bull Difficult to treat diuretic unresponsive ascites requiring frequent large volume paracentesis (LVP) every two weeks
bull Borderline renal function also has Hepatic hydrothorax
AF ExaminationRoutine MustCell countAlbuminCS (bedside blood cs bottles)
Optional Unusual UnhelpfulTotal Pro AFB smear pHGlucose AFB cs LactateLDH Exf cyto CholAmylase TG FibronectinGram Stain Bili
Classification of AF by SAAG
High Grad(gt11gmdl) Low Grad(lt11gdl)
bull Cirrhosis Alc hep Peritoneal Cabull CCF TB pertonitisbull BCS VOD Pancreatic ascitesbull Mixed ascites Biliary ascitesbull Fatty liv of Preg Nephrotic syndrbull FHF Collagen diseasesbull Massive liv mets
bull Goal of cirrhotic ascites treatment - Minimization of ascitic fluid volume and peripheral edema without intravascular volume depletion
bull Limiting sodium intake to 88 mEq (2000 mg) per day (including all foods liquids and medications) is the most practical yet successful level of sodium restriction
bull Most patients with cirrhosis and ascites are treated with dietary sodium restriction and diuretics
REFRACTORY ASCITES
A ) Unresponsive to sodium restricted diet + 400mg spironolactone + 160mg furosemide
b) Recurs rapidly after LVP
c) Have complication of diuretic therapy (encephalopathy SCreat gt 2mg SNa+ lt 120 SK+gt6)
There are three major therapeutic options in patients with diuretic-resistant ascites in the setting of cirrhosis
Liver transplantationSerial therapeutic paracentesis approximately every two weeksTransjugular intrahepatic portosystemic stent shunt (TIPS)
Other modalities such as a peritoneovenous (LeVeen or Denver) shunts ndash only historical interest
TIPSS
bull Transjugular intrahepatic portosystemic shunts (TIPSS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques
bull TIPS used to treat the major consequences of portal hypertension ie variceal hemorrhage and diuretic resistant ascites
TIPS VS LVP
TIPSA) Better control of ascites B) Some studies have shown Tx free survival benefit C) Some studies trend towards more HE D) Some studies no effect on quality of life
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
AF ExaminationRoutine MustCell countAlbuminCS (bedside blood cs bottles)
Optional Unusual UnhelpfulTotal Pro AFB smear pHGlucose AFB cs LactateLDH Exf cyto CholAmylase TG FibronectinGram Stain Bili
Classification of AF by SAAG
High Grad(gt11gmdl) Low Grad(lt11gdl)
bull Cirrhosis Alc hep Peritoneal Cabull CCF TB pertonitisbull BCS VOD Pancreatic ascitesbull Mixed ascites Biliary ascitesbull Fatty liv of Preg Nephrotic syndrbull FHF Collagen diseasesbull Massive liv mets
bull Goal of cirrhotic ascites treatment - Minimization of ascitic fluid volume and peripheral edema without intravascular volume depletion
bull Limiting sodium intake to 88 mEq (2000 mg) per day (including all foods liquids and medications) is the most practical yet successful level of sodium restriction
bull Most patients with cirrhosis and ascites are treated with dietary sodium restriction and diuretics
REFRACTORY ASCITES
A ) Unresponsive to sodium restricted diet + 400mg spironolactone + 160mg furosemide
b) Recurs rapidly after LVP
c) Have complication of diuretic therapy (encephalopathy SCreat gt 2mg SNa+ lt 120 SK+gt6)
There are three major therapeutic options in patients with diuretic-resistant ascites in the setting of cirrhosis
Liver transplantationSerial therapeutic paracentesis approximately every two weeksTransjugular intrahepatic portosystemic stent shunt (TIPS)
Other modalities such as a peritoneovenous (LeVeen or Denver) shunts ndash only historical interest
TIPSS
bull Transjugular intrahepatic portosystemic shunts (TIPSS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques
bull TIPS used to treat the major consequences of portal hypertension ie variceal hemorrhage and diuretic resistant ascites
TIPS VS LVP
TIPSA) Better control of ascites B) Some studies have shown Tx free survival benefit C) Some studies trend towards more HE D) Some studies no effect on quality of life
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Classification of AF by SAAG
High Grad(gt11gmdl) Low Grad(lt11gdl)
bull Cirrhosis Alc hep Peritoneal Cabull CCF TB pertonitisbull BCS VOD Pancreatic ascitesbull Mixed ascites Biliary ascitesbull Fatty liv of Preg Nephrotic syndrbull FHF Collagen diseasesbull Massive liv mets
bull Goal of cirrhotic ascites treatment - Minimization of ascitic fluid volume and peripheral edema without intravascular volume depletion
bull Limiting sodium intake to 88 mEq (2000 mg) per day (including all foods liquids and medications) is the most practical yet successful level of sodium restriction
