Clinical Case Summary

Human alveolar echinococcosis (AE) is a parasitic disease, caused by E. multilocularis eggs ingestion. AE is rare and potentially fatal infection, with multisystemic involvement including the formation of tumor-like hepatic lesions. Differentiation of AE from liver malignancy is of paramount importance due to different prognostic and therapeutic implications (1).
A 33-year-old male patient, previously healthy, was referred for liver MRI due to a cholestatic liver lesion. The MRI revealed dilation of the intrahepatic bile ducts and an irregular mass at the hepatic hilum exhibiting radio-morphological features consistent with Klatskin tumor. Endoscopic ultrasound with fine needle aspiration of the hilar mass and enlarged lymph node (LN) was performed, but cytological examination did not reveal malignant cells. CA 19-9 level was normal. Subsequently, ERCP was performed, complicated with biliary leakage, leading to emergency surgery during which enlarged LN alongside the common bile duct, macroscopically suspicious for carcinoma metastasis was extracted. Again, patohistological (PH) examination revealed only reactive changes. Cytobrush collected during ERCP was negative for malignancy as well. A follow-up MRI after 2 months revealed no signs of disease progression, and PET-CT was inconclusive for malignancy.
Subsequently, patient was re-admitted to hospital due to need for further evaluation. Ultrasound-guided percutaneous biopsy of the lesion in the liver hilum was performed, and the final PH finding was indicative for AE. Treatment with albendazole at a dose of 15 mg/kg/day was initiated. Follow-up ultrasound examination did not show disease progression. Patient is clinically asymptomatic with only mild hepatic enzymes elevation consistent with albendazole treatment.
AE is an uncommon yet life-threatening parasitic infection that predominantly targets the liver. Diagnosis and treatment pose challenges, with clinical misinterpretation as malignancy not being uncommon.

References

Kawamura N, Kamiyama T, Sato N, Nakanishi K, Yokoo H, Kamachi H, et al. Long-Term Results of Hepatectomy for Patients with Alveolar Echinococcosis: A Single-Center Experience. J Am Coll Surg. 2011 May;212(5):804–12. doi: 10.1016/j.jamcollsurg.2011.02.007

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

The "Antimicrobial Resistance in Acute Cholangitis" (ARISE) study is a prospective investigation focused on the antimicrobial resistance patterns in patients with acute cholangitis undergoing ERCP. Conducted across multiple tertiary gastroenterology centers in Romania, this study aims to identify, analyze, and mitigate the challenges posed by multidrug-resistant (MDR) organisms in managing acute cholangitis.

Aims & Methods

Data collected included microbial cultures from bile samples, patient demographics, clinical outcomes, and antibiotic resistance profiles. From the study's onset in January 2024, 138 eligible patients were identified as having positive bile cultures. Among these patients, the predominant symptoms included abdominal pain (82.6%), jaundice (71%), and fever or shaking chills (36.2%). The diagnosis of acute cholangitis was established using TG18 criteria.

Results

Bile cultures were positive in 71.0% of cases. The most frequently isolated bacteria were Escherichia coli, found in 23.2% of positive cultures, followed closely by Enterococcus spp., present in 22.5% of cases. Klebsiella pneumoniae was also notably prevalent, identified in 7.2% of the bile samples. Ciprofloxacin showed the highest resistance rate among the tested antibiotics, with a resistance rate of 23.9%. Ampicillin and gentamicin displayed significant resistance rates at 10.9% and 18.8%, respectively. Piperacillin/tazobactam and trimethoprim/sulfamethoxazole each showed a resistance rate of 15.2%. The study's data on tigecycline and linezolid showed lower resistance rates, with tigecycline maintaining a sensitivity rate of 20.3% and linezolid at 19.6% in cultures where testing was applicable. In comparison, their resistance rates were only 0.7% for each. Multidrug resistance was identified in a significant fraction of isolates, with 15.2% of samples. A concerning finding was the presence of MDR strains of Escherichia coli, which exhibited resistance rates to ampicillin (21.0% sensitivity, 10.9% resistance) and amoxicillin/clavulanic acid (17.4% sensitivity, 14.5% resistance).

Conclusion

We observed a concerning prevalence of MDR organisms in acute cholangitis cases, particularly against antibiotics such as ampicillin, gentamicin, and ciprofloxacin, with a high incidence of MDR Escherichia coli strains.

