Introduction/Objectives: Cytological analysis on specimen obtained by Endoscopic Ultrasound-Fine NeedleAspiration (EUS-FNA) is known as the most accurate technique for the diagnosis of pancreatic adenocarcinoma. Nonetheless, differenzial diagnosis between adenocarcinoma and other pseudotumoral lesions (such as chronic pancreatitis) can be challenging. Almost all pancreatic adenocarcinomas show mutational activation of K-ras oncogene. Analysis of mutations of K-ras on aspirates provided by EUS-FNA could be a helpful method to distinguish neoplasia from benign lesions.

Introduction: Endoscopic Ultrasound-Fine Needle Aspiration (EUS-FNA) has become standard practice in the evaluation of subepithelial masses of the gastrointestinal (GI) tract, since it allows a clear identification of the layer of origin of the lesion and its sampling. This kind of lesions needs a definite diagnosis because some of them, mainly the Gastrointestinal Stromal Tumors (GISTs), bear a malignant potential. However a tissue diagnosis is seldom necessary because usually treatment decisions can be planned mainly on clinical bases.

A 64-year-old woman presented with longstanding dysphagia to solids and a recent onset of nocturnal cough and change in her voice. The patient described restriction to the passage of solids at the level of the neck, but denied odynophagia or weight loss. She had a background of Behcet’s disease with previous colonic and oropharyngeal involvement. She had also been treated for many years with esophageal dilations for an upper esophageal web. Her symptoms of dysphagia improved temporarily after each dilation; however, typically there was recurrence within 2 weeks of treatment. Video fluoroscopy was performed, which demonstrated a small web in the region of the pharyngo-esophageal junction, above which there was pharyngeal dilatation. At least one episode of aspiration occurred during this procedure. After informed consent had been obtained from the patient, repeat esophagogastroduodenoscopy was undertaken using a 5-mm pediatric endoscope (GIF-180; Olympus, Ontario, Canada). Multiple fibrotic-looking rings were noted throughout the hypopharynx (●" Fig.1a) and pharynx (●" Fig.1b,c). There was no ulceration or erythema present. A small diverticulum was seen just above the larynx (●" Fig.1d). The pediatric endoscope was passed into the esophagus, stomach, and duodenum with no other abnormalities being detected. The patient was referred to an ear, nose, and throat (ENT) surgeon for further management. ENT examination confirmed the presence of several fibrotic rings affecting the pharynx and hypopharynx with considerable narrowing toward the glottic opening. It was felt that the degree of restriction at the oropharynx was sufficient to account for the patient’s symptoms. The etiology of the rings remained unclear. Because of her persistent symptoms, it was recommended to the patient that she undergo excision of the rings during direct laryngoscopy using a laser. Histopathology of the specimens confirmed squamous mucosa with submucosal fibrosis and mild chronic inflammatory changes. At a follow-up visit after 2 months, the patient reported considerable improvement in her symptoms. Behcet’s disease is a type of systemic vasculitis that may affect small, medium, and large vessels (arteries or veins). The diagnosis of Behcet’s disease is a clinical one and requires the presence of recurrent mouth aphthous ulcers (at least three times per year), and two of the following: recurrent genital aphthous ulcers, eye lesions, skin lesions, or a positive pathergy test [1]. In the oropharynx, pharyngeal stenosis has been reported in addition to ulceration and it has been postulated that this is secondary to myositis [2]. Although there are reported cases of cicatricial pharyngeal stenosis in patients with Behcet’s syndrome and previous oropharyngeal surgery, this is the first reported case of pharyngeal webs associated with this syndrome. Established associations with pharyngeal webs include iron deficiency anemia, pernicious anemia, rheumatoid arthritis, carcinoma, epidermolysis bullosa, and pemphigoid [3]. Webs in the pharynx are a rare cause of dysphagia that should be considered in patients with persistent dysphagia once esophageal lesions and motility disorders have been excluded. Behcet’s disease may be associated with pharyngeal webs.

