Regístrese
¿Aún no está registrado?
Información relevante

Consulte los artículos y contenidos publicados en éste medio, además de los e-sumarios de las revistas científicas en el mismo momento de publicación

Máxima actualización

Esté informado en todo momento gracias a las alertas y novedades

Promociones exclusivas

Acceda a promociones exclusivas en suscripciones, lanzamientos y cursos acreditados

Crear Mi cuenta
Buscar en
GE - Portuguese Journal of Gastroenterology
Toda la web
Inicio GE - Portuguese Journal of Gastroenterology Duodenal Subepithelial Lesion? An Unexpected Endoscopic Ultrasound Finding
Journal Information
Vol. 22. Num. 6.
Pages 231-286 (November - December 2015)
Share
Share
Download PDF
More article options
Visits
2187
Vol. 22. Num. 6.
Pages 231-286 (November - December 2015)
Images in Gastroenterology and Hepatology
DOI: 10.1016/j.jpge.2015.07.009
Open Access
Duodenal Subepithelial Lesion? An Unexpected Endoscopic Ultrasound Finding
Lesão Subepitelial Duodenal? Um Achado Inesperado na Ecoendoscopia
Visits
2187
Susana Marquesa,
Corresponding author
xsusanamarx@gmail.com

Corresponding author.
, Pedro Pinto-Marquesb, David Serrab
a Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
b Gastroenterology Department, Hospital da Luz, Lisbon, Portugal
This item has received
2187
Visits

Under a Creative Commons license
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (4)
Show moreShow less
Full Text

A 39-year-old female with no significant past medical history presented with intense epigastric, colic pain for the three previous days. Laboratory studies showed mild and isolated C-reactive protein (CRP) elevation (1.9mg/dL); liver function tests and pancreatic enzymes were within normal range. An abdominal computed tomography (CT) was performed and revealed a duodenal (D2/D3) endophytic polypoid, high density, heterogeneous lesion, with 26mm; biliary tree and pancreas were normal (Fig. 1). Upper endoscopy (Fig. 2A) and duodenoscopy (Fig. 2B) identified a 25mm large subepithelial lesion, distal to the duodenal papilla (black circle in Fig. 2A), with ulcerated top, suggestive of gastrointestinal stromal tumor (GIST). Endoscopic ultrasound (EUS) examination confirmed a peripapillary subepithelial lesion with 22mm and massively calcified, with posterior acoustic shadowing (transition zone undefined) (Fig. 3); the common bile duct was normal.

Figure 1.

Abdominal CT, coronal view: duodenal (D2/D3) endophytic polypoid, high density, heterogeneous lesion, with 26mm.

(0.08MB).
Figure 2.

(A) Upper endoscopy; (B) duodenoscopy: 25mm large subepithelial lesion, distal to the duodenal papilla (black circle in A), with ulcerated top.

(0.24MB).
Figure 3.

EUS, D2 position: peripapillary subepithelial lesion with 22mm and massively calcified, with posterior acoustic shadowing.

(0.08MB).

In this patient, EUS findings raised the diagnostic suspicion of a gallstone impacted in the duodenal wall through a peripapillary bilioenteric fistula. Therefore, duodenoscopy was repeated at day 6 but, instead of the lesion previously seen, there was now a large peripappilary orifice, suggestive of a bilioenteric fistula (40mm large after contrast injection and guide-wire exploration) (Fig. 4). There was spontaneous and complete abdominal pain remission in less than a week after admission.

Figure 4.

Duodenoscopy, fluoroscopic image: large peripappilary orifice, suggestive of a bilioenteric fistula (guide-wire exploration).

(0.06MB).

The case presented was particularly challenging as the endoscopic and imagiologic appearance mimicked that of a calcified subepithelial lesion with ulcerated top, such as GIST. Most common subepithelial lesions found in the duodenum are GIST, leyomiomas, lipomas and carcinoids and EUS plays a major role in the differential diagnosis. These lesions may occasionally show calcification, usually focal or punctate.1 However, massive calcification is extremely rare (it has been described in few cases of GIST)1 and may point to an alternative diagnosis such as an impacted gallstone into the duodenal wall, particularly if found in D2. There are only three published case reports of parapapillary fistula with impaction of a gallstone into the duodenal wall.2,3

Conflicts of interest

The authors have no conflicts of interest to declare.

Disclosures

All authors have approved the manuscript and agree with its submission to GE – Portuguese Journal of Gastroenterology. All authors have nothing to disclose.

Author contributions

Susana Marques did the writing of the manuscript. Pedro Pinto-Marques and David Serra were responsible for the revision of its contents.

References
[1]
N. Izawa, T. Sawada, R. Abiko, D. Kumon, M. Hirakawa, Kobayashi, et al.
Gastrointestinal stromal tumor presenting with prominent calcification.
World J Gastroenterol, 18 (2012), pp. 5645-5648
[2]
Y. Okabe, R. Kaji, Y. Ishida, T. Noda, Y. Sasaki, O. Tsuruta, et al.
Successful endoscopic extraction of a large impacted choledocholithiasis in the ampulla of vater: two interesting cases.
Dig Endosc, 22 (2010), pp. 103-106
[3]
I.S. Papanikolaou, D. Polymeros, C. Kontopoulou, D. Chatzilia, K. Triantafyllou.
Impaction of a gallstone into the duodenal wall.
Endoscopy, 42 (2010), pp. 297-298
Copyright © 2015. Sociedade Portuguesa de Gastrenterologia
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

es en pt
Política de cookies Cookies policy Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.