Clinical Case Summary

Patient of 71 years old with CP was admitted for painless jaundice with benign common bile duct (CBD) stricture. ERCP failed at her center due to duodenal edema that prevented seeing the papilla so the patient was transferred to our center for assisted EUS drainage.

After after a first attempt with an unsuccessful rendezvous ERCP due to guidewire loss in the exchange of devices, cholecystoduodenostomy was performed with a coaxial double pigtail after confirmation of cystic duct permeability in the cholangiogram (previously performed under EUS guidance with puncture of the CBD to perform de rendezvous). In a second attempt to treat the stricture, a rendezvous through the gallbladder was performed. After papilloplasty and dilating the stricture, a 10 x 60 mm FCMS was placed. The patient improved and the lumen apposing metal stent of the cholecystoduodenostomy was removed. In followup, proximal migration of the stent was observed, impossible to remove by ERCP at her center due to impossibility of accessing the papilla.

In our center, a new endoscopy was performed. CBD was punctured by EUS with a 22 G needle through the biliary stent to perform a rendezvous and a novagold guidewire was advanced to the duodenum. The CBD was accessed with a monorail sphincterotome over the guidewire and rigid guidewire was advanced to the biliary tract. Papilloplasty was performed againd and the migrated stent was removed with rat tooth forceps. A new FCMS was placed successfully.

To conclude, endoscopic management of patients with CP can be very complex and several advanced combined bile duct access techniques are sometimes required. So, these patients should ideally be managed in referral centers.

Introduction

EUS-guided drainage using lumen-apposing metal stents (LAMS) has become standard treatment of symptomatic walled-off necrosis (WON). The development of these fully covered self-expanding metal stents with special design of the flanges and large diameter, improved the drainage of debris and facilitated further direct endoscopic necrosectomy. Delivery systems with integrated electro-cautery (EC) enable direct access and stent deployment whilst the conventional stent insertion technique requires several steps including access using a needle or cystotome, wire insertion and enlargement of the created tract before the stent placement.

Aims & Methods

In this single center study, we aimed to compare the practicality of EUS-guided procedures and their outcome between conventional LAMS (cLAMS) and those with integrated EC (LAMS-EC).
From our prospectively maintained database, we included consecutive patients undergoing EUS-guided LAMS insertion with or without integrated electro-cautery for drainage of walled-off necrosis. Infection of the walled-off pancreatic necrosis, biliary compression with cholestasis or gastric outlet obstruction were accepted indications for intervention. Data on procedure time, sedation, hospital stay, technical and clinical success as well as adverse events were analysed.

Results

We analysed 107 consecutive procedures of transmural EUS-stenting for drainage of walled-off necrosis. 39 cLAMS and 68 LAMS-EC were placed successfully. Mean size of the walled-off necrosis was 12.9 ± 4.2 cm with mean 30% ± 15% solid necrosis.
Procedure times were shorter with LAMS-EC (18 .0 ± 6.6 min vs. 39.7 ± 8.3 min; p<0.05). All EUS-guided procedures with cLAMS drainage were performed under propofol sedation administered by an anaesthetic team. In the LAMS-EC group, 36 patients tolerated the procedure under iv sedation (fentanyl/midazolam) in left lateral position and 17 interventions were performed as daycase procedures. None of the patients developed sedation related adverse events such as aspiration.
Adverse events, technical success and clinical outcome did not differ between both groups.

Conclusion

The findings of this study suggest that cLAMS and EC-LAMS achieve similar rates of technical and clinical success without difference in the rate of adverse events. Compared to cLAMS, deplayment of EC-LAMS is faster and technically less demanding. This might allow to perform the procedure under conventional intravenous sedation and as daycase procedure in carefully selected patients.

