Revista Española de Enfermedades Digestivas

Pancreas neuroendocrine tumors: not so rare or benign

A single institution's 21-year experience with surgically resected pancreatic neuroendocrine tumors: an analysis of survival and prognostic factors

Background: Pancreatic neuroendocrine tumors (pNETs) comprise a heterogeneous group of tumors with a varied biological behavior. In the present study, we analyzed the experience of 79 pNETs resected between 1993 and 2015. The pathologic prognostic factors (European Neuroendocrine Tumor Society, ENETS; and AJCC) classification, vascular invasion (VI), proliferation index (ki-67) and the presence of necrosis were retrospectively reviewed. Methods: The clinical data of 79 patients with pNETs who underwent surgery were retrospectively analyzed. Mortality rates and Kaplan-Meier estimates were used to evaluate survival over time for pathologic stages, tumor functionality, and vascular invasion. Cox proportional hazards models were used to calculate the hazard ratio regarding ENETS, AJCC staging, sex, tumor functionality and vascular invasion. Results: The male:female ratio was 40:39. Twenty-one patients (26%) had functional tumors and 58 (73.4%) had non-functional tumors, of which 35 (44.3%) were diagnosed incidentally. Seventeen Whipple procedures, 46 distal pancreatectomies (including 26 laparoscopic and 20 open procedures), 8 laparoscopic central pancreatectomies, 1 laparoscopic resection of the uncinated process and 7 enucleations (one laparoscopic) were performed. Vascular invasion and necrosis were observed in 29 of 75 cases (38.6%) and in 16 cases (29%), respectively. The comparison between survivor functions of ENETS staging categories showed statistically significant differences (p = 0.042). Mortality rate was higher in patients with non-functioning tumors compared with hormonally functioning tumors (p = 0.052) and in those with vascular invasion (p = 0.186). Conclusions: In spite of the heterogeneity of pNETs, the ENETS TNM classification efficiently predicts long-term prognosis. The non-functioning tumors and the presence of vascular invasion are associated with poor prognosis.

The use of a segmental endoscopic score may improve the prediction of clinical outcomes in acute severe ulcerative colitis

Background: Acute severe colitis (ASC) remains a challenging complication of ulcerative colitis. The early identification of patients who will not respond to optimal therapy is warranted. Increasing evidence suggests that endoscopy may play a role in predicting important outcomes in acute severe colitis. Methods: The endoscopic activity of consecutive patients with acute severe colitis was evaluated using the Mayo endoscopic sub-score (Mayo) and the ulcerative colitis endoscopic index of severity (UCEIS). Two segmental indexes were also produced by summing the scores of the rectum and sigmoid (seg-Mayo and seg-UCEIS, respectively). Endpoints included the need for salvage therapy with infliximab or cyclosporine, refractoriness to corticosteroids, and colectomy. Results: Of one hundred and eight patients enrolled in the study, 60 (55.6%) were male; with a median age of 34.5 years (range 15-80). All patients received intravenous steroids. Fifty-nine patients (55.6%) showed an incomplete or absent response to steroids, 35 patients (34.3%) received salvage therapy with infliximab or cyclosporine and 38 patients (33.3%) were colectomized during the index hospitalization or within the first year of follow-up. All scores were able to predict the need for surgery, but only the seg-UCEIS significantly predicted refractoriness to steroids. Conclusions: There was a strong correlation between endoscopic severity and unfavorable outcomes. The UCEIS outperformed the Mayo endoscopic sub-score in all important outcomes. Segmental scoring further improved the performance of the UCEIS.