bull Most patients with cirrhosis and ascites are treated with dietary sodium restriction and diuretics
REFRACTORY ASCITES
A ) Unresponsive to sodium restricted diet + 400mg spironolactone + 160mg furosemide
b) Recurs rapidly after LVP
c) Have complication of diuretic therapy (encephalopathy SCreat gt 2mg SNa+ lt 120 SK+gt6)
There are three major therapeutic options in patients with diuretic-resistant ascites in the setting of cirrhosis
Liver transplantationSerial therapeutic paracentesis approximately every two weeksTransjugular intrahepatic portosystemic stent shunt (TIPS)
Other modalities such as a peritoneovenous (LeVeen or Denver) shunts ndash only historical interest
TIPSS
bull Transjugular intrahepatic portosystemic shunts (TIPSS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques
bull TIPS used to treat the major consequences of portal hypertension ie variceal hemorrhage and diuretic resistant ascites
TIPS VS LVP
TIPSA) Better control of ascites B) Some studies have shown Tx free survival benefit C) Some studies trend towards more HE D) Some studies no effect on quality of life
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Goal of cirrhotic ascites treatment - Minimization of ascitic fluid volume and peripheral edema without intravascular volume depletion
bull Limiting sodium intake to 88 mEq (2000 mg) per day (including all foods liquids and medications) is the most practical yet successful level of sodium restriction
bull Most patients with cirrhosis and ascites are treated with dietary sodium restriction and diuretics
REFRACTORY ASCITES
A ) Unresponsive to sodium restricted diet + 400mg spironolactone + 160mg furosemide
b) Recurs rapidly after LVP
c) Have complication of diuretic therapy (encephalopathy SCreat gt 2mg SNa+ lt 120 SK+gt6)
There are three major therapeutic options in patients with diuretic-resistant ascites in the setting of cirrhosis
Liver transplantationSerial therapeutic paracentesis approximately every two weeksTransjugular intrahepatic portosystemic stent shunt (TIPS)
Other modalities such as a peritoneovenous (LeVeen or Denver) shunts ndash only historical interest
TIPSS
bull Transjugular intrahepatic portosystemic shunts (TIPSS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques
bull TIPS used to treat the major consequences of portal hypertension ie variceal hemorrhage and diuretic resistant ascites
TIPS VS LVP
TIPSA) Better control of ascites B) Some studies have shown Tx free survival benefit C) Some studies trend towards more HE D) Some studies no effect on quality of life
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
REFRACTORY ASCITES
A ) Unresponsive to sodium restricted diet + 400mg spironolactone + 160mg furosemide
b) Recurs rapidly after LVP
c) Have complication of diuretic therapy (encephalopathy SCreat gt 2mg SNa+ lt 120 SK+gt6)
There are three major therapeutic options in patients with diuretic-resistant ascites in the setting of cirrhosis
Liver transplantationSerial therapeutic paracentesis approximately every two weeksTransjugular intrahepatic portosystemic stent shunt (TIPS)
Other modalities such as a peritoneovenous (LeVeen or Denver) shunts ndash only historical interest
TIPSS
bull Transjugular intrahepatic portosystemic shunts (TIPSS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques
bull TIPS used to treat the major consequences of portal hypertension ie variceal hemorrhage and diuretic resistant ascites
TIPS VS LVP
TIPSA) Better control of ascites B) Some studies have shown Tx free survival benefit C) Some studies trend towards more HE D) Some studies no effect on quality of life
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
There are three major therapeutic options in patients with diuretic-resistant ascites in the setting of cirrhosis
Liver transplantationSerial therapeutic paracentesis approximately every two weeksTransjugular intrahepatic portosystemic stent shunt (TIPS)
Other modalities such as a peritoneovenous (LeVeen or Denver) shunts ndash only historical interest
TIPSS
bull Transjugular intrahepatic portosystemic shunts (TIPSS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques
bull TIPS used to treat the major consequences of portal hypertension ie variceal hemorrhage and diuretic resistant ascites
TIPS VS LVP
TIPSA) Better control of ascites B) Some studies have shown Tx free survival benefit C) Some studies trend towards more HE D) Some studies no effect on quality of life
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
TIPSS
bull Transjugular intrahepatic portosystemic shunts (TIPSS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques
