Tubercular lymphadenopathy with duodenal fistula

Tuberculosis, both pulmonary and extrapulmonary, is one of the leading causes of significant morbidity and mortality in developing countries. A 29-year-old chronic alcoholic patient presented to gastroenterology outpatient department with complaints of decreased appetite, weight loss, and generalized weakness. On endoscopy, the second part of duodenum appeared edematous with some luminal compromise. There was also presence of an opening in the inferolateral wall of the second part of duodenum, through which milky white caseous material was coming out. Computed tomography demonstrated large conglomerate of paraduodenal, celiac, para-aortic, peripancreatic, and retrocaval nodes with central necrosis. Endoscopic ultrasound showed hypoechoic lymph nodes in paraduodenal, parapancreatic, and celiac axis. Fine needle aspiration cytology showed epithelioid granuloma with Langerhans giant cells suggestive of granulomatous lymphadenitis of tubercular etiology. Tubercular lymphadenopathy eroding into duodenum has been very rarely reported in literature. This case reports the rare possibility of extrinsic tubercular lymphadenopathy eroding into duodenum

Mediastinal pancreatic pseudocyst

Pancreatic pseudocyst is a well-known complication of both acute and chronic pancreatitis. It is a collection of fluid due to acute or chronic inflammation of pancreas or from injury. A pseudocyst with mediastinal extension is a rare entity. There are only few reports of endoscopic transesophageal drainage of mediastinal pseudocysts. We present a case of mediastinal pseudocyst in a 45-year-old male who presented with dysphagia, weight loss, fever, and productive cough which was managed endoscopically by endoscopic ultrasound-guided transesophageal aspiration

Rare cause of lower gastrointestinal bleed

Gastrointestinal (GI) mucormycosis commonly affects adults with neutropenia or other immunocompromising conditions. GI mucormycosis is uncommon but has high mortality rate. We report a case of colonic mucormycosis in a patient of chronic obstructive airway disease who presented with massive lower GI bleed

Coil Migration into Common Bile Duct after Postcholecystectomy Hepatic Artery Pseudo‑aneurysm Coiling

We report an interesting case of 50‑year‑old female who had postcholecystectomy hepatic artery pseudoaneurysm. This pseudo‑aneurysm was coiled by interventional radiologist. Patient later presented with obstructive jaundice which was due to migration of pseudoaneurysm coils into bile‑duct

A case of abdominal pain and abnormal location of gallstone diagnosed by endoscopic ultrasound

A 50‑year‑old male came to us with pain abdomen; endoscopic ultrasound (EUS) made a diagnosis of cholecystoduodenal fistula which was later on confirmed on gastroscopy and surgery. We present interesting images of EUS; a calculus is visualized outside gallbladder with inflammatory changes of duodenal wall

Evanescent eosinophilic gastritis in recurrent Helicobacter pylori infection

Eosinophilic gastroenteritis is characterized histologically by eosinophilic infiltration of the gut wall and clinically manifests by gastrointestinal (GI) symptoms. A high index of suspicion is required for the early diagnosis of this uncommon disease in patients who have concomitant GI symptoms and peripheral eosinophilia. This unusual case who initially had duodenal ulcer with duodenal stenosis, responded to Helicobacter pylori treatment and dilatation. He was symptom free for 2 years. Subsequently, developed evanescent eosinophilic gastritis and recurrent H. pylori infection with refractory prepyloric ulceration, but no duodenal stenosis. Eosinophilic gastritis and H. pylori infection initially responded to treatment, but subsequently the patient developed nonhealing prepyloric ulcer and refractory H. pylori infection and had persistent symptoms; all these necessitated surgical intervention consisting of antrectomy with gastrojejunostomy

Endoscopic Ultrasound‑Guided Fine Needle Aspiration from Pericardial Lesion: A Case of Metastatic Pericardial Involvement from Breast Malignancy

Tissue acquisition from mediastinum is difficult due to anatomic location and presence of vessels. Endoscopic ultrasound provides access to difficult mediastinal locations that are near esophagus. We describe a case of pericardial lesion, endoscopic ultrasound guided guided fine needle aspiration cytology was done and the lesion proved to be metastatic in nature