Antiplatelet agents and/or anticoagulants are not associated with worse outcome following nonvariceal upper gastrointestinal bleeding

Background: Nonvariceal upper gastrointestinal bleeding emerges as a major complication of using antiplatelet agents and/or anticoagulants and represents a clinical challenge in patients undergoing these therapies. Aim: To characterize patients with nonvariceal upper gastrointestinal bleeding related to antithrombotics and their management, and to determine clinical predictors of adverse outcomes. Methods: Retrospective cohort of adults who underwent upper gastrointestinal endoscopy after nonvariceal upper gastrointestinal bleeding from 2010 to 2012. The outcomes were compared between patients exposed and not exposed to antithrombotics. Results: Five hundred and forty-eight patients with nonvariceal upper gastrointestinal bleeding (67% men; mean age 66.5 ± 16.4 years) were included, of which 43% received antithrombotics. Most patients had comorbidities. Peptic ulcer was the main diagnosis and endoscopic therapy was performed in 46% of cases. The 30-day mortality rate was 7.7% (n = 42), and 36% were bleeding-related. The recurrence rate was 9% and 14% of patients with initial endoscopic treatment needed endoscopic retreatment. There were no significant differences between the exposed and non-exposed groups in most outcomes. Co-morbidities, hemodynamic instability, high Rockall score, low hemoglobin (7.76 ± 2.72 g/dL) and higher international normalized ratio (1.63 ± 1.13) were associated significantly with mortality in a univariate analysis. Conclusions: Adverse outcomes were not associated with antithrombotic use. The management of nonvariceal upper gastrointestinal bleeding constitutes a challenge to clinical performance optimization and clinical cooperation.

Validation of the computed assessment of cleansing score with the Mirocam^® system

Background and aims: A computed assessment of cleansing (CAC) score was developed to objectively evaluate small-bowel cleansing in the PillCam capsule endoscopy (CE) system and to overcome the subjectivity and complexity of previous scoring systems. Our study aimed to adapt the CAC score to the Mirocam® system, evaluate its reliability with the Mirocam® CE system and compare it with three validated subjective grading scales. Patients and methods: Thirty CE were prospectively and independently reviewed by two authors who classified the degree of small-bowel cleanliness according to a quantitative index, a qualitative evaluation and an overall adequacy assessment. The authors were blinded for the CAC score of each CE, which was calculated as ([mean intensity of the red channel]/[mean intensity of the green channel] - 1) x 10. The mean intensities of the red and green channels of the small-bowel segment of the "Map View" bar in the Miroview Client® were determined using the histogram option of two photo-editing software. Results: There was a strong agreement between both CE readers for each of the three subjective scales used. The reproducibility of the CAC score was excellent and identical results were obtained with the two photo-editing software. Regarding the comparison between the CAC score and the subjective scales, there was a moderate-to-good agreement with the quantitative index, qualitative evaluation and overall adequacy assessment. Conclusions: CAC score represents an objective and feasible score in the assessment of small-bowel cleansing in the Mirocam® CE system, and could be used per se or as part of a more comprehensive score.

Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation

Introduction: The prevalence of portal vein thrombosis (PVT) in patients that have undergone liver transplantation (LT) is 9.7% (SD 4.5). The aim of our study was to determine the prevalence, assess the factors that are associated with PVT and clarify their association with prognosis in patients with liver cirrhosis (LC) and LT. Aims and methods: From 2005 to 2014, laboratory, radiological and surgical data were collected from patients with LC in our center who had undergone LT for the first time. Results: One hundred and ninety-one patients were included. The mean age was 55 (SD 9), 75.4% of patients were male and 48.7% had HCV. The Child-Pugh scores were A/B/C 41.9%/35.9%/25.5% and the MELD score was 15 (SD 6). Previous decompensations were: ascites (61.4%), hepatic encephalopathy (34.4%), variceal bleeding (25.4%), hepatocellular carcinoma (48.9%) and spontaneous bacterial peritonitis (SPB) (14.3%). The mean post-transplant follow-up was 42 months (0-113). PVT was diagnosed at LT in 18 patients (9.4%). Six patients were previously diagnosed using imaging tests (33.3%): 2 patients (11.1%) by DU and 4 patients (22.2%) by CT scan. All patients with PVT had DU in a mean time of 6 months before LT (0-44) and 90 patients (47.1%) had a CT scan in a median time of 6 months before LT (0-45). PVT was significantly related to the presence of SBP (33.3% vs 12.6%; p = 0.02) and lower levels of albumin (3.1g/dl vs 3.4g/dl; p = 0.05). MELD was higher in patients with PVT (16.6 vs 14.9; p = 0.3). There were no significant differences with regard to the need for transfusion of blood components. Moreover, the surgery time was similar in both groups. PVT correlated with a higher mortality in the first 30 days (8.8% vs 16.7%; p = 0.2). Conclusion: Prior history of SBP and lower levels of albumin were identified as factors associated with PVT. The pre-transplant diagnosis rate is very low and the presence of PVT may have implications for short-term mortality.

