- A 60-year-old man had massive hematochezia requiring multiple blood transfusions. EGD results were negative, and despite colonoscopy showing blood in the colon and in the distal ileum, the bleeding site was not detected. The patient was then admitted to our institute to undergo single-balloon enteroscopy (SBE), which showed fresh blood in the proximal jejunum. However, an excessive loop formation impeded the possibility of going deeper, and the source of bleeding was not identified (Fig. 1A). An urgent CT angiography showed negative results.
- A 65-year-old woman had evidence of enlargement of a cyst in the pancreatic head from 9 to 15 mm. EUS showed a 15.6-mm unilocular pancreatic cystic lesion (PCL) with an 8.1-mm round, hypoechoic mural nodule with hyperechoic rim (Fig. 1A) suggestive of mucus. Secondary to interval cyst enlargement, the decision was made to perform EUS-guided FNA and biopsy. We opted to use a new 20-gauge needle with a side port (EchoTip ProCore 20-gauge needle, Cook Medical) to avoid potential needle obstruction by mucus.
- A 36-year-old woman was referred to our institute because of evidence of biliary stricture after laparotomic cholecystectomy. ERCP showed complete interruption of the proximal common bile duct (CBD), requiring percutaneous biliary drainage. A CT multiplanar reconstruction visualized the stricture and its relation to the adjacent hepatic artery (Fig. 1A). A rendezvous procedure, with the possibility of multiple oblique and craniocaudal projections, was then attempted (Fig. 1B). When the upstream and downstream bile duct areas were properly aligned, the soft hydrophilic tip of a 0.035-inch guidewire was endoscopically passed into the CBD and pushed intraperitoneally into the subhepatic space.
- A 49-year-old man was admitted to the intensive care unit for acute respiratory distress syndrome due to H1N1 influenza infection. He developed acute lithiasic cholecystitis with septic shock. Because of the critical clinical conditions, bedside EUS-guided gallbladder drainage was considered the best choice of treatment.
- A 52-year-old woman with pancreatic insufficiency was referred to our institute for EUS-guided drainage of an 11-cm infected walled-off pancreatic necrosis, which developed after the patient had undergone distal pancreatectomy and splenectomy 2 years previously. The collection was accessed from the stomach by use of a therapeutic linear echoendoscope (GF-UC140P, Olympus Medical Systems, Center Valley, Pa) and a lumen-apposing 15-mm × 10-mm fully covered self-expandable metal stent (Hot AXIOS, Boston Scientific, Marlborough, Mass).
- An 87-year-old woman with recent onset of painless obstructive jaundice and anorexia underwent a CT scan, which showed an enlarged ampulla of Vater infiltrating the common bile duct, with severe upstream duct dilation. Diffuse abdominal lymphadenopathy was also found in association with a small amount of ascites. ERCP at a tertiary referral center was attempted, with unsuccessful biliary cannulation. Biopsy specimens confirmed the histologic diagnosis of ampullary carcinoma. The patient was then referred to our institute for EUS-guided biliary drainage.
- A 70-year-old man with chronic renal failure requiring dialysis treatment at our institution underwent EGDs for epigastralgia. Endoscopy showed a raised lesion 1 cm in diameter, surrounded by normal mucosa, located in the duodenal bulb at the 6-o’clock position (Fig. 1A; Video 1, available online at www.giejournal.org ). Biopsy specimens revealed a neuroendocrine tumor. EUS before endoscopic resection was planned.
- Diagnosis and classification of pancreatic cystic lesions remain a challenge despite advances in diagnostic tools. Diagnosis is achieved by combining demographic and clinical information, radiologic and EUS assessment, intracystic fluid analysis, and cytohistology. Cytology obtained by EUS-guided FNA from cystic fluid has a high specificity but a low sensitivity because of the small number of cells present in the aspirate.
- A 51-year-old patient was admitted to our intensive care unit with fulminant respiratory failure secondary to influenza A (H1N1) requiring urgent extracorporeal membrane oxygenation treatment. The patient developed severe hematochezia. Urgent colonoscopy revealed a 3-cm, oozing, bleeding ulcer located opposite the ileocecal valve, which was initially treated successfully with the injection of fibrin glue. However, the bleeding recurred (Fig. 1A), and, in view of the patient's critical condition, Hemospray (Cook Medical, Winston-Salem, NC) treatment was considered as an ultimate rescue therapy.