bull TIPS used to treat the major consequences of portal hypertension ie variceal hemorrhage and diuretic resistant ascites
TIPS VS LVP
TIPSA) Better control of ascites B) Some studies have shown Tx free survival benefit C) Some studies trend towards more HE D) Some studies no effect on quality of life
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
TIPS VS LVP
TIPSA) Better control of ascites B) Some studies have shown Tx free survival benefit C) Some studies trend towards more HE D) Some studies no effect on quality of life
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Absolute contraindications include
bull Heart failurebull Severe tricuspid regurgitationbull Severe pulmonary hypertension bull sepsisbull Intrinsic kidney diseasebull Overt encephalopathybull MELD gt18bull CTP gt12
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
COMPLICATIONS
bull Early shunt thrombosisbull Uncontrollable encephalopathy after shunt placementbull Shunt stenosis
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Optimizing diureticsvariceal eradication Prevention of SBPHBVHAV vaccination nutrition salt restrictionlisting for liver Txoptimizing till liver TX Treatment of hepatic hydrothorax
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
POST TIPSS FOLLOW UP
bull His ascites improved Diuretics tapered bull Pleural effusion improved after two taps over next
two weeks following TIPSS bull Creatinine normalizedbull Had one episode of HE managed with
LactuloseLOA
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
PRE - TIPSS AFTER TWO WEEKS OF TIPSS
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
CASE 2
bull 39 yrs female with sudden onset lower abdomen discomfort and mild ascites
bull DM bull SP LSCS 12 yrs and 7 yrs backbull SP appendicectomy 13 yrs back
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
LABSHb 107
TC 15000
PLT 370000
LFT
Creat
Normal
079
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
IMAGING STUDIES CECT ABDOMEN
Gross ascites with subtle peritoneal thickening and mild omental thickeningNo malignancyNo features to suggest cirrhosisPortal HTN
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ASCITIC FLUID ANALYSIS
Protein lt3
Albumin lt1
SAAG gt11
Cell count 83
Amylase 74
cytology Negative
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull ANA ndash Negativebull CA ndash 125 - Normalbull TSH ndash Normalbull UPT- Negativebull Viral marker ndash negativebull OGD ndash Normalbull ECHO - Normal
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Ascitic fluid - Transudate (CLDVODHVOTCTD) bull We reviewed CTbull Not convinced about Peritoneal thickening Fluid - high
SAAG
What nextbull Re examine Ascitic fluidbull Liver BXbull Wait for new clues
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Started on salt restricted diet diureticsbull Ascites worsened requiring therapeutic tappingbull Oliguriaanuria over 12 hrs (Creat 45)bull After placing Foleys catheter and fluid challenge oliguria
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
REPEAT IMAGING
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull There is contrast leak from the postero-superior right lateral wall of the dome of the urinary bladder
bull Contrast leaks into the peritoneal cavity with moderate urinary ascites noted
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Conservatively managed with Foleyrsquos catheter insertion for 4 weeks
bull Repeat imaging before removing Foleyrsquos catheter
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
REPEAT IMAGING
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
URINARY ASCITES
bull Occurs when there is rupture of either the ureter or bladder leading to
leakage of urine into the peritoneal space
bull Blunt trauma to the abdomen or iatrogenic such as nicking the ureter
during an abdominal surgery
bull Urinary ascites should be considered after usual causes of ascites such
as cirrhosis or nephrotic syndrome have been excluded
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull An ascites fluid creatinine serum creatinine ratio gt10 is highly
suggestive of an intraperitoneal urine leak
bull The peritoneal fluid is typically bland with few WBCs
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
TREATMENT OF URINARY ASCITES
bull Small leaks can be managed with conservative approach
bull Larger defects requires surgery
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
CASE 3
bull 76 yrs male patient with pain abdomenbull SP Open cholecystectomy 10 yrs backbull Evaluated at two multi specialty hospital bull Found to have large CBD stonebull Two attempts of ERCP done outside Could not extract
the stonebull What Next CBD exploration vs Repeat ERCP
