All right, good afternoon everyone, I'm going to try and wake you up with some interesting cases. All right, so this is my first case, it's going to be on pancreatic fluid collections. So this is a first patient, 49-year-old male, who was admitted with severe abdominal pain and weight loss. And interestingly, he had no history of acute pancreatitis, doesn't smoke, doesn't really drink much alcohol, but he does have some comorbidities, end-stage renal disease, also has a history of renal cell cancer, underwent a left nephrectomy. So this was the CT when he presented to our hospital. So this is the stomach here, you saw previously there are some stents, interestingly. And as you can see, he's got this huge fluid collection next to the pancreas, and it appears to be multi-septated. So we did some digging, and basically it looked like the patient had undergone an US-guided cystogastrostomy earlier this year, in April, using a lumatose middle stent at an outside facility, and also had two sessions of endoscopic necrosectomy until May. And actually, they had removed the lumatose middle stent and replaced it with three plastic double-pigtail cystogastrostomy stents into the tract. But unfortunately, the patient had minimal improvement in symptoms, and not much decrease in the size of the collection, and that's why he presented to our facility. So we did an EUS because of this kind of unusual nature of his presentation. And as you can see, this is huge collection, complex, multi-septated, and this is located basically kind of taking up the entire peripancreatic region. We did an EUS-guided FNA to sample this collection, and this is what we found on cytology. So what do you think? Peter? What do you think? Blue is bad. When I was in medical school, that's the guidance we used when looking at slides. It's a suspicion for mucinous neoplasm. Yeah, so this is basically what this ended up being. So it's actually a mucinous cystic neoplasm. And the reason I included this case is it's just easy to drain these pancreatic fluid collections, but if they don't have a history of acute pancreatitis, don't really have risk factors for pancreatitis, and it looks really unusual like this on imaging and on endoscopic ultrasound, then the best thing to do is take a sample of the fluid, consult surgery, et cetera, and just really think before draining collections. Technically obviously not difficult to do, but whether you should do it or not, I think that's the important question here. All right, so this is our second case. This is, again, a 54-year-old female who presented with abdominal pain, and CT showed this pancreatic fluid collection that we can see on the CT on the right. Again, this lady had no history of acute pancreatitis, non-smoker, no alcohol intake, like our last patient. So she was actually referred for endoscopic drainage of this pancreatic fluid collection, so we did an EUS. So this is the body, the body and tail of the pancreas on EUS, this kidney, as you can see just below the pancreas here. And the important thing about this EUS is that the pancreatic parenchyma in the body and tail is completely normal. The duct is normal, the parenchyma looks normal, so it makes you a little suspicious as to whether this patient has pancreatitis and pancreatic fluid collection. So if we proceed, this is the head and then the ulcerative process area of the pancreas, and as you can see, again, she's got this fluid collection here, and this is the question. So based on how it looks on EUS, what do you think is the most likely diagnosis, psoriasis adenoma, branch duct IPMN, pancreatic pseudocyst, neuroendocrine tumor? To our panel, what do you think? Raj? David? James? Not pseudocyst. Say that again. Not pseudocyst. Not pseudocyst, okay. You have to pick an answer there, you have to commit. Well, I mean, it's very atypical for psoriasis adenoma, which tends to be with smaller compartments than this, although you can see it with large compartments, but atypical for psoriasis adenoma. It's quite large for neuroendocrine tumor. They tend to be smaller, although they can be cystic. So just by exclusion, branch duct IPMN will be my primary consideration, but clearly this is a case that will benefit from sampling, because just based on morphology I'll be hard pressed to strongly favor any of those diagnoses to a point that I can carry on with appropriate therapy. Did she have von Hippel-Lindau or anything like that special? Say that again, James. Did she have von Hippel-Lindau or anything special in her history, medical history, or no? No. Yeah. All right. So my next question is, oh, if I can see it, oh, all right. So to the panel again, so what do we do next? Drain using a lumen-reducing metal stent. Drain using double pigtail plastic. I can do this. This. Okay. Think through the answers. FNA, FMB, through the needle biopsies, refer to surgery. Okay. All right. So we are biopsying. Okay. So this is what we did. We actually did a US-guided final biopsy. And the reason we did that, oh, God, goodness. Okay. Oh, goodness. I'm just going to let it run because I'm not very good at this, is I'll show the collection again, but the wall is very, very thick. And the thickened wall, when you see it around a fluid collection or a cystic lesion, should make you worried. And traditionally, you see this in neuroendocrine tumor, which is what this was. This is the cytology here. And this is our lovely surgical specimen when the patient had a whipple. So the main thing I wanted to convey, even though it's not very exciting and I'm not doing any exciting procedures in this, is as endoscopists and as GI physicians, I think that some of the, we can get overwhelmed with enthusiasm to treat a particular thing or drain a particular collection, but it's really important to try and decide whether the patient needs it in the first place and to consider alternative options and diagnoses, especially when the presentation is a little odd. I think the red flags in both of these patients is that they had no history of acute pancreatitis. They didn't really have much risk factors for acute pancreatitis. And so that should make you feel, in the beginning, very concerned. So there might be something else going on, despite what the CT report may say. So, okay. Thank you. These are my two cases. I will hand over to Amrita.

pancreatic fluid collections

mucinous cystic neoplasm

endoscopic ultrasound

alternative diagnoses

biopsy