Metastatic involvement of the biliary tract and gastrointestinal (GI) system secondary to breast carcinoma is exceedingly rare. We hereby report a case of a 57-year-old woman with a past history of Human Epidermal Growth Factor Receptor 2-positive, estrogen and progesterone receptor-negative breast carcinoma treated 4 years earlier, who presented with jaundice, vomiting, early satiety, and significant weight loss. Biochemical evaluation revealed a cholestatic pattern of jaundice. Magnetic resonance cholangiopancreatography and contrast-enhanced computed tomography revealed intrahepatic biliary dilatation secondary to a mass at the porta hepatis compressing the distal common bile duct, along with significant narrowing of the D1-D2 segment of duodenum. Endoscopic ultrasound-guided biopsy confirmed metastatic adenocarcinoma consistent with a breast primary. Due to anatomical constraints precluding endoscopic biliary stenting, the patient underwent palliative double bypass surgery of cholecystojejunostomy and gastrojejunostomy. Postoperatively, the patient demonstrated resolution of jaundice and restoration of normal oral intake, with marked symptomatic improvement. This case highlights a rare metastatic presentation of breast carcinoma closely mimicking primary hepato-pancreato-biliary malignancies, posing a significant diagnostic challenge. A high index of suspicion is thus essential in patients with a prior history of breast cancer presenting with biliary or upper GI symptoms. In cases where endoscopic interventions are not feasible, surgical double bypass proves to be an effective palliative strategy for symptom relief.

Concurrent malignant biliary obstruction (MBO) and type I duodenal stenosis represent a technically demanding scenario, as luminal narrowing frequently precludes passage of a standard side-viewing duodenoscope and limits conventional transpapillary drainage. Although endoscopic ultrasound-guided biliary drainage and percutaneous transhepatic biliary drainage are established alternative approaches, transpapillary drainage remains desirable when papillary access is achievable. We report a 66-year-old woman with stage IV pancreatic cancer who presented with obstructive jaundice and tumor-related type I duodenal stenosis (i.e., obstruction proximal to the papilla). A side-viewing duodenoscope failed to traverse the stenosis; however, a standard forward-viewing endoscope (GIF-Q260J) successfully reached the major papilla. Selective biliary cannulation was achieved, and a covered multihole self-expandable metal stent (SEMS) (HANAROSTENT Biliary Multihole Benefit) was deployed across the distal biliary stricture using an ultra-slim 5.9-Fr delivery system compatible with the 3.2-mm working channel. Stent placement was technically successful without adverse events, resulting in prompt resolution of cholangitis and enabling the initiation of second-line chemotherapy. This case highlights a practical and reproducible strategy that expands the therapeutic capability of standard forward-viewing endoscopes. The combination of a slim delivery system and covered multihole SEMS may provide a physiological alternative to non-transpapillary drainage in selected patients with MBO and advanced type I duodenal stenosis.

Subtotal esophagectomy with retrosternal gastric tube reconstruction alters upper gastrointestinal anatomy and can create two obstacles to endoscopic retrograde cholangiopancreatography (ERCP): displacement and rotation of the pylorus and proximal duodenum, which impede side-viewing duodenoscopy, and ampullary carcinoma, which may obscure the bile duct orifice and prevent selective cannulation. When endoscopic drainage fails, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) offers an alternative route for internal biliary decompression. Reports of EUS-HGS performed from within a retrosternal gastric tube conduit are limited. A 79-year-old woman with prior subtotal esophagectomy and retrosternal gastric tube reconstruction presented with acute cholangitis and obstructive jaundice caused by ampullary adenocarcinoma. ERCP was abandoned because tumor infiltration obscured the bile duct orifice. EUS-HGS was performed on the same day through the gastric conduit. A 19-gauge puncture and a double-guidewire technique enabled placement of a 7-Fr, 14-cm plastic stent without adverse events. Cholangitis resolved, diet was resumed four days later, and the stent remained patent at 57 days. Histology confirmed adenocarcinoma. EUS-HGS via a retrosternal gastric tube conduit was feasible and achieved internal biliary drainage in a patient with complex post-esophagectomy anatomy and failed ERCP.

