Spontaneous duodenal wall hematoma

59-year-old man, smoker, diabetic and hypertensive. He went to the ER due to fixed abdominal pain in the epigastrium, diaphoresis, dizziness, nausea, and "coffee grounds" vomiting. On examination he presented abdominal distension and pain on palpation in the epigastrium, without peritonism. He had a BP of 235/100 mmHg and in the blood-tests, leukocytosis with neutrophilia and normal hemoglobin. An urgent abdominal CT scan was performed, identifying a 5x6 cm nodular lesion of homogeneous density attached to the wall of the second and third duodenal portions that compressed the lumen, with two vessels with active bleeding within it. Therefore, percutaneous embolization of the gastroduodenal artery was performed. Subsequently, the patient suffered an episode of severe acute pancreatitis that required ICU admission. Finally, he presented a good clinical evolution with ceasing of pain, complete reabsorption of the hematoma and resolution of the obstructive symptoms. (AU)

Atresia duodenal con apple peel asociada a herniadiafragmática congénita: un caso excepcional yrevisión de la literatura / Duodenal atresia with apple peel associated with congenital diaphragmatic hernia: an exceptional case and a literature review

Introducción: La atresia duodenal asociada con appel peel es extremadamente infrecuente. La primera se produce por un defecto en larecanalización en etapas tempranas, mientras que la atresia intestinalparece deberse a causas vasculares en etapas más tardías. La presenciade anomalías asociadas a la hernia diafragmática es común, pero laasociación con la atresia duodenal apenas está descrita.Caso clínico: Presentamos un recién nacido de 31 semanas de gestación y sexo femenino, con atresia duodenal y apple peel, asociada ahernia diafragmática izquierda y cardiopatía mayor. Se realizó un flapmuscular abdominal para el cierre del defecto diafragmático y anastomosis duodenoyeyunal tras la resección de parte del apple peel inviable.Comentarios: A nuestro entender, es el primer caso descrito conesta asociación singular. La combinación de atresia duodenal con apple peel se ha descrito previamente en 11 ocasiones; la asociación de ambascon hernia diafragmática congénita no había sido descrita.

Introduction: Duodenal atresia associated with apple peel is extremely rare. Duodenal atresia occurs as a result of absence of recanali-zation at an early stage, whereas intestinal atresia is seemingly due tovascular causes at later stages. The presence of abnormalities associatedwith diaphragmatic hernia is frequent, but association with duodenalatresia has been little explored.Care report: This is the case of a female neonate born at gestational week 31, with duodenal atresia and apple peel, associated withleft diaphragmatic hernia and major heart disease. An abdominal muscle flap was performed for diaphragmatic defect closure purposes, and duodenojejunal anastomosis was carried out following resection of partof the non-viable apple peel.Discussion: To our knowledge, this is the first case described with this rare association. The combination of duodenal atresia and applepeel had been previously described 11 times. However, the associationof both with congenital diaphragmatic hernia had not been reported yet.

Waugh's syndrome: a rare cause of bowel obstruction in adults

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Endoscopic stenting for gastroduodenal outlet obstruction of a malignant origin, real life experience in a single center

AIM: to evaluate the safety and effectiveness of self-expandable metal stent placement for malignant gastric outlet obstruction (GOO). METHODS: a retrospective, analytic cohort study at a single, tertiary-care center. RESULTS: thirty-six patients that underwent stent placement for GOO of malignant origin were identified during the study period. Technical success was achieved in 36 (100 %) patients and clinical success was achieved in 31 patients (86.1 %). Before the procedure, 17 (54.8 %) patients had a gastric outlet obstruction score (GOOSS) of 0, which is a complete inability of oral intake. Twenty-three patients were alive 30 days after the procedure, two (8.6 %) patients had a GOOSS of 1, ten (43.3 %) had a GOOSS of 2 and eleven (47.9 %) had a GOOSS of 3. Abdominal pain was present in all 31 patients before the procedure and only seven (22.6 %) patients continued with abdominal pain 24 hours after the procedure. During follow-up, ten (30.3 %) patients developed complications related to the stents and none of them was fatal. Additional therapy due to partial occlusion of the stent was necessary in three patients. The stents functional duration had a median of 72 days (IQR 25-75 15-105 days) and was closely related to overall survival. CONCLUSION: palliative stenting for gastroduodenal obstruction is a safe, feasible and effective therapy to treat patients with malignant gastric outlet obstruction

