Clinical Case Summary

A 47-year-old Iranian man with chronic pancreatitis was referred due to abdominal pain. He reported previous heavy alcohol and tobacco consumption with slight pain improvement after abstinence. EUS and MRCP showed main pancreatic duct (MPD) dilation with intraductal stones, the largest with 16mm being impacted in the isthmus. Two prior attempts of endoscopic therapy through conventional ERCP were performed in Iran which were unsuccessful because the impacted stone could not be transposed with the guidewire.
Pancreatoscopy-assisted electrohydraulic lithotripsy (EHL) was proposed. A side-viewing duodenoscope, a 3.6mm cholangioscope (Spyglass™DSII) and Autolith™ EHL System were used during a 3-hour procedure. Deep MPD cannulation was achieved. After 8mm hydrostatic balloon dilation of the papilla and distal MPD the cholangioscope was advanced showing dense, hard and whitish intraductal stones in the pancreatic head and a proximal obstructive large stone impacted in the isthmus. Pancreatoscopy-guided EHL was performed until complete fragmentation of the largest stone, nevertheless being limited by its extreme hardness requiring three different probes. Stone fragments were removed with a Dormia basket and extraction balloon, but some debris persisted. A 5-French 12cm plastic stent was deployed. Sporadic abdominal pain was reported after 3 months.
A second session of EHL was further performed, but stone clearance was not accomplished. In order to avoid long-term pancreatic stent placement, a third session using pancreatoscopy-assisted laser lithotripsy was schedulled 6 months later. A residual 8mm stone was evident in the pancreatic body during pancreatoscopy. Intraductal lithotripsy using holmium laser (AURIGA XL™) with a 365um LightTrail™ fiber allowed complete stone fragmentation. Removal of all fragments was possible with an extraction balloon and saline instillation through a nasopancreatic tube left during 24h. The patient became asymptomatic after the procedure.

References

Images of pancreatoscopy, including electrohydraulic and laser lithotripsy
Fluoroscopic images of the procedures

Introduction

Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) is currently the leading cause of chronic liver disease worldwide, affecting more than 65% of patients with Type 2 Diabetes Mellitus (T2DM). The aim of our study was to determine the prevalence of MASLD among T2DM patients, with or without coexisting significant fibrosis, to assess its association with diabetic complications, and to identify the factors linked to MASLD in our population.

Aims & Methods

We conducted a retrospective, descriptive, and analytical study including T2DM patients admitted to the Endocrinology Department in 2019. MASLD diagnosis was based on the presence of hepatic steatosis detected by abdominal ultrasound or a Hepatic Steatosis Index (HSI) >36. Fibrosis was assessed using the Fibrosis-4 (FIB-4) index (with a threshold of ≥1.3 or <1.3). Chronic Kidney Disease (CKD) associated with T2DM was defined by an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² and/or dipstick-positive proteinuria (>1+). Diabetic Peripheral Neuropathic Pain (DPNP) was assessed using the Douleur Neuropathique 4 (DN4) questionnaire, and Diabetic Retinopathy was diagnosed via dilated eye examination.