Mechanisms responsible for neuromuscular relaxation in the gastrointestinal tract

The enteric nervous system (ENS) is responsible for the genesis of motor patterns ensuring an appropriate intestinal transit. Enteric motor neurons are classified into afferent neurons, interneurons and motorneurons. Motorneurons are excitatory or inhibitory causing smooth muscle contraction and relaxation respectively. Muscle relaxation mechanisms are key for the understanding of physiological processes such as sphincter relaxation, gastric accommodation, or the descending phase of the peristaltic reflex. Nitric oxide (NO) and ATP or a related purine are the primary inhibitory neurotransmitters. Nitrergic neurons synthesize NO through nNOS enzyme activity. NO diffuses across the cell membrane to bind guanylyl cyclase, and then activates a number of intracellular mechanisms that ultimately result in muscle relaxation. ATP is an inhibitory neurotransmitter together with NO. The P2Y1 receptor has been identified as a the purine receptor responsible for smooth muscle relaxation. Although, probably, no clinician doubts about the significance of NO in the pathophysiology of gastrointestinal motility, the relevance of purinergic neurotransmission is apparently much lower, as ATP has not been associated with any specific motor dysfunction yet. The goal of this review is to discuss the function of both relaxation mechanisms in order to establish the physiological grounds of potential motor dysfunctions arising from impaired intestinal relaxation.

El sistema nervioso entérico (SNE) es responsable de la génesis de los patrones motores que aseguran un correcto tránsito intestinal. Las neuronas entéricas se clasifican en aferentes, interneuronas y motoneuronas, que pueden a su vez ser excitatorias, causando contracción, o inhibitorias, provocando la relajación de la musculatura lisa. Los mecanismos de relajación muscular son claves para entender procesos fisiológicos como la relajación de los esfínteres, la acomodación gástrica o la fase descendente del reflejo peristáltico. El óxido nítrico (NO) y el ATP o una purina relacionada son los principales neurotransmisores inhibitorios. Las neuronas nitrérgicas sintetizan NO a partir del enzima nNOS. El NO difunde a través de la membrana celular uniéndose a su receptor, la guanilil ciclasa, y activando posteriormente una serie de mecanismos intracelulares que provocan finalmente una relajación muscular. El ATP actúa como neurotransmisor inhibitorio junto con el NO y el receptor de membrana purinérgico P2Y1 ha sido identificado como elemento clave para entender cómo el ATP relaja la musculatura intestinal. Aunque probablemente ningún clínico duda de la importancia del NO en la fisiopatología motora digestiva, la relevancia de la neurotransmisión purinérgica es aparentemente mucho menor puesto que el ATP no ha sido todavía asociado a una disfunción motora concreta. El objetivo de esta revisión es mostrar el funcionamiento de ambos mecanismos de relajación para poder establecer las bases fisiológicas de posibles disfunciones motoras asociadas a la alteración de la relajación intestinal.

Sprue-like enteropathy associated with olmesartan in a patient with villous atrophy, HLA-DQ2 genotype and antinuclear antibodies

Ulcerated submucosal gastric tumor: could it be a benign condition?