Incomplete physical examinations especially omissions of Central nervous system (CNS) assessments remain a major cause of missed or delayed diagnoses of serious neurological conditions in febrile children with nonspecific symptoms. I report the case of a 22-month-old male initially presenting with prolonged fever, coffee-ground vomiting, nonbloody diarrhea, and recurrent convulsions, leading to a presumptive diagnosis of gastroenteritis with sepsis at Mwananyamala regional referral hospital. Despite initial management, his condition deteriorated. Subsequent evaluation at Muhimbili National Hospital revealed focal neurological deficits, hepatomegaly with jaundice, and severe coagulopathy. Brain magnetic resonance imaging (MRI) demonstrated extensive intraventricular hemorrhage with obstructive hydrocephalus and multifocal acute cerebral infarcts in the setting of severe dengue-associated coagulopathy. Although an underlying vascular malformation was considered, vascular imaging was not performed and this remained unconfirmed. This case highlights the critical diagnostic challenge in pediatric care where common gastrointestinal symptoms can mask severe systemic and neurological conditions, particularly in dengue-endemic areas. It highlights the urgent need for high suspicion of central nervous system pathology, comprehensive neurological examinations, and early neuroimaging in children presenting with persistent nonspecific symptoms and new-onset seizures, crucial for timely diagnosis and management.

Obstructive jaundice is mostly caused by malignant lesions such as pancreatic head cancer and cholangiocarcinoma. Atypical benign conditions such as intramural duodenal hematoma (IDH), can imitate malignant processes in both clinical and radiological presentation. The diagnostic workup included computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS) with biopsy. A 65-year-old patient was referred for assessment of obstructive jaundice and endoscopic retrograde cholangiopancreatography (ERCP). Initial presentation included hematemesis, anemia, cholestasis, and coagulopathy. Imaging (MRCP, CT) showed dilation of intra- and extrahepatic bile ducts and pancreatic duct, suggesting obstruction at the pancreatic head. CT also revealed a heterogeneous mass in the duodenum. ERCP demonstrated duodenal stenosis due to external compression and distal bile duct narrowing, and a self-expandable metal stent (SEMS) was inserted. Endoscopic ultrasound with biopsy revealed an intramural duodenal hematoma without malignant features. The patient's medical history was significant for multiple comorbidities and previous anticoagulation therapy. Follow-up imaging demonstrated complete regression of the hematoma, confirming its benign nature. The observed clinical course was consistent with spontaneous resolution; consequently, there was no need for surgical intervention. Intramural duodenal hematoma is a rare but important condition that may mimic pancreatic head tumors causing obstructive jaundice. Early detection using imaging techniques is critical to accurately establish the diagnosis. Early recognition facilitates conservative treatment and helps avoid unnecessary highly invasive surgical procedures.