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
bull EST followed by large balloon dilation (ESLBD)bull Mechanical lithotripsybull ESWLbull Laser lithotripsy through Spyglass systembull Biliary endoprosthesis (stenting)bull LAP CBD exploration
4 lumen catheter
optical probe biopsy forceps
PERORAL CHOLANGIOSCOPY
Single operator system ldquoSpyglassrdquo
Benign biliary stricture
Single operator system ldquoSpyglassrdquo
biopsy forceps
Malignant biliary stricture
Single operator system ldquoSpyglassrdquo
EHL of large bile duct stone
Single operator system ldquoSpyglassrdquo
Diagnostic Resultsbull 64 of procedures altered patient
managementbull 88 of biopsies adequate for histologybull 66 sensitivity for intrinsic malignancies
Therapeutic Resultsbull 92 procedural successbull 71 had complete stone clearance in 1
session
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Check cholangiogram and stent removal after 4 weeks
CASE 4
bull 36 yrs male kco EHPVO bull SP Splenectomy and splenorenal shunt sx in 2011
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
stentingbull Also had CKD BX ndash MPGN Creat normal
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Recently had cholangitis with septicemiabull Underwent ERCP at middle East Stent exchange was done
However sepsis was persisting and creatinine ndash 5mgdl
bull Came back to India for further treatment
bull Initially stablised in ICU
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
PORTAL BILIOPATHYbull Portal hypertensive biliopathy (PHB) refers to abnormalities of
the entire biliary tract including intra and extrahepatic bile ducts cystic duct and gallbladder in patients with portal hypertension
bull PHB is not confined to EHPVO also in patients with portal hypertension due to
Cirrhosis of liver NCPF
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Prospective studies - 81 Tto 100 of patients with EHPVO have PHB on ERC
bull Only minority have symptoms
bull PHB caused byPressure on the bile ducts from collateralsIschaemic injury to bile ducts during portal vein thrombosis
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Asymptomatic
bull Chronic cholestasis likely to be caused by biliary stricture
bull Biliary pain or acute cholangitis likely to be caused by stricture and secondary biliary stones
bull Secondary biliary cirrhosis
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Management
bull Treatment of portal hypertension
bull Relief of obstructive jaundice
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
TREATMENTbull Endotherapy is the preferred treatment for patients with CBD
stones cholangitis or patients with dominant biliary stricture but without a shuntable vein
bull Portosystemic shunt should be performed in patients with dominant biliary strictures with a shuntable vein Rarely second stage biliary bypass (HJ) may be required
bull Liver transplantation may be required for intractable and advanced disease
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
LABSTC 28800
TB 32
ALT 34
ALP 574
CREAT 204
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
IMAGING STUDIES
bull USG ABDOMEN
IHBRD with stent in CBD
bull MRCP vs ERCP (Stent block)
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ERCP
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
LABS
TC 33000 26800
TB 42 23
ALP 422 584
CREAT 196 172
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
MRCP
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Post stenting status with stents in the left biliary ductal system
bull Hepatomegaly with dilatation of the right biliary ductal system secondary to portal biliopathy
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
REPEAT ERCP
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
LABSTC 14000
TB 11
ALP 456
CREAT 139
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
What next
bull Biliary by pass (HJ) vs Endoscopic treatment bull Liver transplant bull Surgical Gastro opinion
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ELECTIVE ADMISSIONAsymptomatic
LABS TB ndash 11 ALP ndash 210 TC -10500
USG bull Residual dilatation of the right lobe intrahepatic biliary ducts
noted All the right lobe hepatic ducts are seen communicating with each other
bull Left biliary ducts are collapsedbull Small calculus noted in the gall bladderbull Post splenectomy status
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Planned for Rendezvous procedure
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ERCP
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ERCP
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Case 5