Results

Among the 202 patients included, the median age was 57 years (±12 years) with a marked female predominance (sex ratio = 2.6). Regarding comorbidities, 58.4% of patients had hypertension and 34.2% had dyslipidemia. The median Body Mass Index (BMI) was 27 kg/m² (±5.62), with overweight or obesity present in 61.4% of the cohort. The median duration of diabetes was 10 years (±7.8 years). Impaired renal function (eGFR <60 ml/min/1.73 m²) was found in 9.9% of patients, and proteinuria in 6.9%. Diabetic neuropathy (DN4 score ≥4) was present in 7.9% of patients, while diabetic retinopathy was diagnosed in 37.6% of cases.
The prevalence of MASLD in our cohort was 73.3%. The median FIB-4 score was 0.91 (±0.63), with 25.7% of patients presenting a FIB-4 >1.3. Statistical analysis identified several factors significantly associated with the presence of MASLD: female sex (p=0.004), dyslipidemia (p=0.004), BMI (p<0.001), alanine aminotransferase (ALT) levels (p<0.001), low-density lipoprotein cholesterol (LDL-C) levels (p=0.006), and triglyceride levels (p=0.013). In particular, higher BMI was strongly associated with MASLD (Odds Ratio [OR] = 1.970; 95% Confidence Interval [CI]: 1.580–2.460; p<0.001), as were elevated ALT levels (OR = 1.115; 95% CI: 1.053–1.18; p<0.001).
However, after adjustment, LDL-C levels (p=0.163), triglycerides (p=0.402), dyslipidemia (p=0.329), and sex (p=0.360) were no longer significantly associated with MASLD. Finally, a significantly higher proportion of CKD was observed in patients with MASLD (22.3%) compared to those without MASLD (9.2%, p=0.036), although this association was not maintained in the subgroup with advanced fibrosis (FIB-4 >1.3).

Conclusion

Our study confirmed the high prevalence of MASLD among patients with T2DM. Early screening is therefore essential, particularly in female patients and in those presenting with chronic kidney disease or other associated cardiometabolic risk factors such as obesity and dyslipidemia.

References

Younossi ZM, Golabi P, Price JK, Owrangi S, Gundu-Rao N, Satchi R, Paik JM. The Global Epidemiology of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis Among Patients With Type 2 Diabetes. Clin Gastroenterol Hepatol. 2024 Oct;22(10):1999-2010.e8. doi: 10.1016/j.cgh.2024.03.006. Epub 2024 Mar 21. PMID: 38521116.

Clinical Case Summary

A 54-year-old male with chronic myeloid leukemia (CML) diagnosed in May 2015, on Imatinib since April 2023, presented in October 2024 a severe anemia (Hb 5.2 g/dL [13-17]). Investigations done at that time, including bone marrow analysis, hemolysis workup and a FIT test were normal. An abdominal CT scan was also done at that time and was also normal.. In December 2024, the patient reported two weeks of melena. A bidirectionnel endoscopy didn’t show any lesion. CT scan revealed hepatomegaly and gallstones, without any GI mass.
Video capsule endoscopy showed active jejunal bleeding without being able to identify the underneath lesion. Enteroscopy revealed two ulcerated jejunal lesions of around 2 cm in diameter with an adherent clot, one meter from the papilla, [Figure 1,2]. Surgical resection was then performed [Figure 3]. Histology confirmed epithelioid angiosarcoma with submucosal infiltration, numerous mitoses, endolymphatic tumor emboli, and ERG+, cytokeratine AE1/AE3+ immunoprofile. Resection margins were clear; 0/3 lymph nodes were involved. [Figure 4a-b-c-d] As part of the metastatic workup, brain MRI showed multiple cerebral metastases.
Following the diagnosis, the treatment plan consisted of paclitaxel in combination with bevacizumab (Avastin).
This case illustrates the diagnostic challenge of unexplained anemia in hematologic patients, particularly when standard evaluations fail to identify a clear cause. In this instance, gastrointestinal bleeding ultimately revealed a rare small bowel malignant lesion—epithelioid angiosarcoma. While epithelioid angiosarcoma has no established association with chronic myeloid leukemia (CML) or its treatment, it is worth noting that the use of tyrosine kinase inhibitors may obscure the clinical presentation of angiosarcoma. This is due to their antiangiogenic effects, which can alter vascular structures and potentially delay diagnosis. Therefore, high clinical suspicion remains essential.