Spectrum of Esophageal Motility Disorders in Patients with Motor Dysphagia and Noncardiac Chest Pain ‑ A Single Center Experience

Aims and Objective: High‑resolution esophageal manometry is the most important investigation for the evaluation of patients with dysphagia and noncardiac chest pain (NCCP). Chicago Classification (CC) utilizing an algorithmic approach in analyzing high‑resolution manometry has been accepted worldwide, and an updated version, CC v3.0, of this classification has been developed by the International high‑resolution manometry working Group in 2014. Data on the spectrum of esophageal motility disorders in Indian population are scarce as well as a newer version of CC has not been used to classify. The aim of our study is to evaluate clinical presentation and manometric profile of patients with suspected esophageal motility disorders using CC v3.0. Methodology: In this retrospective study, consecutive patients referred for esophageal manometry at our center from 2010 to 2015 were included in the study. High‑resolution esophageal manometry was performed with 22‑channel water‑perfusion system (MMS, The Netherlands). Newer version of CC (CC v3.0) was used to classify motility disorders. Results: A total of 400 patients were included, with a mean age of 44 years and 67.5% were males. Out of these, 60% (n = 240) patients presented with motor dysphagia while 40% (n = 160) had NCCP. Motility disorder was present in 50.5% (n = 202) of the patients while 49.5% (n = 198) patients had normal manometry. Disorders of esophagogastric junction outflow were the predominant type of disorder, found in 33.75% (n = 135). About 14.25% (n = 57) of the patients had minor disorders of peristalsis while 5% (n = 20) of the patients had other major disorders of peristalsis. Achalasia was the most common motility disorder present in 30% (n = 120) patients. Conclusion: Dysphagia was the most common esophageal symptom followed by NCCP in our series. Achalasia was the most common esophageal motility disorder followed by fragmented peristalsis

Unusual Source of Gastrointestinal Bleed and Endoscopic Management

Gastrointestinal (GI) bleeding due to jejunal diverticula is very rare. Capsule endoscopy is a useful diagnostic tool for localizing the bleeding site, but single‑balloon enteroscopy is a good therapeutic modality for the management. Here, we report two cases, in whom the cause of GI bleeding was jejunal diverticula and they managed successfully with endoscopic management

Impact of endoscopic ultrasound-guided fine needle aspiration of small lymph nodes

Background: There is very limited literature on results of fine needle aspiration (FNA) of small (defined as ≤1 cm at long and short axis) lymph nodes, particularly in the setting of pyrexia of unknown origin (PUO). Methods: The study was conducted from July 2014 to December 2015 at a tertiary care center. A total of 34 endoscopic ultrasound (EUS)-guided FNAs in 33 patients were done for lymph nodes ≤1 cm at long and short axis and these were included in the analysis. Results: The study cohort comprised 33 patients; 23 males and 10 females, mean age of 58 ± 12 years. Indication of FNA was to look for malignancy (n = 15), PUO (n = 16), unexplained weight loss (n = 1), and presence of lymphadenopathy in prospective liver donor (n = 1). The FNA was taken from mediastinal nodes (n = 20, 14 subcarinal) and abdominal (n = 14, 8 at porta). The mean size of lymph nodes was 87 ± 11 mm at large axis and 68 ± 17 mm at short axis. A total of 3 (8.8%) FNAs were nondiagnostic (inadequate material). The cytopathologic diagnosis was malignancy in 8 (23.5%), granulomatous change in 8 (23.5%), and reactive lymphadenopathy in 15 (44.1%). Thus, EUS-guided FNA of these small nodes changed the management decisions in 44% of cases (one patient had tubercular lymphadenopathy at two sites). The 22-gauge EUS FNA needle was used in majority of patients (n = 26). There was no significant difference between pathologic (malignant and granulomatous) and reactive lymph nodes regarding size at long or short axis, ratio of long and short axis, hypoechogenicity, and sharply defined borders. Conclusion: EUS-guided FNA of small lymph nodes showed pathological enlargement in 44% of cases