gency ward for bronchopneumonia with hemoptysis. A computed tomography (CT) scan disclosed an incidental 18-mmwide lesion in the pancreatic tail that appeared cystic with magnetic resonance imaging, with a thick wall and a solid projection, both contrast-enhanced. Serological tumor markers were in the normal range. Endoscopic ultrasound (EUS) evaluation showed an oval, protruding mass with a mixed solid and cystic echo structure (●" Fig. 1). Fine-needle aspiration (FNA) produced cystic fluid; two slides were smeared and onewas stainedwith hematoxylin and eosin for rapid on-site evaluation. Part of the fluid was sent to the laboratory for tumor marker analysis, while the remainder was preserved in 95% ethanol for cell block preparation. The observation by the onsite cytopathologist of a small group of cells suspected of being a pancreatic endocrine neoplasm (PEN) (●" Fig. 2) prompted the request for analysis of chromogranin A in the cystic fluid. Cell-block sections showed discohesive epithelial cells with a plasmocytoid appearance, regular nuclear membrane, and finely granular chromatin; immunocytochemistry (ICC) results (positivity for chromogranin A and synaptophysin) confirmed the endocrine differentiation. The proliferation index with Ki-67 was positive in < 1% of neoplastic cells (●" Fig. 3). The final cytological diagnosis of a neuroendocrine tumor was supported by the cyst fluid analysis, showing high levels of chromogranin A (138 ng/mL, normal range 20–100 ng/mL), while amylase and carcinoembryonic antigenwere low. Pancreatic endocrine neoplasms are occasionallymanifested as cystic lesions [1–4]. Differential diagnosis of pancreatic cystic neoplasms is significantly enhanced by cyst fluid analysis [5]. To our knowledge, this is the first report that demonstrates a high chromogranin A level in the fluid of a cystic pancreatic neuroendocrine tumor sampled during EUS-guided FNA. This can be a useful diagnostic tool confirming a preoperative diagnosis of PEN, especially in those cases where FNA gives little material for traditional cytological and ICC investigations.

A 28-year-old man presented at the emergency ward for bronchopneumonia with hemoptysis. A computed tomography (CT) scan disclosed an incidental 18-mm-wide lesion in the pancreatic tail that appeared cystic with magnetic resonance imaging, with a thick wall and a solid projection, both contrast-enhanced. Serological tumor markers were in the normal range.

omy is carried out for stones that are too big [1–7] and also in cases where the terminal bile ducts are too small [1,7]. It was first described in 2003 [1] and is different from balloon sphincteroplasty without sphincterotomy. Severe bleeding following the procedure has been reported only twice [2,3]. A 39-year-old man was referred for ultrasound as his jaundice had not improved 1 month after stopping alcohol. A 16-mm stone, blocking the lower choledochus (●" Fig. 1), was seen along with dilated bile ducts. The bilirubin level was 165 μmol/L and creatinine and coagulation tests were normal. The patient was taking no medication. Retrograde cannulation of the papilla had failed. A needle-knife section of the papilla was easy to carry out and bloodless (●" Fig. 2), as was a sphincterotomy. However, the balloon procedure failed to extract the stone. Progressive dilation with a CRE balloon, 12–15mm (Boston Scientific, Nanterre Cedex, France), allowed disappearance of the notch sign at 15mm (●" Figs. 3 and 4) with the usual technique [1–7]. Total duration of the procedure was 1 minute. Stone extraction with the latex balloon was easily accomplished and elicited routine, low grade oozing of blood (●" Fig. 5). At 2 hours, however, the patient had a massive bleed from a large artery, impeding vision. Injection of 20mL of 1:10000 epinephrine failed to stop the bleeding but surgery involving over-sewing was successful. Bleeding recurred the next day with temporary cardiac arrest. A second attempt at intervention could not visualize the bleeding artery and more of the bleeding region was sewn up. However, the bleeding failed to stop and embolization was carried out to occlude one of the two arteries. The third attempt at intervention succeeded and involved further over-sewing of the papilla. There was evidence of pancreatitis with cytosteatonecrosis. Bleeding did not recur but severe, infected necrotizing pancreatitis and a duodenal fistula necessitated 3 months’ stay in an intensive care unit. A total of 18 units of packed red cells, 16 units of fresh frozen plasma, and 2 units of concentrated platelets were infused. Life-threatening hemorrhage caused by balloon dilation after sphincterotomy for extraction of a large stone