Clinical Case Summary

A 90-year-old woman was referred to our endoscopy unit from another hospital for urgent rescue therapy because of impacted Dormia basket during ERCP performed for symptomatic recurrent choledochal lithiasis. In attempt to perform extracanalar lithotripsy Dormia basket was broken near the handle. Another ERCP was performed, and the contrast cholangiography showed dilated common bile duct (up to 13mm) with a constriction in the middle part and impacted Dormia basket with multiple gallstones, confirmed by Spyglass single-operator per-oral cholangioscopy with direct visualization. Electrohydraulics lithotripsy with Autolith EHL system (2437 pulses, medium-high power) was performed with stones fragmentation but Dormia basket entrapped stone fragments. Dormia basket distal margin was caught with a biopsy forceps and passed in duodenoscope working channel. Then biliary clearance was completed with ballon catheter and the following cholangiography confirmed successful biliary drainage and optimal bile outflow without contrast biliary or duodenal spreading. Postprocedural course was regular, and the patient was discharged after three days of hospitalization.

Clinical Case Summary

Introduction: Superior mesenteric artery pseudoaneurysms (SMA) are rare vascular entities, but can potentially result in significant morbidity and mortality (up to 60%) if rupture occurs. Traditionally, SMA pseudoaneurysms are associated with arterial dissection, pancreatitis, infection, trauma, tumor invasion, or arise as post-operative and iatrogenic complication.^1-8
Case report: A 51-year-old man with a medical history of chronic alcohol consumption and chronic pancreatitis presented with multiple episodes of hematemesis and hematochezia, jaundice and severe abdominal pain with a supraumbilical pulsatile mass. The patient was haemodynamically unstable (BP: 79/45 mmHg, HR: 123/min) with inadequate resuscitation despite transfusions of blood products and intravenous fluids. Laboratory tests showed significant reduction in hematocrit (Hct: 23,9%, Hb: 7,7 g/dL) and abnormal liver function tests (TBL: 7,21 mg/dL, DBL: 4,88 mg/dL, SGOT: 156 U/l, SGPT: 92 U/l, γGT: 1822 U/l, ALP: 1577 U/l). An abdominal vascular lesion was suspected and an urgent CT angiography was performed. The CT scan confirmed the presence of a ruptured superior mesenteric artery pseudoaneurysm, 11.5cm in diameter, localized inside a giant pancreatic pseudocyst (Figure A). Ultimately, as the patient was a poor surgical candidate we decided to treat him using endovascular therapy. Arterial catheterization and angiographic evaluation of the superior mesenteric artery pseudoaneurysm was performed, showing active contrast agent extravasation treated by a fully covered stent placement (Figure B). The final angiogram confirmed the the success of the intervention. The postoperative course was uneventful and the patient was discharged on the 8^th postoperative day.
Conclusions: In conclusion, physicians should keep alert to this rare etiology of haemobilia. It is of utmost importance to urgently manage SMA pseudoaneurysms because of the high risk of rupture and potential life-threatening haemorrhage.

References

1. Guirgis M, Xu JH, Kaard A, Mwipatayi BP. Spontaneous Superior Mesenteric Artery Branch Pseudoaneurysm: A Rare Case Report. EJVES Short Rep. 2017 Oct 12;37:1-4.
2. Patelis N, Doukas P, Dodos I, Karampelas T, Kanellopoulos I, Kyriakopoulou K, Bisdas T. Endovascular Repair of a Complex Isolated Dissecting Aneurysm of the Superior Mesenteric Artery. EJVES Short Rep. 2019 Jun 17;44:5-8.
3. Kochar S, Sharparis Y, Banerjee B, Karasek M, Brennan S. Endovascular Coil Embolization of Superior Mesenteric Artery Branch Pseudoaneurysm. Cureus. 2021 Sep 16;13(9):e18014.
4. Camarasa Pérez Á, Soto Sánchez A, Pérez Sánchez E, Hernández Barroso M, Hernández Hernández G, Barrera Gómez M. Obstructive jaundice secondary to a pseudoaneurysm of the superior mesenteric artery. Rev Esp Enferm Dig. 2022 Dec;114(12):756.
5. Kimbara Y, Sato Y, Hasegawa T, Morinaga H, Murata S, Imai Y, Hara K, Okuno N, Inaba Y. Covered stent placement for emergency repair of a ruptured superior mesenteric artery pseudoaneurysm in advanced pancreatic head cancer. Radiol Case Rep. 2018 Oct 29;14(1):133-135.
6. Dávila Arias C, Ruiz-Rodríguez AJ, Cabrera Peña Á. Hematochezia secondary to hemosuccus pancreaticus due to a pseudoaneurysm associated with a pancreatic pseudocyst. Rev Esp Enferm Dig. 2021 Aug;113(8):618.