Waht is this procedure?

shot... where are the pictures?
I will try again

more pics

can someone show me how to show the pictures

دكتور بس بتعمل copy لرابط الصورة وبعدين بتلصقه بالتعليق + image icon

One hint: The patient initial presentation is acute abdominal patient , sever in the epigastric region radiating to the back. The pain improved later but another dull discomfort developed in the epigastric region not allowing him to eat.
Any idea?

بالنسبة للايكو ما شفت شي
ما خطر ببالي هو التالي التهاب بنكرياس تالي لانسداد قناة جامعة بحصاة و وبظن ما يجرى هو خزع مصرة أودي بERCP .
كنت ما بدي شارك بس قلت لحالي جرب

You are close . The first half is true. The patient had pancreatitis. but can you look at the second image (where there is a strapped blue wire) look at the mucosa there and tell me where is the scope ?

[img] On the ultrasound: look at the black space and the fine white line (pointed at with black arrows)

Picture6.jpg 9.17 كيلوبايت
[img]

Ok .. here another hint
For the US : you see one large "black space" . Usually black (anechoic) material is liquid.
The picture is taken from the stomach as well as the intervention . Any idea?

مخاطية معدة معناها أنا شاطرة
بصراحة ما عرفت شو هي العملية التي تتم عن طريق المعدة فدورت بالنت و طلعت بالاختراع التالي :
مريضنا تشكل عنده pseudocyst والعملية هي drainage the pseudocyst through the stomach by creating a small opening between the cyst and the stomach during endoscopy
هالمرة صح ؟

و ماذا شكلها هي السودوسيست؟

التهاب البنكرياس لاحقا قد يسبب تنخر بالبنكرياس بالاضافة لتجمع السوائل فبيعطينا كيسة كاذبة يمكن هي الظاهرة بالايكو باعتبار في ظل أسود = سائل
وبظن أفضل وسيلة لرؤيتها هي الCT وهي صورة

وهي صورة ترسيمية لكيفية تشكلها

صح

You got it. This an example where endoscpic treatment has progressed . Typically such patients used to be treated with external drain (placed by radiologist) or by surgery. Nowadays and espcially with the help of endoscopic ultrasound we can see the pseudocyst and puncture it with a needle then pass a wire and dilate the tract (by creating a whole from the stomach into the wall of the cyst to finally leave 2 drains (last picture) that will drain patients pseudocyst into the stomach .
Patient does not feel anything .
Here is a view of the same patients CT scan

the pseudocyst is the low density structure in the middle of the CT image infront of the spine and behind the stomach (which is partially filled with dye: very white and partially has air(very black)

Ok
let me make the question a little harder.
This patient has recurrent pancreatitis for 4 years. However he had some treatment... that made him feel better for almost 2 years with no more attacks (there are some clue about that treatment on the CT scan)
But lately the pancreatitis recurred and was preceded with right upper quadrent pain and liver enzymes ALT 87 AST 55. Later in his course the pain resolved except the dullness and fullness described above and the latest liver enzymes
ALT 25 AST 44.
The patient does not know how alcoholo taste or smell and does not take medications except for bisoprolol for hypertention.
The question
1- What do you thing is the cause for his recurrent pancreatitis and why
2- What was the treatment that he had 2 years ago which helped him for a while
3- What is the recommeded treatment now

emmmm
شكلي عم صعبها كتير... ما

you can tell me frankly so I can avoid such difficult topics in the future

how did that resolved,I mean it was just the usual supportive Tx of pancreatitis...

O.K I have a theory.....

recurrent acute pancreatitis in the past years was because of gallstones....(whenever I hear reacurrent acute pancreatitis I instantly think of gallstones-is that wrong doc?? I do this cuz it is on of the two most common causes of acute pancreatitis,and on the other hand it doesn't cause chronic pancreatitis......)

so,recurrent ap treated supportively and then they found gallstones on echo ,so they decided to do sphincterectomy(whcih I really don't know if can be shown on the CT)

now for the new pain,,,
I'd like to ask a few more things:

the ruq pain that preceded the pancreatitis,how long did it last???
fever???
what about bilirubin???
alp???
[/eng]

Fouad
WOW
I really appreciate your efforts and imagination. I want to pay your attention to
1- The white small objects in the gallballder bed along the edge of the liver.
2- The CT cut is above the left kidney (not shown here) and shows only small portion of the right kidney that is secreting the IV dye and you can see the renal cortex well enhanced
3- I am not sure why you can necrosis of the liver ? can you describe what you see in more details
mbs2380
very good analysis but you said

Can you tell us how do you think sphincterotomy is going to help or treat the gallbladder stones?

here some more cuts

The T tube information is rather old and obsolete. It is rarely (if ever done) after the spread of ERCP.

One more time you got it right drhanadi: the patient had cholecystectomy 2 years ago (and those white small objects seen at the site of the gallbladder bed are surgical clips used to clip the cystic duct before removing the gallbladder laparoscopically (try to see them in the first CT scan image)
So Fouad you did not seen gallbladder stones because simply there is no gallballder

So patient had recurrent "biliary pancreatitis" and he experienced good relief after laparoscopic cholecystectomy. Fisrt question answered
Now why did he have another episode of pancreatitis (with the pattern of liver enzymes mentioned above)
You can search "recurrent pancreatitis " and tell me what is the most common cause for it?