Endoscopic diagnosis

Endoscopic Diagnosis, Staging & Palliation of Malignant Obstructive Jaundice
A 75 yrs male was referred to us for the favor of evaluation of exact etiology of obstructive jaundice. The
total bilirubin was 23mg% and patient had few episodes of fever with chill recently. Hence EUS was
considered to evaluate the exact etiology of obstructive jaundice. EUS revealed a large mass in the
pancreatic head which appeared malignant and was seen invading the duodenal wall, lower CBD, MPD,
SMA & SMV. Further more, large hypoechoic nodes were seen in the celiac axis region. In view of these
findings EUS guided FNA was performed from the pancreatic head mass and the celiac axis nodes.
Subsequently due to recurrent cholangitis ERCP was performed and after biliary sphincterotomy a self
expandable. metal stent was placed into the CBD which showed free flow infected bile. The procedures
were performed on OPD basis and patient was sent home the same evening

1.EUS showed a large hypoechoic mass In the
pancreatic head leading to obstructive jaundice

2. Large hypoechoic mass in the pancreatic head
invading the SMA and SMV

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3.Hypoechoic nodes were seen in the celiac axis
region- suggestive of distant nodal metastasis

4.EUS guided FNA of the pancreatic head mass
performed.Needle was passed transduodenally
under EUS guidance.

5.ERCP showed dilated upper CBD with a stricture
In the region of pancreatic head

6.ERCP and placement of Self expandable Metal
biliary stent

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Expert Comments: As we can see in this case due to very advanced nature of pancreatic tumor
which eventually turned out tobe a poorly differentiated adenocarcinoma on EUS guided FNA of the
mass and nodes, a single step detection, diagnosis, staging and palliation of malignant obstructive
jaundice was performed in one sedation on an OPD basis. Several studies have shown that whenever
there is a patient of obstructive jaundice of uncertain diagnosis, EUS will provide accurate diagnosis in
most cases. It is a standard protocol at Endoscopy Asia that if a patient has obstructive jaundice and if
the diagnosis is not clear on previous other imaging studies, then patient will be subjected to EUS sos
EUS guided FNA if there is a mass lesion followed by ERCP and ductal clearance if stones are seen or
stenting if a malignant lesion is encountered. Studies have shown that most patient who are diagnosed
with Pancreatic adenocarcinoma who present with obstructive jaundice are advanced in their
presentation and hence Surgery should be considered only if there is a chance of cure and R0 resection
without nodal involvement, and in most centres across the world role of palliative surgery is now
diminishing. Since the advent of EUS / FNA and Metal Biliary stenting / Duodenal stenting, endoscopic
palliation is now a preferred approach. If patient has intractable pain due to advanced pancreatic cancer
then in the same sedation we can also offer EUS guided Coeliac Plexus Neurolysis (EUS-CPN) thus
completing the entire spectrum of palliative care.
This approach of EUS sos ERCP provides accurate diagnosis and optimal management of obstructive
jaundice in most patient without any additional investigations or interventions. This has been our
practice for over 13 years since I pioneered Pancreato-biliary EUS in India and we hope that more such
centres across the country will incorporate such a protocol in years to come.
Case Capsule 7
Management of Obstructive Jaundice of Unknown Etiology

Management of Obstructive Jaundice of Unknown Etiology

1. Tubular filling defects seen in a dilated CBD-A live 2. ERCP-After selective cannulation of CBD biliary
round worm
phincerotomy was performed
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3. ERCP-Cholangiogram showed a tubular filing 4. Live round worm from CBD was removed with a
defect in a midly dilated CBD
stone extraction balloon catheter

5. To prevent reentry of the round worm a 7Fr stent
was placed into the CBD

6. Multiple live roundworms were seen in the third
part of the duodenum,one of them managed to
enter the bile duct and caused all the symtoms

A 25 yrs female was referred to us for the favor of EUS sos ERCP for suspected block in the CBD leading
to recurrent epigastric pain with mild LFT abnormality and no stones were seen in Gall bladder on USG
abdomen, however, mild dilatation of CBD was seen without any obvious stone or filling defects. EUS at
Endoscopy Asia revealed a large tubular structure in the dilated CBD and this was suspected to be a
large round worm. There was no other pathology in the pancreato-biliary system apart from this
findings and therefore ERCP was considered. ERCP showed a filling defect on cholangiogram and
confirmed the EUS findings. Biliary sphincterotomy was performed and the round worm was extracted
using a stone extraction balloon catheter. Few more live round worms were also seen in the third part of
duodenum and therefore after ductal clearance a 7 fr stent was placed to ensure effective ductal
drainage. Patient was treated on an OPD basis and sent home the same day.
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Expert Comments: As we have seen in the previous case that patients with obstructive jaundice
without a definitive diagnosis of etiology of obstructive jaundice can be diagnosed accurately on EUS.
Here we managed to clear the duct of a live round worm which was causing intermittent obstruction of
the bile flow leading to mild LFT abnormality and severe epigastric pain. This patient was then given oral
antihelminthic medication to take care of rest of the round worms. Since there are still some serious
hygienic issues in our society especially in the rural and slum areas that we have to keep such pathology
in mind at the time of management of such patients.
I would like to share here with our readers that it is a standard protocol at Endoscopy Asia that unless
EUS proves that there is a definitive pathology in the bile duct that needs treatment we will not proceed
with ERCP. In other words we at Endoscopy Asia do not have negative ERCP so to speak and in the era of
such accurate modalities such as EUS & MRCP, diagnostic ERCP has no role in most cases.

-----------------------------------------------------------------------------------------------------------------------------------------Endoscopy Asia
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