References

Figure 1,2 : Enteroscopy revealing ulcerated jejunal lesion with an adherent clot. Images obtained during enteroscopy performed at Hôtel-Dieu de France University Hospital, Beirut, Lebanon.
Figure 3 : Resected jejunal segment showing two hemorrhagic polypoid tumors, one marked with a hemostatic clip. The lesions correspond to an ulcerated angiosarcoma. Image obtained post-surgical resection at Hôtel-Dieu de France University Hospital, Beirut, Lebanon.
Figure 4a : Histological appearance of epithelioid angiosarcoma H&E stain, high magnification
Figure 4b : Histological appearance of epithelioid angiosarcoma H&E stain, intermediate magnification
Figure 4c : Histological appearance of epithelioid angiosarcoma H&E stain, low magnification
Figure 4d : Histological appearance of epithelioid angiosarcoma ERG nuclear immunostain, intermediate magnification
Figure 4e : Histological appearance of epithelioid angiosarcoma Cytokeratin AE1/AE3 immunostain, intermediate magnification

Clinical Case Summary

We present a case, which demonstrates endoluminal vacuum (EndoVac) therapy as an efficient technique when used for postoperative esophago-jejunal anastomotic leakage. A 59-year-old male, who underwent a total gastrectomy with esophago-jejunal Roux-en-Y anastomosis for stomach adenocarcinoma, presented with abdominal pain, tachycardia, fever and dyspnea a few days after the operation. A CT demonstrated a large anastomotic leakage in the esophago-jejunoanastomosis. An upper endoscopy was performed, revealing an anastomotic defect with a diameter up to 20mm. A 120mm fully covered esophageal stent was inserted. The stent was fixated with three 16mm clips. Due to clinical deterioration a follow up CT was performed. The images showed proximal migration of the stent with a perianastomotic inflammatory cavity. The stent was retrieved and 2.5L of pus-like fluid was evacuated, followed by placement of EndoVac System. During the procedure, a 15fr PEG-J feeding tube was placed, ensuring enteral nutrition. Additionally VATS was performed immediately after the endoscopy and two redon drains were placed.
Four EndoVac sponges were exchanged in a period of 12 days, during which a significant clinical improvement was observed and the patient was discharged shortly after. Eight weeks later gastroscopy and CT were performed with no evidence of a fistula and complete recovery of the patient, the PEG-J was removed. We demonstrate with our case that EndoVac therapy is an effective method in managing postoperative esophageal leaks and it should be considered as an initial technique when dealing with such complications.

References

Endoscopy photo of the ansatomotic leak
Endoscopy photo EndoVac
Endoscopy photo of the PEG-J
Endoscopy photo of the final result

Introduction

Hirschsprung’s disease is caused by the absence of ganglia in the deep intestinal wall, leading to dysfunction [1]. Resection of the affected area is the only cure, so accurate margin detection is essential. Currently, intraoperative rapid pathology is used, requiring tissue sampling and staining, but each test takes over 30 min and may need multiple samples, sometimes delaying decisions up to 3 h. A quick on-site method to detect ganglia around 200 μm deep is needed.
Various methods, including confocal microscopy [2], have been studied, but issues remain, such as dye toxicity and limited depth (>200 μm) imaging.

Aims & Methods

For non-destructive and stain-free visualization of tissues, we focused on Near-Infrared Hyperspectral Imaging (NIR-HSI)[3][4]. Near-infrared light—particularly in the 1000–1400 nm range—exhibits high tissue penetrability and is effective for detecting deep tissues. In addition, the near-infrared region provides spectroscopic information based on molecular vibrations, enabling component analysis. NIR-HSI holds promise for the identification of cancer and other biological tissues without the need for fluorescence or external marking [4][5].
To implement NIR-HSI, we developed a novel microscopic optical system capable of guiding near-infrared light. The near-infrared light source, which combines a supercontinuum light source and an acousto-optic tunable filter, allows for the selection of arbitrary wavelengths and irradiation of the target by adjusting the applied voltage [6]. This configuration enables the acquisition of near-infrared spectral images (NIR-HSI) at arbitrary wavelengths.
For performance validation, ex vivo experiments were carried out using mouse intestine in which the nerve plexus was selectively labeled with GFP (Green Fluorescent Protein). In these experiments, near-infrared light ranging from 850 to 1400 nm was irradiated in 10-nm increments, and 77 spectral images were captured. As a reference, GFP fluorescence images were acquired in the same field of view as the near-infrared images. Based on the fluorescence images, annotations were performed to delineate the enteric nerve plexus, and near-infrared spectra were obtained from both the nerve and non-nerve regions. Furthermore, using pixel-wise spectral data, segmentation of the nerve regions was performed with a machine learning model, and the accuracy of identification was evaluated.

