Jonathan Weinberger, MD, Matthew Grunwald, MD, Daniel J. Waintraub, MD, Maryanne Ruggiero, MD, Rebecca Rhee, MD, Ira Mayer, MD, Dmitriy O. Khodorskiy, MD
Maimonides Medical Center, Brooklyn, NY
Introduction: Therapeutic echoendoscopic ultrasonography (EUS) is vital in the diagnosis, staging, and tissue acquisition of gastrointestinal (GI) malignancies. However, its use is typically limited to upper GI tract and rectum due to limited visualization and instrument length. We present a case of evaluating an extraluminal lesion adjacent to the distal small bowel, utilizing a linear echoendoscope.
Case Description/Methods: 65 year old male with a history of cecal perforation in the setting of ischemic colitis (no pathologic evidence of malignancy), status post right hemicolectomy, COPD, DM and CHF was admitted with right sided abdominal pain without change in bowel habits. CT scan revealed a mass in the mid abdomen. The mass appeared inseparable from the small bowel (ileum) just proximal to the ileocolic anastomosis; however, it was unclear if the mass was extraluminal or invading the lumen. Colonoscopy was performed and there was no evidence of an intraluminal mass. Interventional radiology was contacted for biopsy of the mass, however, there was no safe window for biopsy. GI was re-consulted and a decision was made to attempt an EUS with fine needle biopsy (FNB) in order to avoid diagnostic laparoscopy.
Ileum was intubated with a pediatric colonoscope and a 0.035 inch guidewire was advanced into the small bowel. Two endoclips were placed proximal to the ileocolic anastomosis for fluoroscopic guidance. The colonoscope was then exchanged for a linear echoendoscope which was advanced alongside the guidewire with an inflated forward balloon using endoscopic and fluoroscopic guidance. The mass was identified and FNB was performed. Cytology revealed atypical lymphoid cells consistent with high grade diffuse large B cell lymphoma.
Discussion: Linear echoendoscope is often used for evaluation of distal colonic lesions. Traditionally the miniprobe is used for diagnosis of lesions not reachable with a linear endoscope, but lacks the ability for tissue acquisition. Recently, a forward viewing echoendoscope has been developed however it is not yet widely available. We describe a case of an innovative use of linear echoendoscope in the proximal colon/distal small bowel, sparing a more invasive surgical procedure. In addition, we describe a novel use a forward balloon as a safety mechanism for advancing a side viewing endoscope in areas of limited visualization.
Citation: Jonathan Weinberger, MD, Matthew Grunwald, MD, Daniel J. Waintraub, MD, Maryanne Ruggiero, MD, Rebecca Rhee, MD, Ira Mayer, MD, Dmitriy O. Khodorskiy, MD. P1495 - INNOVATIVE USE OF LINEAR EUS. Program No. P1495. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.