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Oclusión de asa biliopancreática por intususcepción yeyunal en paciente con bypass gástrico previo / Biliopancreatic limb obstruction due to jejuno-jejunal intussusception in a patient with previous Roux-en-Y gastric bypass

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Infiltraciones calcificadas difusas de la vía biliar intrahepática: metástasis de adenocarcinoma mucinoso / Diffuse calcificated infiltrations of the intrahepatic bile duct: Metastasis of mucinous adenocarcinoma

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Obstrucción digestiva alta secundaria a prolapso transpilórico de angiolipoma gástrico / Upper gastrointestinal tract obstruction secondary to transpyloric prolapse of a gastric angiolipoma

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Obstrucción duodenal por hematoma intramural como complicación de la biopsia endoscópica / Duodenal obstruction due to intramural haematoma as a complication of endoscopic biopsy

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A novel rescue maneuver for a distal dislodged lumen-apposing metal stent (LAMS): "LAMS-in-LAMS" technique

Introduction: the appearance of the lumen-apposing metal stent (LAMS) has meant an authentic revolution. To date, the results are promising but it is necessary to note the technical incidents and LAMS-related complications. Case report: an EUS-transmural guided drainage using a HotAXIOS was planned for a 36-year-old man with oral intolerance due to a voluminous walled-off necrosis. The distal flange was left in the collection, but a total distal malposition occurred during the proximal flange delivery, despite correct apposition with visualization of the black mark. A rescue technique was performed inserting a second LAMS over-the-guidewire salvaging the initial failed transmural drainage. Discussion: This case is a reminder that in similar scenarios, extreme tension of the echoendoscope can cause a malfunction of the AXIOS stent delivery system, and lead to a total distal malposition. This "LAMS-in-LAMS" technique is feasible, effective, and a very helpful rescue technique in cases of dislodged LAMS

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Obstrucción duodenal congénita en un preescolar / Congenital duodenal obstruction in an infant

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Supportive care in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is one of the cancers with poorest prognosis and represents the third leading cause of cancer-related deaths in Western countries. Despite advances in diagnostic procedures and treatment, diagnosis is made in most cases when the disease is locally advanced or metastatic. Supportive care aims to improve symptoms, reduce hospital admission rates, and preserve quality of life. Proper symptomatic management is critical to allow administration of chemotherapy and radiotherapy. Symptomatic management should be accomplished in a multidisciplinary fashion. Its primary aims include relief of biliary or duodenal obstruction, prevention and/or treatment of thromboembolic disease, and control cancer-related pain. Nutritional support and optimal replacement therapy in patients with endocrine and/or exocrine insufficiency, is mandatory. This manuscript highlights the most significant problems faced when caring for patients with advanced PDAC and provides an evidence-based approach to symptomatic management (AU)

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Síndrome de la arteria mesentérica superior. Presentación de un caso y revisión de la literatura / Superior mesenteric artery syndrome. A case report and review of the literature

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Primer caso publicado de síndrome de Bouveret asociado a perforación duodenal y vesicular al retroperitoneo / First case reported of Bouveret´s syndrome associated to duodenal and biliary perforation to retroperitoneum

Presentamos el caso de una mujer de 69 años con diagnóstico de colelitiasis, que acudió a urgencias por cuadro de dolor abdominal intenso, náuseas y vómitos. Un TAC abdominal mostró obstrucción duodenal causada por cálculo biliar de 4 cm, fístula colecistoduodenal y neumobilia, lo que en conjunto se conoce como síndrome de Bouveret, una forma rara de íleo biliar. Adicionalmente presentaba perforación duodenal y vesicular libre a retroperitoneo en el mismo punto de tránsito colecistoduodenal. La paciente fue intervenida quirúrgicamente, realizando colecistectomía dificultosa, enterolitotomía, reparación del defecto duodenal, lavado exhaustivo y drenaje del retroperitoneo. El postoperatorio transcurrió sin complicaciones salvo infección de la herida quirúrgica (AU)

