An incidental diagnosis by endoscopic ultrasound

January 16, 2019 By: Dario Ligresti, Ilaria Tarantino and Mario Traina

Image courtesy of D Ligresti.

An incidental diagnosis by endoscopic ultrasound

What has been detected by follow-up EUS in a patient with a multifocal IPMN?

An asymptomatic 66-year-old male patient with a multifocal intraductal papillary mucinous neoplasm (IPMN) underwent a follow-up EUS examination with a linear array echoendoscope. His medical history included diabetes, hypertension and smoking. While advancing the echoendoscope in the oesophagus, the endoscopic ultrasound (EUS) image shown was captured.

 

 

 

 

 

 

WHAT IS YOUR DIAGNOSIS?

A. Oesophageal duplication cyst

B. Aortic aneurism

C. Mediastinal cyst

D. Aortic dissection

Discussion

Following EUS examination (figure 1), the patient underwent a CT scan (figure 2) and was diagnosed with an aortic dissection confined to the descending thoracic aorta (Stanford type B). On the basis of the clinical characteristics, the patient was treated conservatively with medical therapy.1

Aortic dissection is a relatively common acute emergency, affecting 2–3 per 100,000 people per year. It usually presents with severe chest or abdominal pain, depending on which part of the aorta is affected. However, in a small number of patients, aortic dissection can have a subclinical course and remain unrecognized. In fact, in about 30% of patients, aortic dissection can be diagnosed in its chronic state.For Stanford type B chronic dissection, conservative treatment associated with strict monitoring of blood pressure is advisable. Actually, medical management has been demonstrated to be related to a lower mortality rate when compared with surgery (10% versus 30%).3

EUS has been shown to be useful not only for the study of gastrointestinal diseases, but also for mediastinal pathologies. Some case reports have been published showing the importance of EUS for the unintentional diagnoses of cardiovascular pathologies. Considering that EUS examination of mediastinal lymph nodes and cardiovascular system from the oesophagus takes about one minute and that cardiovascular diseases are potentially life-threatening, EUS-based mediastinal screening should be considered as a part of the standard EUS examination for gastrointestinal diseases.4

 

Figure 1 | EUS view of the aortic dissection. A | B-mode image showing the dissected thoracic aorta with the intimal flap (arrows) separating the two lumens. B | Colour Doppler showing blood flow in the true lumen (*) and no flow in the false lumen (**). C| Spectral Doppler signal of the true lumen showing arterial pattern. D | Spectral Doppler showing no signal in the false lumen. Image courtesy of D Ligresti. 

 

Figure 2 | Contrast CT scan showing dissection of the thoracic aorta. The true lumen (*) and false lumen (**) can be clearly distinguished.Image courtesy of D Ligresti.

Answer

Correct answer: d.

About the authors

Dario Ligresti is attending physician in the Endoscopy Service, Department of Diagnostic and Therapeutic Services at IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) in Palermo, Italy. He graduated in 2009 and completed is residency program in general surgery and interventional endoscopy. His main clinical and research field of interest is pancreatobiliary and therapeutic endoscopy.

Ilaria Tarantino is attending physician in the Endoscopy Service at IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) and associate professor of medicine at the University of Pittsburgh.She graduated in 1998 from the University of Palermo and completed her residency in gastroenterology in 2002. Her main focus is pancreatobiliary endoscopy with a special interest on interventional EUS. 

Mario Traina is Chief of the Digestive Endoscopy Service at IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) and associate professor of medicine at the University of Pittsburgh. He graduated at the University of Palermo in 1981 and specialized in diseases of the digestive system in 1985. His main focus is the treatment of biliary complications in liver transplant recipients, multispecialty complex procedures on biliary ducts and the pancreas, also on paediatric patients.

 

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