Revista Española de Enfermedades Digestivas

Endoscopic ultrasonography: an established technique with a brilliant future

Transesophageal access to the cardiac cavities and descending thoracic aorta via echoendoscopy: An experimental study

Objective: the applications of endoscopic ultrasonography have diversified over recent years. The possibility of reaching cardiac territory has been successfully explored in experimental models, opening up a new field of possibilities for diagnostic and therapeutic interventions that were unthinkable until very recently. The aims set out in this study are to evaluate cardiac anatomy, its approach, the safety of the experimental procedure and the resulting morphological and histological changes after the procedure. Material and methods: the study has been performed on two adult pigs. They have undergone different surgical approaches to the cardiac cavities and descending thoracic aorta with excellent results. Results: different cardiac structures have been identified and operated upon (right auricle, left auricle, left ventricle, cardiac valves), as well as major vessels. The use of contrast, both intracavitary and from a peripheral vein, enabled us to verify the anatomical spaces studied. During the procedures we monitored for arrhythmias, hemodynamic behavior, possibility of infection by obtaining sample hemocultures before and after procedures, and response to punctures. Conclusions: the present study has enabled us to evaluate access to the heart from the esophageal lumen using endoscopic ultrasonography, with results that are very similar to those described in the current bibliography. However, we offer two novelties: puncture of the right auricle through the interauricular partition and puncture of the descending thoracic aorta, both performed with ease and apparent safety.

Objetivo: las aplicaciones de la ultrasonografía endoscópica se han diversificado en los últimos tiempos. La posibilidad de acceder al territorio cardiaco se ha explorado en modelos experimentales con buenos resultados, abriendo un campo de nuevas posibilidades de intervencionismo diagnóstico y terapéutico hasta hace poco impensables. Los objetivos planteados en este trabajo pretenden evaluar la anatomía cardiaca, su abordaje, la seguridad del procedimiento experimental y los cambios morfológicos e histológicos derivados. Material y métodos: se ha trabajado con dos animales adultos de la especie porcina a los que se han practicado diversos abordajes a cavidades cardiacas y aorta torácica descendente con excelentes resultados. Resultados: se han identificado y abordado diversas estructuras cardiacas (aurícula derecha, aurícula izquierda, ventrículo izquierdo, válvulas cardiacas) y grandes vasos. El uso de contraste intracavitario y desde una vía venosa periférica ha permitido asegurar los espacios anatómicos estudiados. Durante los procedimientos se ha monitorizado la aparición de arritmias, el comportamiento hemodinámico, la posibilidad de infección mediante la obtención de hemocultivos antes y después de aquellos y la respuesta a las punciones. Conclusiones: el presente trabajo nos ha permitido evaluar el acceso al corazón desde la luz esofágica mediante ultrasonografía endoscópica, con unos resultados muy similares a los observados en la literatura, ofreciendo dos novedades como la punción de la aurícula derecha a través del tabique interauricular y de la aorta torácica descendente, de forma fácil y aparentemente segura.

Validity of tests performed to diagnose acute abdominal pain in patients admitted at an emergency department

Objective: to determine the real importance of anamnesis, physical examination, and various tests in the assessment of acute abdominal pain. Methods: a retrospective observational study with patients complaining of abdominal pain at the Emergency Department, Altiplano Health Area (Murcia) was performed. In our study we considered the following variables: socio-demographic data, history of previous surgery, symptoms, place and type of pain. Imaging tests were labeled as positive, negative, or inconclusive for assumed diagnoses, which were retrospectively assessed by an external radiologist who was unaware of the patient's final diagnosis. Results: our study includes 292 patients with a mean age of 45.49 years; 56.8% of these patients were women. Regarding the frequency of the different acute abdomen diagnoses, appendicitis was the main cause (approx. 25%), followed by cholecystitis (10%). We found a significant diagnostic correlation between pain location in the right hypochondrium (RHC) and a diagnosis with cholecystitis. This location was also significant for acute appendicitis (up to 74%). Regarding clinical signs, we only observed a significant correlation between fever and viscera perforation, and between Murphy's sign and cholecystitis. Sensitivity and specificity found in relation to the psoas sign were similar to those seen in other series, 16 and 95% respectively, and slightly lower than the Blumberg or rebound sign, which we found to be around 50 and 23%, respectively. Conclusions: a) anamnesis and physical examination offer limited accuracy when assessing acute abdomen; b) ultrasound scans offer a low diagnostic agreement index for appendicitis; and c) laparoscopy may prove useful for diagnosis, and is also a possible treatment for acute abdominal pain despite its low diagnostic efficiency.

