VIDEO PLENARY 1: VID-LUM-03: Endosonographic yin yang sign for identifying aneurysm in wall-off necrosis

A 56-year-old gentleman presented with complaints of hematemesis and melena. He had no postural symptoms. He had a history of acute pancreatitis, for which he was admitted in our unit 2 months ago. He underwent an upper gastrointestinal (GI) scopy which showed patchy elevated and erythematous duodenal mucosa in the first part. No blood was noted within the stomach. A computed tomographic angiogram was done with the clinical suspicion of pseudoaneurysm, this showed walled-off pancreatic necrosis (WOPN) around the head of pancreas and the gastroduodenal artery coursing close to WOPN. No obvious aneurysmal dilatation was noted. While in hospital, he had another large bout of hematemesis after a week (approximately 500 ml), at which a repeat upper GI scopy was done which showed a small opening in the first part of duodenum discharging purulent material. An endoscopic ultrasound (EUS) was done for assessment of the vessels. EUS showed a vessel (gastroduodenal artery) within WOPN with an aneurysmal dilatation. Turbulent flow noted within the aneurysm (Yin Yang sign was seen). The patient subsequently underwent a digital subtraction angiography which revealed aneurysm in the gastroduodenal artery, for which coil embolization was done. The case highlights the utility of EUS in identifying vascular abnormalities.