Endoscopic approach of adenovo-perivaterian abscess. Perivaterian abscess is an uncommon complication of ERCP which is attributed to 0.5-2% of the cases. Adenovo-perivaterian abscess consists an absolutely rare condition hardly described in the literature. Nevertheless, interventional endoscopic approach can provide solutions and therefore allow patients to avoid surgery such as pancreatic oedygenectomy. A 53-year-old patient presented to our clinic with persistent fever up to 38.5 degrees and deterioration of her clinical state. Her lab values revealed a mild leukocytosis and a decrease of hemoglobin compatible with hypochromic anemia. The initial blood and urine cultures were negative. She had empiric antibiotic treatment with no results whatsoever. CT scan showed a wall thickening of the D1-D2 corner and the second portion of the duodenum. No abnormalities from the pancreas or the pancreatic duct were seen. A consecutive MRI verified the CT findings and showed further cystic elements of around 2 cm between the head of the pancreas and the duodenal wall. The cyst was compressing partially the common bile duct. We performed an abrupt GI endoscopy followed by an endoscopic ultrasound and noticed a 2 cm irregular cyst between the head of the pancreas and the duodenal wall. The cyst was very close to the ampulla of utter, which appeared normal. In elastography, it had a somehow inhomogenic texture. For the next step, we performed a contrast enhanced endoscopic ultrasound. Here you can see that there is a mild contrast uptake of the cystic wall, the findings suspicious of an abscess. We then performed a finital aspiration, which revealed the presence of viscous fluid, which was verified later as a pass in the cytology. The cavity could not be completely suctioned via aspiration, thus we decided to form a fistula between the duodenal lumen and the abscess. We used the FNA catheter to forward a 0.035 inches guide wire into the cyst. Over the guide wire we were able to advance the needle knife. As you can see, several passages were performed. The guide wire was very useful to stabilize the tract and to ensure safe passages of the needle knife into the cyst. After several passages we were able to perform and create successfully a fistula between the duodenal lumen and the abscess, following the same tract with a needle knife over and over again. The pus was seen to flow endoscopically after the end of the procedure. The patient showed a rapid improvement of her clinical state. A CT scan two weeks as well as an MRI two months later revealed no longer thickening or cysts in the area of the second part of the duodenum. The patient remained asymptomatic thereafter. Interventional endoscopy can be extremely useful for the diagnosis and treatment exceedingly rare conditions such as de novo periveterian abscess. In this case the combination of endoscopic ultrasound and techniques used in ERCP prevented the patient from having a pancreatic duodenectomy as her last resort.

adenovo-perivaterian abscess

complications from ERCP

endoscopic ultrasound

interventional endoscopy

drainage of pus