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Volume 84 - 2021 - Fasc.1 - Clinical images

Muscular rim sign at endoscopic ultrasound in a patient with a suspected cyst of the pancreatic head

A 67 years old male patient was referred in September 2019 to the Gastroenterology and Endoscopy Unit of the Sahlgrenska University Hospital, in Göteborg (Sweden), to undergo an endoscopic ultrasound (EUS) examination. The patient was asymptomatic, without other relevant gastroenterological comorbidities and referred for the suspicion of a pancreatic cyst and/or intraductal papillary mucinous neoplasia (IPMN) of the pancreatic head; the suspicion was raised by a recent magnetic resonance imaging (MRI) examination performed in our center for other reasons. Multiple EUS scans excluded any pancreatic cysts. The endoscopic view of the duodenum confirmed the presence of both the minor and the major duodenal papilla. However, just below the major duodenal papilla, a mucosal bulging extended for 2.5 centimeters, with normal mucosa and with a papilla-like orifice in the proximal part was found (Figure 1a) and evaluated with EUS (Figure 1b). What is the diagnosis on the basis of the EUS image?


Gastrointestinal bleeding with joint pain

A 22-year-old male presented with fever, diffuse abdominal pain and melena for 2 days. He also had symmetric polyarthralgia involving knee and ankle. Physical examination showed no peripheral lymphadenopathy or joint swellings. Investigations showed normal blood count, kidney function tests with raised serum transaminases, AST 76 U/L and ALT 82 U/L (normal <40U/L). Urinalysis revealed no hematuria or proteinuria. Computed tomography (CT) abdomen showed diffuse thickening of small bowel (Figure 1A). Esophagogastroduodenoscopy showed hyperemic edematous mucosa with ulcerations in the duodenum (Figure 1B). After two days patient developed multiple reddish purpura over bilateral lower limbs (Figure 2). What is the possible diagnosis?


A curious case of diarrhea

77-year old woman presented with a two-month history of diarrhea. She had a past medical history of infectious colitis dating from 2005, including duodenitis with partial villous atrophy on duodenal biopsy. Celiac serology was negative at the time. Her medication included pantoprazole, aspirin, loop diuretic, statin, levothyroxin, angiotensin-converting-enzyme inhibitor (ACE-inhibitor), benzodiazepine and diltiazem. She reported smoking a few cigarettes a day. A colonoscopy was performed, which showed spontaneous mucosal tears with bleeding in the right colon (Fig. 1 : A-B). What is your diagnosis? A. Ischemic colitis B. Collagenous colitis C. Barotrauma secondary to insufflation during colonoscopy D. Ulcerative colitis The correct answer is B. The pathology report confirmed the presence of collagenous colitis (CC). Given the impressive presentation, the patient was started on budesonide, with complete resolution of the symptoms a few weeks later. A follow-up gastroscopy was performed to obtain new duodenal biopsies. These showed no signs of celiac disease. Pantoprazole was stopped, as the gastroscopy was normal, as were the statins. Budesonide was tapered over a 12-week period. She was also advised to quit smoking.