Results

The NIR images captured by the system showed nerve distributions and mesh-like patterns similar to those in the GFP images. Spectral differences were observed between nerve and non-nerve regions. This likely reflects tissue composition differences, as muscle tissue has higher transmittance and nerve tissue higher reflectance in the NIR range [4][5][6].
Segmentation based on spectral data successfully extracted nerve contours and distribution patterns, achieving ~80% classification accuracy.

Conclusion

To enable non-invasive, label-free visualization of deep nerve distributions, we developed a NIR-HSI microscope by integrating near-infrared hyperspectral imaging with a microscopic optical system. In mouse intestine experiments, spectral differences were observed between enteric nerve plexus and surrounding tissue. The results suggest that mesh-like nerve structures can be estimated and outlined using NIR images alone. Future work will focus on imaging human samples.

References

1. Taguchi, T.et al., “The incidence and outcome of allied disorders of Hirschsprung's disease in Japan: Results from a nationwide survey,” Asian Journal of Surgery, vol.40-1, pp.29-34, 2017.
2. Kobayashi, M., Sumiyama, K., Shimojima, N., Ieiri, S., Okano, H., Kamba, S., Fujimura, T., Hirobe, S., Kuroda, T. and Takahashi‐Fujigasaki, J., “Technical Feasibility of Visualizing Myenteric Plexus Using Confocal Laser Endomicroscopy,” Journal of Gastroenterology and Hepatology, vol.32(9), pp.1604-10, 2017.
3. S. Hayashi et al., “Near-Infrared Multispectral Imaging Rigid Endoscope System for High-Speed Target Identification Using LED Rotating Light Source”, Advanced Biomedical Engineering , Vol.14, pp.79-88, 2025.
4. Akbari, H et al., “Cancer detection using infrared hyperspectral imaging”, Cancer Science, Vol. 102, No.4, pp.852–857, 2011
5. Afromowitz,et al., “Multispectral imaging of burn wounds: a new clinical instrument for evaluating burn depth”, IEEE Transactions on Biomedical Engineering, Vol35, No.10, pp.842-850, 1988.
6. R. Fukushima et al., “Detection of Exposed Nerves in Two Individuals In Vivo and Unexposed Nerves Ex Vivo with Near-Infrared Hyperspectral Laparoscope,” 2024IEEE/SICE International Symposium on System Integration (SII), Ha Long, Vietnam, pp. 19-24, 2024.

Clinical Case Summary

Our patient was a 66yr Chinese man who was treated for active Chronic Hepatitis B from 2009 with Lamivudine, Adefovir and then switched to Tenofovir from 2020 with long term undetectable Hepatitis B viral load (HBV VL) and normal Liver function tests. His ultrasound liver was normal and Fibroscan 6.9kpa in 2021. Hepatitis B Surface quantification was 87 IU/ml. ALT 28.
The patient was enrolled in a research trial which randomized him to stopping Tenofovir with close follow up.
At week 4 after stopping Tenofovir, his HBV VL became detectable at 2.53log and ALT 31.
At week 8, his HBV VL increased to 5.55log and ALT 35.
At week 10, HBV VL was 6.85, ALT 384, Bilirubin and INR normal. HBeAg remained negative and the patient remained asymptomatic.
He was promptly restarted on Tenofovir but his ALT continued to rise and peaked at 832 at week 12 before gradually returning to normal as did his Hepatitis B viral load.
At week 13, he developed tingling over his hands and feet.
At week 14, he was admitted for clumsiness with reduced sensation over the feet and hands. He had no other systemic symptoms suggestive of any infections.
Examination revealed subjective reduction in sensation over the distal peripheral limbs. Power was normal but reflexes were absent over the ankles and knees.
MRI brain was normal.
Lumbar puncture showed high CSF protein 0.7gL but normal cell count. Nerve Conduction study (NCS) reported acute inflammatory demyelinating polyneuropathy.
EMG was unremarkable.
A probable diagnosis of GBS was made.
His ALT was down to 304 and HBV VL 3.82 log.
NCS repeated 2 months later and showed similar inflammatory demyelinating polyneuropathy.
NCS repeated 4 months later showed significant improvement which confirmed a diagnosis of GBS
1 year from his first presentation, he recovered fully.
Only 7 cases of Hepatitis B related GBS have been reported in the literature. Our case highlights GBS resulting from Hepatitis B flare