Endoscopic management of late complication of blunt traumatic total pancreatic transection

Visceral leishmaniasis with mediastinal lymphadenopathy diagnosed by endoscopic ultrasound-guided fine needle aspiration

Porcelain gallbladder

Duodenal stump recurrence of gastric adenocarcinoma after subtotal gastrectomy

Perivascular epithelioid cell tumor of the ileum: a case report

Perivascular epithelioid cell tumors (PEComa) are tumors of perivascular epithelioid cells with immunohistochemical features of smooth muscle and melanocytic tumors. The PEComa of the gastrointestinal tract is rare. The treatment is surgical, although there are data that suggest a good response to rapamycin.

Los tumores de células epiteliodes perivasculares son tumores de células epiteliales vasculares con características inmunohistoquímicas de músculo liso y células melanocíticas. Los gastrointestinales son infrecuentes. El tratamiento es quirúrgico aunque existen datos que indican buena respuesta a la rapamicina.

Hirschsprung disease with debut in adult age as acute intestinal obstruction: case report

Hirschsprung's disease is characterized by absence of ganglion cells in submucosal and myenteric plexus of distal bowel. Most cases become manifest during the neonatal period, but in rare instances, this disease is initially diagnosed in adult age. It usually presents as severe constipation with colonic dilatation proximal to the aganglionic segment. The treatment is surgical, removing the aganglionic segment and restoring continuity of digestive tract. The disease rarely presents as an acute intestinal obstruction. We report a case not previously diagnosed, which presented as a massive colonic dilatation with a maximum diameter of 44 cm, with imminent risk of drilling that forced to perform an emergency surgery. We include a review of existing literature.

La enfermedad de Hirschsprung consiste en la ausencia de células ganglionares en los plexos submucosos y mientérico del intestino. Suele diagnosticarse en el periodo neonatal, siendo muy poco frecuente que se descubra en el adulto. Suele presentarse como estreñimiento severo con dilatación cólica proximal al segmento agangliónico. El tratamiento es quirúrgico, extirpando el segmento agangliónico y restableciendo la continuidad del tubo digestivo. En muy raras ocasiones, esta enfermedad se presenta como un cuadro de obstrucción intestinal aguda. Presentamos el caso de un paciente, no diagnosticado previamente, que debutó como un cuadro de dilatación cólica masiva, con un diámetro máximo de 44 cm, con riesgo de perforación inminente, lo que motivó la realización de una cirugía urgente. Incluimos una revisión de la literatura existente al respecto.

Endoscopic management of a gastric leak after laparoscopic sleeve gastrectomy using the over-the-scope-clip (Ovesco^®) system

Laparoscopic sleeve gastrectomy is currently used for the management of morbid obesity. Gastric fistula is the primary life-threatening complication, and its resolution continues to be a strong challenge for surgeons. Multiple treatment options are available, ranging from conservative therapy to endoscopic use of clips or stents, and even surgical reoperation involving total gastrectomy or conversion to a different bariatric technique. The applicability of each individual option will depend on the type of fistula and the patient clinical status. A clinical case is reported of a 29-year-old male patient with a body mass index at 49% who following laparoscopic sleeve gastrectomy had a delayed gastric fistula that failed to respond to conservative management but was successfully treated using the over-the-scope clip (Ovesco®) system.

La gastrectomía tubular laparoscópica se realiza hoy en día como procedimiento para el tratamiento de la obesidad. La fístula gástrica es la principal complicación que puede comprometer la vida del paciente y cuya resolución es un gran reto para el cirujano. Existen múltiples opciones de tratamiento que van desde un tratamiento conservador hasta medidas endoscópicas con clips o prótesis e incluso reintervenciones quirúrgicas que implican una gastrectomía total o la conversión a otra técnica bariátrica. La aplicabilidad de cada una de ellas va a depender del tipo de fístula y del estado general del paciente. Se presenta un caso clínico de un paciente varón de 29 años de edad con índice de masa corporal de 49% que tras una gastrectomía vertical laparoscópica presenta una fístula gástrica tardía que fracasó al manejo conservador y cuya resolución se consiguió mediante el sistema "over-the-scope clip" (Ovesco®).

