- A 48-year-old woman presented with gastric outlet obstruction from chronic pancreatitis. A CT scan demonstrated a gastric fluid level and duodenal stenosis. The posterior gastric wall was in close proximity to the distal duodenum. After procedural consent was obtained, EUS-guided gastroduodenostomy was attempted. A pediatric colonoscope was advanced to the ligament of Treitz, where a guidewire was placed into the jejunum. The colonoscope was withdrawn, leaving the guidewire in place. A dilating balloon was passed over the guidewire to the distal duodenum and inflated to serve as a target for transgastric puncture.
- A 20-year-old woman presented with abnormal liver chemistry levels. She had previously undergone left lobe liver transplantation from a living related donor, with Roux-en-Y hepaticojejunostomy (HJ) for biliary atresia. She had a history of a HJ stricture. Previously, percutaneous drainage was poorly tolerated because of underlying autism spectrum disorder, and single-balloon ERCP was unsuccessful. MRCP showed intrahepatic ductal dilation and stricture of the HJ. After informed consent was obtained from the patient’s guardian, a linear echoendoscope was advanced into the stomach.
- A 60-year-old man was admitted with jaundice and gastric outlet obstruction from widely metastatic pancreatic adenocarcinoma. Abdominal CT showed an unresectable pancreas mass compressing the second duodenum with gastric distension, extrahepatic biliary dilatation, and a hydropic gallbladder. Endoscopically, the duodenum was completely obstructed. A forward-viewing, curvilinear array therapeutic channel echoendoscope was used to puncture the gallbladder, given its optimal endosonographic window for intervention.
- A 69-year-old man presented for treatment of choledocholithiasis. His medical history included ascending cholangitis related to choledocholithiasis and Billroth II surgery for peptic ulcer disease. An ERCP demonstrated a filling defect in the common bile duct. A 10F, 7-cm plastic stent was placed for decompression. The patient was referred for further intervention. A standard duodenoscope was passed into the afferent limb to the level of the papilla. A biliary sphincterotomy was performed. Cholangiography (Fig. 1) demonstrated a 15-mm stone, known as a “cat's eye” calculus, in the mid-common duct, with a central surgical clip from his prior cholecystectomy.
- A 57-year-old man presented for resection of a lateral wall duodenal polyp. Previous upper endoscopy demonstrated the large duodenal polyp, and biopsies revealed a tubulovillous adenoma with low-grade dysplasia. A CT scan identified the 3 × 5-cm multilobulated polyp beginning below the ampulla in the second and proximal third duodenum. A therapeutic upper endoscope was advanced to the second duodenum where the polyp was identified (Fig. 1A). EMR was performed by using a standard polypectomy snare after the polyp was fully lifted (Fig. 1B; Video 1, available online at www.giejournal.org ).
- Clinically severe acute pancreatitis and organ failure developed in a 50-year-old man with multiple comorbidities. Initial abdominal CT scan demonstrated inflammation of the pancreatic body and tail. Repeat imaging on hospital day 7 demonstrated an evolving fluid collection. An abdominal CT scan on hospital day 17 revealed a large, gas-containing area of walled-off necrosis (WON) extending into the lesser sac along the posterior gastric wall, in addition to a pancreaticocolic fistula at the splenic flexure (Fig. 1A).
- A 73-year-old female presented for definitive treatment of biliary papillomatosis after a Whipple procedure 5 years prior for an ampullary adenoma with intraductal extension (Video 1, available online at www.giejournal.org ). Most recently, she developed abnormal liver chemistries and intrahepatic bile duct dilatation on CT imaging. ERCP was attempted locally but failed. PTC demonstrated a hilar mass, and bilateral biliary drainage catheters were placed. Cholangioscopic biopsy specimens revealed histologic findings consistent with biliary papillomatosis, a rare entity characterized by multiple small papillary adenomas of the biliary tree.