Nikhil Sonthalia

Splenic epidermoid cysts are rare true congenital cysts that may closely masquerade as hydatid cysts in endemic regions, posing a significant diagnostic challenge.

A. Sharp foreign body ingestion

Recent advancements in endoscopic technology have established endoscopic ultrasonography (EUS) as a valuable tool for gastroenterologists. The integration of complementary imaging techniques, such as contrast enhancement and elastography, has significantly enhanced the capabilities of EUS. EUS-guided elastography (EUS-E) is an innovative imaging modality that improves the diagnostic accuracy of standard B-mode EUS by measuring the mechanical properties of tissues, particularly their elasticity or stiffness. These measurements are indicative of pathological changes and can aid in differentiating benign from malignant tissues. By combining elastography with EUS, it is now possible to assess tissue stiffness in organs such as the liver, pancreas, and lymph nodes. This approach not only aids in differential diagnosis but also enables the identification of the most accurate areas for EUS-guided tissue acquisition. EUS-E is performed using two main techniques: strain elastography and shear wave elastography, each with distinct advantages and limitations. This article provides an in-depth review of EUS-E, including its principles, techniques, clinical applications, and inherent limitations.

Objectives: This work aims to describe technical feasibility and clinical outcomes of endoscopic‐ultrasound‐guided gastrojejunostomy (EUS‐GJ) as a first line treatment option for malignant gastric outlet obstruction (mGOO).Methods: This is a large multicenter study where patients undergoing EUS‐GJ across seven tertiary care centers from India were analyzed. The primary outcomes were technical success defined as correct stent placement without any leak, and clinical success defined as improvement in gastric outlet obstruction symptom score (GOOSS) on follow‐up. Secondary outcomes were (a) adverse events rates, (b) symptoms recurrence, (c) death on follow‐up, and (d) resumption of chemotherapy.Results: A total of 71 patients underwent EUS‐GJ with technical success of 94.3%. After successful stent placement, all patients tolerated oral liquid diet on day 1, whereas 89.5% and 95.5% tolerated oral solid diet on day 2 and day 7, respectively. Overall, 9/71(12.6%) patients had major adverse events, which included maldeployment in 6/71(8.4%). Mean duration of follow‐up was 76.13 ± 58.09 days. On follow‐up, reintervention was required in two (3%) patients. Around two‐thirds of patients gained weight and could resume their chemotherapy post‐EUS‐GJ. Kaplan–Meier survival analysis showed that post EUS‐GJ, mean overall survival (symptom recurrence or death) of 144.39 ± 11.53 days (95% CI 121.7–167.0).Conclusion: EUS‐GJ is an excellent modality for the palliation of mGOO, providing high clinical success with extremely low rates of reintervention and acceptable safety profile. It should be considered as a primary modality for managing these patients, and enteral stent should be reserved for patients where EUS‐GJ is not possible.

Background and Aim: Although rapid on‐site cytological evaluation (ROSE) for endoscopic ultrasound (EUS)‐guided tissue acquisition (EUS‐TA) may increase diagnostic yield, it is not widely available. Macroscopic on‐site evaluation (MOSE) is an alternative modality although it is not standardized for EUS‐guided fine‐needle biopsy (FNB). We evaluated diagnostic performance of MOSE compared with conventional technique of EUS‐TA using core biopsy needle. Methods: Consecutive patients undergoing EUS‐FNA for solid lesions were randomized to MOSE or conventional arms. The primary and secondary outcome measures were diagnostic accuracy, diagnostic yield, sensitivity, specificity, positive and negative predictive values, and the number of passes, respectively. The optimum parameters for macroscopic visible core (MVC, i.e., length, number) by MOSE to achieve accurate diagnosis were evaluated. Results: Ninety‐six patients (48 conventional and 48 MOSE) were enrolled. Mean lesion size was larger in MOSE arm (32.67 ± 7.22 vs 29.31 ± 6.98 mm, P = 0.023). Diagnostic accuracy (95.8% vs 91.6%), diagnostic yield (97.9% vs 95.8%), procedure duration, and adverse events of the two methods were similar. Median number of passes with MOSE was less (2 vs 3 P = 0.000). Area under the receiver operating characteristic curve showed that with MOSE, obtaining a total MVC length of 11.5 mm had 93.3% sensitivity, and 2.5 MVC cores (each 4 mm) had 86.7% sensitivity for malignancy diagnosis. Conclusions: EUS‐FNB with MOSE, a simple reliable technique, can achieve a high and comparable diagnostic accuracy with lesser number of passes. Obtaining longer length and greater number of MVC increase the sensitivity to diagnose malignancy with MOSE.

Background and Objectives: Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) for pain relief in chronic pancreatitis (CP) has wide variation in results as reported in the literature. The objective was to find out the efficacy of EUS-CPB in painful CP from our region where phenotype of CP is different from West and to find out factors favoring response to EUS-CPB. Methods and Results: Patients with known CP who underwent EUS-CPB were assessed for response to CPB. Response to EUS-CPB was recorded as more than 50% reduction in visual analogue scale (VAS) score for pain severity at 1 week, 4 weeks, 12 weeks and 24 weeks after procedure. Factors between responders and nonresponders were analyzed. Among 29 patients who underwent EUS-CPB during the study period, response was seen in 72.4% patients after the procedure. The mean time to response to EUS-CPB was 1.22 (± 0.43) days. Mean duration of response was 8 months (± 4.73). Short duration of painful CP (≤2 years) was seen in 15 patients (51.72%) and long duration (>2 years) was seen in 14 (48.27%). Among responders (21/29), those patients who had short duration of disease had significantly lower median VAS score at 12 weeks, (1 versus 3, p-value= 0.026) and at 24 weeks, (1.5 versus 2.5, p-value= 0.049), as compared to those with longer duration of disease. Overall, 83.3% males responded as compared to 54.54% females (p = 0.04). Significant proportion of subjects who responded either stopped or used analgesics occasionally (p < 0.0001). There was no statistically significant difference in response to EUS-CPB with respect to age, prior history of endoscopic retrograde cholangiopancreatography (ERCP), etiology of CP, prior history of surgery, or whether only EUS-CBP was done (p > 0.05 for all). Conclusion: EUS-CPB can be effective when used in select group of painful CP patient who are not immediate candidates for surgery especially in early course of disease. It can be offered to patients with persistent pain despite optimum medical therapy. When effective, it can reduce need for analgesic medication at least in short to medium term.