World Endoscopy
WEO
Organization
A-PSDE
JGES
Digestive Endoscopy
DEN
specimens are both required for definitive diagnosis, so that appropriate therapy can be started in suspected CMV infec- tion. Endoscopic features of CMV duodenitis are quite vari- able, such as ulceration, erosion, pseudotumor formation, perforation and bleeding.1,2 During endogastroduodenos- copy, CMV infection should be considered in the differential diagnosis of duodenitis. Nevertheless, typical images of CMV duodenitis are rarely published. Therefore, we present this valuable image for future reference.
Authors declare no conflict of interests for this article.
Shinya Sugimoto,1 Yukihiro Yoshimura2 and
Hirokazu Komatsu1
Departments of 1Gastroenterology and 2Infectious Disease, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan doi: 10.1111/den.12027
REFERENCES
1 Kelesidis T, Tozzi S, Mitty R, Worthington M, Fleisher J. Cytomegalovirus pseudotumor of the duodenum in a patient with AIDS: An unrecognized and potentially treatable clinical entity. Int. J. Infect. Dis. 2010; 14: e274-82.
2 Moroi R, Sato Y, Sakurai T et al. Multiple hemorrhagic duodenal ulcers caused by cytomegalovirus infection. Endoscopy 2009; 41 (Suppl 2): E216-7.
Diagnosis of adrenocortical carcinoma via endosonography-assisted fine-needle aspiration of inferior vena cava thrombosis: First case in the literature
Dear Editor,
Endosonography-guided fine-needle aspiration (EUS- FNA) has previously been reported twice when taking biop- sies from tumor thromboses within the portal vein.1,2 Here we report the first case where EUS-FNA was used to take samples from intracaval tumor thrombosis.
A 55-year-old woman was admitted for diffuse abdominal pain. A contrast-enhanced computed tomography (CT) scan of the abdomen disclosed a right adrenal mass measuring 5.5 cm × 4.5 cm in diameter invading the inferior vena cava (IVC) (Fig. 1A). Her laboratory data were within normal limits.
In order to evaluate the adrenal mass an EUS was carried out. A hypoechoic lesion measuring 2 cm × 3 cm was noted in the lumen of the IVC at the level of the entrance to the right atrium. On power-flow Doppler, no flow was seen in the IVC. EUS-guided FNA was carried out (Fig. 1B). Cytopa- thology confirmed a poorly differentiated adrenal cortex car-
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B
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cinoma (ACC) (Fig. 2). The patient died within a month due to metastatic disease to the lungs.
During EUS, transduodenal visualization of the right adrenal gland is more cumbersome than transgastric visual- ization of the left adrenal gland. For this reason, a normal or minimally enlarged right adrenal gland is seen in only 30% of patients on EUS.3 Fortunately, the IVC can be shown from the level of the right renal vein to its entry to the right atrium. Thus, tumor thromboses within the IVC can easily be sampled via EUS-FNA by distinguishing the structures around this major vein.
To our knowledge, this is the first reported case of EUS- FNA of an IVC tumor thrombosis originating from the adrenal cortex.
C 2013 The Authors
Digestive Endoscopy @ 2013 Japan Gastroenterological Endoscopy Society
Authors declare no conflict of interests for this article.
Gurhan Sisman,1 Yusuf Ziya Erzin1 and Hakan Senturk2
1Department of Gastroenterology, Istanbul University
Cerrahpasa Medical Faculty and 2Department of Gastroenterology, Bezmialem University School of Medicine, Istanbul, Turkey doi: 10.1111/den.12028
REFERENCES
1 Cedrone A, Rapaccini GL, Pompili M et al. Portal vein throm- bosis complicating hepatocellular carcinoma. Value of ultrasound-guided fine-needle aspiration biopsy of the thrombus in the therapeutic management. Liver 1996; 16: 94-8.
2 Michael H, Lenza C, Gupta M, Katz DS. Endoscopic ultrasound- guided fine-needle aspiration of a portal vein thrombus to aid in the diagnosis and staging of hepatocellular carcinoma. Gastroen- terol. Hepatol. 2011; 7: 124-8.
3 Dietrich CF, Wehrmann T, Hoffmann C, Hermann G, Caspary WF, Seifert H. Detection of the adrenal glands by endoscopic or transabdominal ultrasound. Endoscopy 1997; 29: 859-64.
Hepatobiliary alveolar echinococcosis infiltration of the hepatic hilum diagnosed by endoscopic ultrasonography-guided fine-needle aspiration
A 46-year-old woman was admitted to our department for further evaluation of dilated intrahepatic bile ducts sur- rounded by soft tissue with minimal calcification detected on computed tomography. Physical examination was unre- markable. Laboratory tests showed elevated serum hepato- biliary enzymes. Endoscopic retrograde cholangiogram revealed multiple strictures in the bile duct (Fig. 1). During the same session, multiple bile duct biopsies were obtained prior to biliary stenting. Although the pathological exami- nation yielded no evidence of malignancy, a definitive diag- nosis could not be reached. Endoscopic ultrasonography- guided fine-needle aspiration (EUS-FNA) was carried out for a histological diagnosis of the echogenic lesion sur- rounding the common bile duct (Fig. 2, arrows). The histo- pathological analysis demonstrated a cuticular layer (Fig. 3, arrows) associated with hyaline-like necrosis consistent with alveolar echinococcosis (AE). An enzyme-linked immunosorbent assay using recombinant Em18 antigen1 was positive. A diagnosis of AE was made based on the serological and histopathological findings. Despite treat-
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ment with albendazole for 15 weeks, the patient developed an abscess in the right hepatic lobe. We ultimately carried out a right caudate hepatectomy with extrahepatic bile duct resection for control of the cholangitis and the hepatic abscess. The postoperative course was uneventful.
AE is a parasitic disease caused by Echinococcus mul- tilocularis. The liver is the most frequent site of involvement and is infested in 50-70% of patients. Most patients with AE are asymptomatic, and the cysts are recognized during imaging studies for non-specific abdominal symptoms; approximately 5-20% of patients present with biliary obstruction and cholangitis.2,3 However, AE with non- visualized cysts by imaging modalities that infiltrate around the common bile duct is a rare condition. Therefore, histo- logical diagnosis around the bile duct by transpapillary bile duct biopsy is very difficult. EUS-FNA was highly useful for