bull Diabetic for 7 yearsbull Osteoporosis of D12 and L3bull Weight loss and intermittent fever 4 years backbull USG Bulky pancreasbull LFT ndash Normal CA 19 ndash 9 420 bull CECT ABDOMEN with MRI and MRCPbull Evaluated in many hospitals with
CECTMRCPEUSPET CTDOTANAC SCAN
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull April -2011 EUS ndash Cystic neoplasm IPMNbull FNAC NETbull Slide review Acute pancreatitis
bull SChromognanin levels ndash 542bull IgG4 ndash normal
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
MARCH 2014
bull LFT Mildly elevated ALP and GGTPbull CECT ABDOMEN New findings - Mildly dilated biliary systembull SChromognanin levels ndash 900bull Reviewed all old imagesbull Suspicion for AIPbull Managed conservatively
AFTER ONE MONTHbull Readmitted with abdomen pain pruritus feverbull LFT Cholestatic picture
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
MRI WITH MRCP
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ERCP
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ERCP
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
AUTOIMMUNE PANCREATITIS - REVIEW
bull AIP - Distinct chronic inflammatory and sclerosing disease of the pancreas
bull Characteristic of the disease - Dense infiltration with lymphocytes and plasma cells many of which express IgG4 on their surface
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Studies from Japan - 6 of all patients evaluated for chronic pancreatitis have autoimmune pancreatitis
bull The most common extrapancreatic conditions includes Biliary strictures Hilar lymphadenopathy Sclerosing sialadenitis Retroperitoneal fibrosis Tubulointerstitial nephritis
bull Overlap with an unusual variant of Sjoumlgrenrsquos disease
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
More likely to have biliary tract disease retroperitoneal renal or salivary gland disease
Without systemic involvement
High relapse rate Do not experience relapse
Less likely associated with IBD More frequently associated with inflammatory bowel disease
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
EPIDEMIOLOGY AND CLINICAL FEATURES
More common in men (2 1) and usually in middle age More than 85 of patients are above 50 years
Most common presentations Painless obstructive jaundice - By enlarged pancreas Infiltration of the biliary tree by
inflammatory process
Mass - confused with pancreatic carcinoma or lymphoma Present in 85 of patients in an early report of 26 patients
Weight loss vomiting and glucose intolerance Abdominal and referred back pain may occur
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
BLOOD INVESTIGATIONS
Elevated serum immunoglobulins in 50-66 especially in IgG4
A large study US using an IgG4 cut-off of 140 mgdL as normal and 280mgdl as diagnostic for AIP
bull Found a sensitivity of 76 and a specificity of 93bull Histologically proven AIP may have a normal serum level of IgG4bull 10 of patients with adenocarcinoma may have elevations in IgG4
levels
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
TREATMENT
Autoimmune chronic pancreatitis may progress rapidly from the initial symptoms to end-stage chronic pancreatitis within months
Glucocorticoids therapy - Rapid resolution of both symptoms and radiographic abnormalities
30 to 40 mg of prednisone orally per day for four to eight weeks
Repeat pancreatic imaging at four weeks assess for clinical response Once response is clear-cut taper prednisone at a rate of 5 mg per weeks
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
50-75 pts responds to glucocorticoids but about 25 percent requires a 2nd course of treatment while a smaller proportion needs continuous treatment
Time to response is variable - usually 2 weeks to 4 months
CT findings of diffuse swelling and a halo (a hypoattenuating rim) were predictive of a favorable response to glucocorticoids
Predictors of a suboptimal response were ductal strictures and a focal mass-like swelling that persisted after resolution of diffuse changes
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
FOLLOW UP
bull We started on oral steroids for our patientbull LFT slowly improved and was normal except for Low
albuminbull Repeat imaging during follow up
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
CASE 6
bull Obstructive jaundice referred to us from surgical team for biliary drainage Pre ndash operative
bull Imaging studies done in Kerala
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Ill defined lesion in the region of the GB neck and confluence of the right and left hepatic ducts-could represent the cholangiocarcinoma
bull 3 biliary stents in situ with minimal biliary dilatation predominantly in segments V and IVA
bull No definite cholangitic abscesses