Intussusception as clinical presentation of primary non-Hodgkin lymphoma of the colon in a HIV-patient

Intestinal intussusception rarely occurs in the adult population and accounts only for 1% to 5% of all the causes of intestinal obstruction. This complication is more frequent in the small bowel and can be due to different aetiologies, including inflammatory, infectious or neoplastic diseases. Malignancies account for 50% to 60% of all cases of colon invagination. The gastrointestinal (GI) tract is the most common site for extra-nodal non-Hodgkin lymphomas (NHL), representing 5% to 20% of all the cases. However, primary NHL of the GI tract is a very infrequent clinic-pathological entity and accounts only for 1% to 4% of all the neoplasms of the GI tract. Primary NHL of the colon is a rare disease and it comprises only 0.2% to 1.2% of all colonic malignancies. Here we describe a case of an AIDS adult patient who developed an intussusception secondary to a primary large B cell lymphoma of the transverse colon. English and Spanish literature was reviewed.

La invaginación (intususcepción) intestinal es una complicación poco frecuente en la población adulta, representando sólo del 1% al 5% de todas las causas de obstrucción intestinal. Es más frecuente en el intestino delgado, donde puede responder a causas inflamatorias, infecciosas o neoplásicas, y rara en el colon, en donde en el 50%-60% de los casos se origina en neoplasias subyacentes. El aparato digestivo es el sitio más común de localización de los linfoma no Hodgkin (LNH) extranodales, incluyendo del 5% al 20% del total de los mismos. Sin embargo, los LNH primarios del tracto gastrointestinal son entidades clínico-patológicas muy raras y representan sólo del 1% al 4% de todas las neoplasias del tubo digestivo. Los LNH primarios de colon son tumores muy infrecuentes y representan del 0,2% al 1,2% del total de las neoplasias colónicas. Se describe el caso de un paciente adulto con sida, que desarrolló una invaginación colónica secundaria a un linfoma difuso de grandes células B primario del colon transverso. Se revisan los hallazgos clínicos, imagenológicos e histopatológicos y se realiza una revisión de la literatura inglesa y española sobre este tema.

Mesalamine-induced myopericarditis: a case report

Myopericarditis has occasionally been reported as a side effect of mesalamine in patients with inflammatory bowel disease. We present a 20-year-old woman with ulcerative colitis admitted with chest pain. After thorough investigation she was diagnosed with myopericarditis potentially related to mesalamine. There was complete clinical and laboratorial recovery following drug withdrawal. Although uncommon, the possibility of myopericarditis should be considered in patients with inflammatory bowel disease presenting with cardiac complaints. Early recognition can avoid potential life-threatening complications.

Severe halitosis as presentation of epiphrenic diverticulum

Halitosis is a common condition, whose main etiology does not respond to diseases of the gastrointestinal system. Epiphrenic diverticula are a rare cause of this manifestation, thus they are not frequent and they are usually asymptomatic. However, they may produce symptoms with inability for patient. A patient with severe halitosis is presented. In his study, an epiphrenic diverticulum is diagnosed and the laparoscopic abdominal diverticulectomy is performed with a complete resolution of symptomatology.

La halitosis es una condición común cuya principal etiología no responde a enfermedades del sistema gastrointestinal. Los divertículos epifrénicos son una causa rara de esta manifestación, de hecho estos son poco frecuentes y suelen ser asintomáticos. Sin embargo, pueden llegar a producir síntomas con incapacidad para el paciente. Se presenta un paciente con halitosis severa, en cuyo estudio se diagnostica un divertículo epifrénico, al cual se le realizó diverticulectomía por vía laparascópica abdominal con completa resolutividad de la sintomatología.

In response to the editorial "Sedation in endoscopy in 2016: is it safe sedation with propofol led by the endoscopist in complex situations?

Author's reply to the letter: In response to the editorial "Sedation in endoscopy in 2016: is it safe sedation with propofol led by the endoscopist in complex situations?

Rupture of esophagus by compressed air