Visceral pseudoaneurysm is a rare but well-described complication of pancreatitis 1,2 caused by the autodigestive function of pancreatic enzymes. 3 The splenic, gastroduodenal, pancreaticoduodenal, and hepatic arteries are most commonly affected. 2,4 Pseudoaneurysms require active management because of the high complication and mortality rates associated with rupture. 2,5 Traditional treatment options include aneurysm exclusion, surgical excision or ligation, revascularization, and endovascular techniques such as angiographic embolization. 2,4,6 We report a case of a visceral pseudoaneurysm managed by EUS-guided thrombin injection and discuss the role of this novel technique. CASE REPORTA 43-year-old man with chronic alcoholic pancreatitis was admitted with epigastric pain and hematemesis. The patient remained hemodynamically stable, although the hemoglobin count dropped to 9.5 g/dL. Upper GI endoscopy showed no blood in the stomach, and no esophageal or gastric varices or peptic ulcer disease was seen. Spiral CT demonstrated large dilated vessels around the stomach compatible with collateral vessel formation, pronounced inflammation around the pancreas, and a mass at the tail of the pancreas measuring 4 ϫ 3.2 cm with the appearance of a pseudoaneurysm of the splenic artery (Fig. 1). Subsequently, a superselective angiogram was performed by using a C2 and Symmons type 1 catheter (Boston Scientific, Natick, Mass). The celiac trunk, splenic, hepatic, gastroduodenal, left and right gastric, and inferior and superior mesenteric arteries were visualized. The vascular stalk, however, could not be identified (Fig. 2). Neither percutaneous nor surgical management was feasible because of large collateral vessels, the location of the pseudoaneurysm, and the recent attack of acute-on-chronic pancreatitis with subsequent inflammation and adhesions. EUSguided thrombin injection was selected because of the close proximity of the lesion to the gastric wall. The pseudoaneurysm, originating from the left gastric artery, was located by using a linear echoendoscope (Pentax Hitachi 7500; Pentax Hitachi, Montvale, NJ). A standard 22-gauge needle (Cook Endoscopy, Limerick, Ireland) was used to puncture the pseudoaneurysm, which was followed by injection of a total of 7 mL of a thrombin-collagen compound (D-stat; Vascular Solutions Inc, Minneapolis, MN). Color Doppler confirmed the complete obliteration of the lesion (Fig. 3).The patient recovered fully with complete resolution of all symptoms and was discharged within 24 hours. CT angiographies at 6 weeks and 10 months showed no recurrence of the pseudoaneurysm (Fig. 4). The patient remains asymptomatic, without rebleeding, after 10 months in follow-up.

Abdominal lymphadopathy in Human Immunodeficiency Virus (HIV) infection remains a diagnostic challenge. We performed a prospective cohort study recruiting thirty-one symptomatic HIV+ patients with abdominal lymphadenopathy assessing diagnostic yield of endoscopic ultrasound (EUS) fine needle aspiration (FNA). Mean age was 38 years, 52% were female, mean CD4 count and viral load were 124 cells/pl, and 4 log respectively. EUS confirmed additional mediastinal nodes in 26 %. Porta-hepatis was the most common abdominal site. EUS FNA was subjected to cytology, culture and polymerase chain reaction (PCR) analysis. Mycobacterial infections were confirmed in 67.7% and 31% had reactive lymphadenopathy. Cytology and culture had low sensitivity whereas PCR identified 90% of mycobacterial infections. Combining appearance of EUS FNA and cytology a diagnostic algorithm was developed to indicate when analysis with PCR would be useful. PCR performed on an EUS guided aspirate was highly accurate in confirming mycobacterial disease and determining genotypic drug resistance.