bull Few enlarged loco-regional nodes
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
USG guided Bx from GB fossa
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
HISTOPATHOLOGY
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
>
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Case 7
67 yrs female
bull SP Total gastrectomy CTRT for ca stomach in 2007bull SP Right DJ stenting in 2012bull SP Sx for peritoneal deposits in the region of the bladder bull Hysterectomy 25 yrs back
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Admitted with sudden onset abdomen distention non bilious vomiting
bull Intestinal obstruction
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
IMAGING STUDIES
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
COLONOSCOPY
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
SURGERY VS ENDOSCOPIC MANAGEMENT
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
COLONIC STENTING
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
COLONIC STENTING FOR MALIGNANT COLORECTAL
OBSTRUCTION bull Stenting for acute obstruction for decompression in order to
permit elective surgical intervention
bull Reserved for patients who are at increased risk for complications of emergency surgery (eg patients with multiple significant comorbidities) or who would benefit from having their medical status optimized prior to surgery
bull Pt with near total obstructive colon ca planned for chemo Prophylactic stenting
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Stenting for long-term palliation in patients with advanced colorectal cancer
Problems with stentbull Tumor ingrowth and stent migration
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
CASE 8
bull 35 yrs male referred for esophageal perforationbull Had tachypnea and Left pleural effusion
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
CECT CHEST AND ABDOMEN
Leakage of contrast through the lower end of oesophagus with associated hydropneumothorax and passive collapse of left lung
Normal distal passage of oral contrast agent in duodenum and jejunum
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull ICD was placed into left side of chest
bull What next for Leak
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Esophageal covered SEMS was placed
bull He had multiloculated collections which was drained under CT guidance
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Antibiotics were given as per the CS of pleural fluidbull Slowly started on oral feeds
bull However started having non bilious vomitingbull Stent block Migration Reflux
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
DILUTE BARIUM SWALLOW STUDIES
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
bull Started on NJ feeds Added prokineticsbull In the mean time his ICD volume decreasedbull After a week NJ tube got dislodgedbull He was slowly started on oral feeds and dischargedbull After 7 weeks he came back requesting for stent removal
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ESOPHAGEAL PERFORATIONCauses of Esophageal Perforation
bull 60 Iatrogenic secondary to esophageal instrumentationbull 15 ndash 30 Boerhaavesbull Trauma foreign body ingestion operative injury
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
GOALS OF THERAPY
bull Closure of the perforationbull Drainage of associated contaminationbull Establishment of enteric nutrition
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
TREATMENT OF ESOPHAGEAL PERFORATION
bull Historically operative therapy was the SOC
bull New endoscopic techniques have expanded the management options
bull
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ENDOSCOPIC THERAPY
bull Esophageal stenting
bull Endoscopic clips
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ESOPHAGEAL STENTING
1 Polyflex stent (Boston Scientific) is a silicone covered polyester stent
2 Self expandable metal stents
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
Esophageal perforation N = 17 treated with endoscopic stenting
bull Leak occlusion achieved in 1617 (94) bull Initiated oral nutrition within 72 hours of stenting(82) bull Stent migration in 3 (18) patients bull Stents removed 52 +- 20 days after Placement bull Hospital stay 8+-9 days
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
RETRIEVABLE ESOPHAGEAL STENTS
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
SEMS(partially covered)
SEMS(fully covered)
Polyflex
Delivery device diameter in mm
5ndash10 5ndash10 1214
Costs +(++) +(++) ndash
Effectiveness in leak sealing
+(++) +(++) +(++)
Induction of stenoses ++ + +
Risk for migration - + +
Easy to removal - + ++
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