Objetivo: determinar la importancia real que en sí tienen la anamnesis, la exploración física y las diferentes pruebas complementarias en la valoración del dolor abdominal agudo. Métodos: estudio observacional y retrospectivo en una población a estudio: Área V de Salud - Altiplano (Murcia). Enfermos que consultan por dolor abdominal en el Servicio de Urgencias. Se realiza una revisión de las historias clínicas. Variables a estudio: datos socio-demográficos, antecedentes personales de cirugía previa, síntomas asociados, localización del dolor y tipo del mismo. Las pruebas complementarias de imagen se etiquetaron como positivas, negativas y no concluyentes para el diagnóstico de presunción y fueron a posteriori reevaluadas por un radiólogo externo que desconocía el diagnóstico final del enfermo. Resultados: el número de pacientes estudiados fue de 292, cuya edad media estuvo en los 45,49 años. El 56,8% fueron mujeres. En cuanto a la frecuencia de los diferentes diagnósticos de abdomen agudo podemos hablar de la apendicitis como principal causa con un porcentaje cercano al 25%, seguido de la colecistitis con un 10%. Encontramos una concordancia diagnóstica significativa entre la localización del dolor en HCD y el diagnóstico de colecistitis. Esta localización también resulta significativa en el caso de la apendicitis aguda, en esta, hasta un 74%. En cuanto a los signos clínicos sólo hemos encontrado una correlación significativa entre la fiebre y la perforación de víscera hueca y entre el signo de Murphy y la colecistitis. La sensibilidad y especificidad encontradas con respecto al signo del psoas son muy similares a las encontradas en otras series entorno al 16 y 95% respectivamente; siendo algo menores con respecto al Blumberg o signo de rebote que se sitúa en nuestro estudio entorno al 50 y 23%. Conclusiones: a) la anamnesis y la exploración física tienen una exactitud limitada a la hora de valorar abdomen agudo; b) la ecografía presenta con respecto a la apendicitis un índice de concordancia diagnóstica bajo; y c) la laparoscopia puede resultar un instrumento útil para el diagnóstico y posible tratamiento del dolor abdominal agudo, aunque la eficiencia diagnóstica que determinaría su utilización sea baja.

Improvement of functional bloating by an enterovaccine: a preliminary study

Background: bloating is a fastidious symptom reported by many patients who also have other gastrointestinal functional disorders. Bloating is more common in women, and it is often associated with meals and improves or disappears overnight. No specific treatments are to date available for this disturbing symptom. Aims: to evaluate the effects of an oral enterovaccine (Colifagina®) on bloating and other abdominal symptoms in patients with prevalent complaints of functional bloating. Patients and methods: one hundred and forty-eight patients with functional bloating according to Rome III criteria were recruited. Questionnaires and a VAS scale on their symptoms were administered at baseline and after four weeks of therapy with Colifagina®. Results: after treatment, a significant amelioration of bloating (p < 0.0001), abdominal pain (p < 0.0001) and flatus (p < 0.0001) was observed; nausea and vomiting scores were not significantly different at the end of the treatment. Subjective wellbeing was also generally improved (p < 0.001) in treated patients. Conclusion: treatment with an enterovaccine may help improve symptoms in patients with functional bloating.

Laparoscopic surgery into mixed hiatal hernia: Results pre-operative and post-operative

Introduction: the complications of the mixed hernia need, often, surgical treatment. In the asymtomatic patients this one treatment is controversial, due to her complex repair and the high percentage of relapse informed in the long term. The surgical classic routes, they present raised morbi-mortality related to the extent of the incisions, to long hospitable stays and slow recovery. Material and methods: between October, 2001 to November, 2007 we check 39 patients with hernia hiatal mixed with a middle ages of 65 years (35-78 years). In Lloyd-Davies's position, the content diminishes hernia and the redundant sack is resected. The diaphragmatic props are sutured by material not reabsorbable. Mesh of reinforcement intervened in 7/39 repairs. It concludes with a partial or complete antirreflux depending on the report. Results: the operative average time was of 126 min; the hospital stay of 2.46 days. The complications perioperatives are principally cardiorespiratory. A patient died for an intestinal inadvertent perforation during the intervention and of late diagnosis. We realize traffic gastroduodenal to 12 months in 28 patients (71.7%). We find relapse in 8 patients (20.5%). Four asymtomatic patients, with chance find in the radiological control. Three patients with pirosis that needs treatment and one of the relapses needed reintervention for strangulation of a gastric volvulus. Conclusions: the laparoscopic surgery offers safety and efficiency with rapid postoperatory recovery, minor morbidity and hospitable stay. After the surgery, the long-term relapse presents similar results to the opened surgery, though the interposition of mesh can propitiate her decrease.

