ≥6 biopsy samples. Analyses included comparisons of resection attempts, heavy manipulation, biopsy sampling, and the detection of high-grade dysplasia on biopsies (as a marker of improved lesion assessment and targeted sampling). Trends in practice changes were assessed using the Chi-square test for trend.

Results

1407 LNPCP were treated by ER. There was a significant trend toward fewer prior failed attempts at resection over sequential time periods with 30% in Period 1 and only 11% in Period 5 (p<0.001); fewer LNPCP subjected to heavy manipulation with 61% in Period 1 and 27% in Period 5 (p<0.001) and fewer LNPCP with prior biopsy sampling with 77% in Period 1 and 47% in Period 5 (p<0.001). However, there was no trend found for an improvement in biopsy sampling yields of HGD with 18% in Period 1 and 25% in Period 5 (p=0.1).

Conclusion

In a large cohort of ER of LNPCP, this study demonstrates a significant reduction over time in failed resection attempts, heavy manipulation, and biopsy sampling of LNPCP before referral to a tertiary centre for endoscopic resection (ER). This suggests an improvement in endoscopic lesion assessment and decision making by general endoscopists. However, heavy manipulation remains a significant problem. Although fewer LNPCP are biopsied prior to referral, the yield of significant findings did not change, suggesting biopsies are not effectively targeted, and highlighting the need for further improvements in lesion assessment.

Introduction

EUS-hepatico-gastrostomy(HGS) has become indispensable procedure in case of inaccessible cases due to malignant invasion to the duodenum etc. , failed ERCP cases, and failed cases after single balloon assisted ERCP(SBE-ERCP) in surgical altered anatomy.

Aims & Methods

From January, 2016 to April, 2024, we have performed EUS-HGS in 131(Male:79, Female 52, averaged age: 72) cases. The indication of EUS-BD was inaccessible to the duodenal papilla due to malignant invasion or failed cases of ERCP in cases of normal anatomy. In cases without duodenal invasion and intrahepatic bile duct dilatation, we perform EUS-CDS and we perform EUS-BD rendezvous in cases of accessible normal anatomy. And we performed EUS-HGS in remained cases. In surgical anatomy cases, we firstly perform SBE-ERCP, EUS-HGS were performed after failed SBE-ERCP. We have investigated the safety and usefulness of HGS.

Results

The subjects were consisted of malignant diseases (pancreatic cancer: 61(46.6%), biliary cancer: 20(15.3%), and others 35(26.7%) and benign disease (stenosis of bilio-jejunum anastomosis 7(5.3%), bile duct stone7(5.3%), primary sclerosing cholangitis 1(0.8%)). The reason for EUS-HGS were consisted of duodenal invasion 84 (64.1%) cases, inaccessible 21(16%), failed deep canulation 20(15.3%), others 6(4.6%). And normal anatomy cases were 90 (68.7%) and surgical anatomy 41(31.3%). Technical and clinical success was 128(97.7%) and 116(88.5%). The median procedure duration was 36 minutes (range 11-109). The used needle was 19 guage: 113(86.3%) and 22 guage: 18(13.7%). The puncturing branch was B3: 95(72.5%), B2: 35(26.7%), and B1: 1(0.8%). The averaged size of punctured branch was 5.0mm (range2.0-13.0). The dilation method was bougie: 97(74%), balloon: 21(16%), electrocautery: 6(4.6%), drill dilator: 5(3.8%), and not dilate: 2(1.5%). The used stent was plastic stent (PS): 105(80.2%) and covered metallic stent (CMS): 24(18.3%). The stent patency was PS: 120 days and CMS: 226 days (p=0.13). The early complication was peritonitis: 10(7.6%), bacteremia: 5(3.8%), cholangitis: 4(3.1%), bleeding: 2(1.5%), and migration: 3(2.3%). The multivariate analysis revealed only longer procedure duration (more than 36 min.) corelated to early complication(p=0.01).

Conclusion

EUS-HGS is safe and effective and essential for inaccessible cases, failed cases after ERCP and SBE-ERCP. And longer procedure duration corelated with early complication.