CASE 949 yrs diabetic lady Sp Parathyroid Sx 1 year back Hypothyroidism bull Dyspepsia and marginal weight loss for
6 monthsbull No Clinical signs
bull Endoscopy in Oct 2013 D1 ndash Small sub mucosal lesion (8 mm) HPE and IHC Neuroendocrine tumour
bull CECT abdomen Fatty liver
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
HISTOPATHOLOGY
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Classification WHO(20002004)
bull Well differentiated neuroendocrine tumour (Benign behavior)
bull Well differentiated neuroendocrine tumour (Uncertain behavior)bull Well differentiated neuroendocrine carcinoma (Low grade malignant)bull Poorly differentiated neuroendocrine carcinoma
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
Criteria for classification
bull Sizebull Functioning non functioningbull Local Invasionbull Vascular invasionbull Ki67bull Metastases
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
OUR PATIENT
Oct 2013 March 2014
SChromogranin levels 6141 ngml 130
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
What nextbull Endoscopic management vs Surgery vs Follow up
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
bull Reported bleed from a duodenal diverticulum - 7
bull Ulceration because of ectopic Gastric mucosa or inflammation
bull NSAIDs also been attributed to ulcerations
bull Treatment options include endoscopic haemostasis embolization and surgery
CASE 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
REFRACTORY ASCITES
Slide 8
TIPSS
TIPS VS LVP
Slide 11
Slide 12
COMPLICATIONS
Slide 14
Slide 15
POST TIPSS FOLLOW UP
Slide 17
CASE 2
LABS
IMAGING STUDIES
Slide 21
ASCITIC FLUID ANALYSIS
Slide 23
Slide 24
Slide 25
REST OF THE REPORTS
REPEAT IMAGING
Slide 28
Slide 29
REPEAT IMAGING (2)
URINARY ASCITES
Slide 32
TREATMENT OF URINARY ASCITES
CASE 3
TREATMENT OPTIONS FOR LARGE CBD STONES (gt15cm)
PERORAL CHOLANGIOSCOPY
Slide 37
Slide 38
Slide 39
SPYGLASS CLINICAL REGISTRY
OUR PATIENT
Slide 42
Slide 43
Slide 44
Slide 45
Slide 46
Check cholangiogram and stent removal after 4 weeks
CASE 4
Slide 49
PORTAL BILIOPATHY
Slide 51
Slide 52
Management
TREATMENT
LABS (2)
IMAGING STUDIES (2)
ERCP
LABS (3)
MRCP
Slide 60
REPEAT ERCP
LABS (4)
Slide 63
ELECTIVE ADMISSION
Slide 65
ERCP (2)
ERCP (3)
Case 5
Slide 69
Slide 71
Slide 72
MARCH 2014
MRI WITH MRCP
ERCP (4)
ERCP (5)
AUTOIMMUNE PANCREATITIS - REVIEW
Slide 78
Slide 79
EPIDEMIOLOGY AND CLINICAL FEATURES
BLOOD INVESTIGATIONS
Slide 82
TREATMENT (2)
Slide 84
FOLLOW UP
CASE 6
Slide 87
Slide 88
Slide 89
Slide 90
USG guided Bx from GB fossa
HISTOPATHOLOGY
Slide 93
Case 7
Slide 95
IMAGING STUDIES (3)
Slide 97
COLONOSCOPY
Slide 99
COLONIC STENTING
Slide 101
Slide 102
FOLLOW UP AFTER 2 WEEKS
COLONIC STENTING FOR MALIGNANT COLORECTAL OBSTRUCTION
Slide 105
CASE 8
CECT CHEST AND ABDOMEN
Slide 108
Slide 109
Slide 110
DILUTE BARIUM SWALLOW STUDIES
Slide 112
STENT REMOVAL AND END RESULT
ESOPHAGEAL PERFORATION
Slide 115
Slide 116
ENDOSCOPIC THERAPY
ESOPHAGEAL STENTING
ESOPHAGEAL POLYFLEX STENT FOR IATROGENIC PERFORATION
RETRIEVABLE ESOPHAGEAL STENTS
Slide 121
CASE 9
HISTOPATHOLOGY
Slide 124
Slide 125
Classification WHO(20002004)
Criteria for classification
OUR PATIENT (2)
Slide 129
CARCINOID TUMOURS
OUR PATIENT (3)
Slide 132
AFTER 4 WEEKS
CASE 10
Slide 135
CAUSES OF OGIB
Slide 137
Slide 138
SINGLE BALLOON ENTEROSCOPY
PICTURES OF OUR PATIENT
PICTURES OF OUR PATIENT (2)
NON SPECIFIC ILEAL ULCER
NON SPECIFIC ILEAL ULCER (2)
Slide 144
Slide 145
CASE 11
CAUSES OF SEVERE UGI BLEED
Slide 148
CECT ABDOMEN WITH CT ANGIOGRAPHY
Slide 150
Re look endoscopy
Slide 152
DUODENAL DIVERTICULAR BLEED
Slide 154
Slide 155
Slide 156
CARCINOID TUMOURS
bullEndoscopic excision of primary duodenal carcinoids appears to be
appropriate for tumors lt 1 cm
bullDuodenal carcinoids smaller than 2 cm may be excised locally for tumors
between 1 cm and 2 cm complete resection is ensured by operative full-
thickness excision Follow-up endoscopy is indicated
bull Appropriate management of tumors larger than 2 cm can be problematic These tumors can be treated with operative full-thickness excision and regional lymphadenectomy
OUR PATIENT
>
bull What nextbull CT abdomen with oral
contrast No leakage of contrast Pneumoperitoneum seen
bull Managed with NPO IV antibiotics and analgesics
bull Discharged after 5 days
AFTER 4 WEEKS
>
CASE 10
bull Young male patient had syncope when he was in market and found in the midst of altered blood pool
bull Resuscitated in our ER shifted to MICUbull Hb 9gm bull OGD Normalbull COLONOSCOPY Few aphthoid erosions in the terminal
ileumbull CECT abdomen with angiography was normal
bull However stable during the ICU stay No further drop in Hb