Kawasaki disease (KD) is a systemic inflammatory illness characterized by medium blood vessel vasculitis and is considered to be the leading cause of acquired heart disease in children less than 5 years old in developed countries. KD can present as either a classical or atypical/incomplete presentation based on distinct laboratory parameters seen in Table 1. The exact cause of KD remains unknown; however, specific purported infectious agents have been theorized to be linked to it. It classically presents with fever and four of the following: conjunctival injection, oral mucosal changes, cervical lymphadenopathy, changes in the extremities and polymorphous rash. Rarely, KD can present with hepatobiliary syndrome such as hepatic congestion, obstructive jaundice, acalculous cholecystitis and gallbladder hydrops. We present a case of a 12-year-old, otherwise healthy male who presented with an 8-day history of upper respiratory infection symptoms and fevers up to 102 F along with significant jaundice, dilated common bile duct and transaminitis initially thought to be ascending cholangitis. His clinical course evolved to also show rash, abdominal pain, vomiting, diarrhea, cervical lymphadenopathy and non-exudative, bilateral conjunctival injection with limbic sparing. Absence of improvement to antibiotic and distinct clinical evolution prompted the diagnosis of atypical KD. He received high dose IVIG and high dose aspirin with apparent clinical improvement. His surveillance echocardiography studies and subsequent physical exam findings have all been reassuring. This case underscores how KD can initially present as cholangitis and how it can manifest as a concomitant process during a viral infection.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging, especially when the papilla is poorly oriented relative to the endoscope. We report a case of traction-assisted ERCP using an S-O clip for difficult biliary cannulation in a patient with Billroth II reconstruction and tumor-associated distortion. A patient with a history of distal gastrectomy with Billroth II reconstruction for gastric cancer presented with obstructive jaundice caused by recurrent gastric cancer with biliary stricture. During double-balloon enteroscopy-assisted ERCP, marked papillary malorientation due to distortion of the afferent limb made standard biliary cannulation difficult. To improve papillary visualization, an S-O clip was placed on a mucosal fold on the oral side of the papilla, and the loop was anchored to the anal-side intestinal wall to create clip-to-wall traction. This maneuver improved frontal visualization of the papillary orifice and stabilized the biliary axis, allowing successful biliary cannulation with an MTW ERCP catheter and guidewire. Endoscopic sphincterotomy and plastic stent placement were then completed without adverse events. Although similar traction-assisted ERCP techniques have been reported, this case highlights the usefulness of the method in tumor-associated distortion, where traction did not dramatically reposition the papilla but provided sufficient frontal visualization for biliary cannulation. Traction-assisted ERCP may be a useful adjunctive technique in selected cases with altered anatomy and compromised papillary orientation.

IntroductionAdenomyomatous hyperplasia (AH) of the Vaterian system is a rare benign lesion, often clinically mistaken for carcinoma and leading to unnecessary Whipple surgery.MethodsIn this multicentre cohort, Whipple pancreaticoduodenectomy specimens were identified and operated on with a clinical diagnosis of ampullary tumor, which on histological examination, however, showed AH, collected over 3 years (2022-2024). In this retrospective observational study, we analyzed the clinico-radiological and histological details of 12 of such patients and described them here.ResultsIn these 12 patients with pancreaticoduodenectomy, the mean age was 51.7 years (range 29 to 63 years) with a male-to-female patient ratio of 9:3. Although abdominal pain was the most common presentation (11/12 patients); obstructive jaundice occurred in two. The preoperative imaging revealed common bile duct dilatation (11/12) and double duct sign (6/12), with the suspicion of carcinoma in all. Grossly, the lesions measured 0.4 to 4.3 cm (median 1.4 cm), six centered on the ampulla, others extending to the pancreatic head or the distal bile duct. Microscopy showed bland mucous glands, smooth muscle, and fibroblasts; immunohistochemistry confirmed keratin 7, MUC6, MUC5AC, and actin positivity. Ki-67 index was low. No recurrences occurred during 6-48 months follow-up.ConclusionsClinicoradiologically, ampullary AH mimics ampullary malignancy. However, AH should be considered in the clinicopathologic differential diagnosis of ampullary lesions.

Pancreatic acinar cell carcinoma (PACC) is a rare exocrine pancreatic malignancy accounting for approximately 1-2% of adult pancreatic neoplasms. Although historically grouped with pancreatic ductal adenocarcinoma (PDAC), accumulating evidence demonstrates that PACC represents a biologically distinct entity with unique clinical, pathologic, and molecular characteristics. Compared with PDAC, PACC more commonly presents as a large pancreatic mass, is less frequently associated with obstructive jaundice, and exhibits lower rates of KRAS mutations. Recent genomic studies have identified recurrent alterations involving DNA damage repair pathways, WNT/β-catenin signaling, and actionable kinase fusions, including BRAF and RAF1 rearrangements. In advanced disease, fluoropyrimidine- and platinum-based regimens appear to demonstrate greater activity than traditional gemcitabine-based approaches, although prospective comparative data are lacking. This review summarizes the current understanding of the epidemiology, clinical presentation, pathology, molecular landscape, treatment approaches, and prognostic factors associated with PACC. We highlight emerging opportunities for precision oncology and discuss ongoing challenges in the management of this uncommon pancreatic malignancy.