References

none

Introduction

Indeterminate biliary strictures pose a significant diagnostic challenge, as they can result from a wide spectrum of both benign and malignant conditions. Differentiating between these is crucial due to different management strategies. Conventional methods like endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology have limited sensitivity, often leading to repeated procedures and delays in treatment. Peroral cholangioscopy (POC) offers direct bile duct visualization and targeted biopsies, improving diagnostic accuracy. Modern systems, like the SpyGlass™ DS, enhance procedure feasibility and image quality.

Aims & Methods

Aims: The aim of our study is to assess the effectiveness of single-operator peroral cholangioscopy system (POCS) with its digital version SpyGlass^TM Direct Visualization System with SpyBite biopsies as a promising modality for accurate diagnosis of biliary strictures.
Method: We performed a two-center retrospective analysis of prospective database from March 2019 to March 2025. Each patient underwent peroral cholangioscopy using SpyGlass^TM Direct Visualization System with SpyBite biopsies for the diagnosis of indeterminate biliary strictures.

Results

We identified 162 patients who underwent peroral cholangioscopy during the study period (96 males and 66 females). The medium age of the patients was 63.04 years. There was 100 % technical success of the procedure. All patients underwent POCS due to indeterminate biliary strictures. Before the procedure CT scan was performed and positive for biliary stenosis in 115 (70.9%) of the cases. The biliary stenoses were located as follows: 20 (12.3%) in the distal common bile duct, 29 (17.9%) in the proximal common bile duct, 102 (62.9%) at the hepatic hilum and 11 (6.7%) in the intrahepatic bile ducts.
Benign disease was diagnosed in 39 (24.07 %) of the patients. Visual impression for malignant desease (at least one of the following- tortuous dilated vessels, friability and easily bleeding, infiltrative stricture, polipoid mass, nodular eleveted lesion, vegetative mass, fish-egg lesion, finger - like villiform lesion and irregular papillary or granular lesion) was found in 123 (75.9%) of the patients. The most reliable correlation with malignancy was found to be the presence of infiltrative strictures - 113 (69.7%) patients. A final diagnosis of cholagiocarinoma was established in 84
(51.8%) of them. In 39 (24.07%) patients, no tumor cells were found in the specimen. Visual impression accuracy with SpyGlass was 100% (with 100% sensitivity and 100% specificity). SpyBite biopsies accuracy was 69.05 % (with 68. 3% sensitivity and 100% specificity).

Conclusion

POC has proven valuable in evaluating indeterminate biliary strictures, offering advantages over ERCP by allowing real-time visualization and targeted biopsies. Our study supports POC's superior accuracy, especially in identifying malignant lesions, with visual impression achieving up to 100% sensitivity and specificity. However, POC adoption is limited by operator expertise, the need for standardized interpretation, and availability. While adverse events are rare (<10%), careful patient selection is essential. In conclusion, POC holds substantial promise as a key diagnostic tool for indeterminate biliary strictures, with ongoing improvements enhancing its clinical role.

Disclosure

No conflict of interest