We present the case of a 69 year old woman with a history of cholecystitis, who consulted for severe abdominal pain, nausea and vomiting. Abdominal CT showed duodenal obstruction caused by a gallstone, cholecystoduodenal fistula and pneumobilia, what is known as Bouveret's syndrome, a rare form of gallstone ileus. Additionally, she presented free duodenal and vesicular perforation to retroperitoneum at the same level of the cholecystoduodenal transit point. The patient underwent a difficult cholecystectomy, enterolithotomy, repair of the duodenal defect, extensive washing and drainage of the retroperitoneum. The postoperative course was uneventful except for a laparotomy infection (AU)

Síndrome de Bouveret / Bouveret Syndrome

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Recomendaciones para el diagnóstico, la estadificación y el tratamiento de las lesiones premalignas y el adenocarcinoma de páncreas / Recommendations for the diagnosis, staging and treatment of pre-malignant lesions and pancreatic adenocarcinoma

Antecedentes y objetivo. El tratamiento del adenocarcinoma de páncreas es complejo y requiere un enfoque multidisciplinar, al igual que sucede con las lesiones premalignas, cuyo diagnóstico es cada vez más frecuente. Este documento constituye una puesta al día sobre el diagnóstico y el tratamiento de las lesiones premalignas y del adenocarcinoma de páncreas. Pacientes y método. Para ello, el Grupo Español Multidisciplinar en Cáncer Digestivo organizó una conferencia en Barcelona durante la cual un panel formado por expertos en esta enfermedad, procedentes de diversas especialidades (Gastroenterología, Cirugía, Radiología, Anatomía Patológica, Oncología Médica y Oncología Radioterápica), estableció las bases para la revisión y la elaboración del manuscrito. Resultados. Se ha revisado la literatura, discutido y, finalmente, deliberado sobre las evidencias. Conclusiones. Con todo ello, se han establecido unas recomendaciones (AU)

Background and objective. Clinical management of adenocarcinoma of the pancreas is complex, and requires a multidisciplinary approach. The same applies for the premalignant lesions that are increasingly being diagnosed. The current document is an update on the diagnosis and management of premalignant lesions and adenocarcinoma of the pancreas. Patients and methods. A conference to establish the basis of the literature review and manuscript redaction was organized by the Grupo Español Multidisciplinar en Cáncer Digestivo. Experts in the field from different specialties (Gastroenterology, Surgery, Radiology, Pathology, Medical Oncology and Radiation Oncology) met to prepare the present document. Results. The current literature was reviewed and discussed, with subsequent deliberation on the evidence. Conclusions. Final recommendations were established in view of all the above (AU)

Malrotación-vólvulo intestinal: hallazgos radiológicos / Intestinal malrotation - volvulus: imaging findings

El radiólogo debe ser capaz de reconocer los signos de la malrotación intestinal en la imagen al tratarse de una entidad patológica con complicaciones potencialmente letales, como el vólvulo de intestino medio. Para diagnosticarla correctamente, es tan importante que exista un índice de sospecha clínica elevado como que el radiólogo sepa reconocer los signos específicos de malrotación y las variantes de la normalidad que pueden conducir a un diagnóstico erróneo. Aunque la posición no retroperitoneal de la tercera porción duodenal en ecografía, TC o RM parece ser un signo fiable para el diagnóstico, el tránsito gastrointestinal continúa siendo el estándar de referencia para ver la unión duodeno-yeyunal en una posición anómala. Nuestro objetivo es revisar los principales signos radiológicos de esta enfermedad y hacer hincapié en el papel de la ecografía para diagnosticar el vólvulo de intestino medio (AU)

Radiologists must be able to recognize the imaging signs of intestinal malrotation because this condition can lead to potentially lethal complications such as midgut volvulus. The correct diagnosis depends on both high clinical suspicion and the radiologist's ability to recognize the specific signs of malrotation and the normal variants that can lead to the wrong diagnosis. Although the location of the third portion of the duodenum outside the retroperitoneal area on ultrasonography, CT, or MRI seems to be a reliable sign of malrotation, the gold standard for determining whether the duodenojejunal flexure is in an abnormal location continues to be the upper gastrointestinal series. In this article, we review the most important imaging signs of malrotation and emphasize the role of ultrasonography in diagnosing midgut volvulus (AU)

Desarrollo de un íleo duodenal y obstrucción gástrica por cálculo biliar en un paciente con un divertículo duodenal gigante / Development of a duodenal gallstone ileus with gastric outlet obstruction in a patient with a huge duodenal diverticulum

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