Introducción: las complicaciones de la hernia mixta requieren, con frecuencia, tratamiento quirúrgico. En los pacientes asintomáticos este tratamiento es controvertido, debido a su compleja reparación y al elevado porcentaje de recidivas informado a largo plazo. Las vías quirúrgicas clásicas presentan elevada morbimortalidad relacionada con la amplitud de las incisiones, con largas estancias hospitalarias y lenta recuperación. Material y métodos: entre octubre de 2001 a noviembre de 2007 revisamos 39 pacientes con hernia hiatal mixta con una edad media de 65 años (35-78 años). En posición de Lloyd-Davies, se reduce el contenido herniario y se reseca el saco redundante. Se suturan los pilares diafragmáticos con material no reabsorbible. Se interpuso malla de refuerzo en 7/39 reparaciones. Se finaliza con un antirreflujo parcial o completo dependiendo del informe manométrico. Resultados: el tiempo operatorio medio fue de 126 min. La estancia hospitalaria de 2,46 días. Las complicaciones perioperatorias son principalmente cardiorrespiratorias. Un paciente falleció por una perforación intestinal inadvertida durante la intervención y de diagnóstico tardío. Realizamos tránsito gastroduodenal a los 12 meses en 28 pacientes (71,7%). Encontramos recidiva en 8 pacientes (20,5%). Cuatro pacientes asintomáticos, con hallazgo casual en el control radiológico. Tres pacientes con pirosis que requiere tratamiento y una de las recidivas precisó reintervención por estrangulación de un vólvulo gástrico. Conclusiones: la laparoscopia ofrece seguridad y eficacia con rápida recuperación postoperatoria, menor morbilidad y estancia hospitalaria. Tras la cirugía, la recidiva a largo plazo presenta similares resultados a la cirugía abierta, aunque la interposición de malla puede propiciar su disminución.

Endoscopic ultrasound in the diagnosis and staging of pancreatic cancer

Pancreatic cancer is the 5th leading cause of cancer-related death in Western countries. The 5-year survival rate is approximately 4%, without significant changes over the last 50 years. This poor survival rate and bad prognosis are associated with the diagnosis of advanced-stage disease, which precludes the only potential curative treatment - surgical resection. In this setting, the main objective in the management of pancreatic cancer is to perform an early diagnosis and a correct staging of the disease. Endoscopic ultrasonography (EUS) appears to be an essential tool for the diagnosis and staging of pancreatic cancer. EUS diagnostic accuracy for detecting pancreatic tumors ranges from 85 to 100%, clearly superior to other imaging techniques. EUS accuracy for the local staging of pancreatic cancer ranges from 70 to 90%, superior or equivalent to other imaging modalities. EUS-guided fine-needle aspiration allows a cyto-histological diagnosis in nearly 90% of cases, with a very low complication rate. At present, the formal indications for EUS-guided fine-needle aspiration are the necessity of palliative treatment or whenever the possibility of neoadjuvant treatment is present. It could be also indicated to differentiate pancreatic adenocarcinoma from other pancreatic conditions, like lymphoma, metastasis, autoimmune pancreatitis or chronic pancreatitis. We can conclude that EUS is an essential tool in the management of patients with pancreatic tumors.

Small bowel perforation by an unusual foreign body

Spontaneous aneurysmal portohepatic fistula

Bilateral pulmonary thromboembolism and Budd-Chiari syndrome in a patient with Crohn's disease on oral contraceptives

Budd-Chiari syndrome can be defined as an interruption or diminution of the normal blood flow out of the liver. Patients with Budd-Chiari syndrome present with varying degrees of symptomatology that can be divided into the following categories: fulminant, acute, subacute and chronic. The subacute form is the most common presentation. A majority of patients with Budd-Chiari syndrome have an underlying hypercoagulability state. We present the case of a young woman with Crohn's disease on oral contraceptives who developed bilateral pulmonary thromboembolism and Budd-Chiari syndrome.

El síndrome de Budd-Chiari consiste en la interrupción o disminución de flujo de las venas suprahepáticas. Tiene una gran variabilidad clínica en cuanto a su forma de presentación siendo la más frecuente la forma subaguda. La gran mayoría de los pacientes responden a estados de hipercoagulabilidad. Presentamos el caso de una paciente joven con enfermedad de Crohn que estaba en tratamiento con anticonceptivos orales y desarrolló un cuadro clínico de tromboembolismo de pulmón bilateral y síndrome de Budd-Chiari.

Spontaneus bacterial peritonitis

Dieulafoy's lesion in Treitz's angle

Retroperitoneal bronchogenic cyst in a patient with Crohn's disease

Recurrent intestinal hemorrhage caused by duodenal neurofibroma

Mixed cryoglobulinemia associated with hepatitis C virus: Diagnosis by transjugular renal biopsy

Chronic pancreatitis over pancreas divisum heat-resistant to medical and endoscopic treatment

Acute mesenteric ischemia: importance of an early diagnosis