Primer reporte nacional de técnica de puestow modificada para el tratamiento de la pancreatitis aguda recidivante en pediatría / First national report of modified puestow technique for the treatment of recurrent acute pancreatitis in pediatrics / Primeiro relatório nacional de técnica puestow modificada para o tratamento de pancreatite aguda recorrente em pediatria

Se comunica el primer reporte nacional del tratamiento de pancreatitis aguda recidivante mediante derivación Wirsung-yeyunal en pediatría. Se trata de un paciente con múltiples ingresos hospitalarios por episodios de pancreatitis, con complicaciones evolutivas de pseudoquistes pancreáticos, estenosis y litiasis del conducto de Wirsung. Se realiza derivación Wirsung-yeyunal por vía convencional con buena evolución posterior.

The first national report of the treatment of recurrent acute pancreatitis by means of Wirsung-jejunal diversion in pediatrics is communicated. This is a patient with multiple hospital admissions for episodes of pancreatitis, with evolutionary complications of pancreatic pseudocysts, stenosis, and Wirsung duct lithiasis. Wirsung-jejunal bypass was performed by conventional route with good subsequent evolution.

O primeiro relato nacional do tratamento de pancreatite aguda recorrente por derivação Wirsung-jejunal em pediatria é relatado. Trata-se de um paciente com múltiplas internações hospitalares por episódios de pancreatite, com complicações progressivas de pseudocistos pancreáticos, estenose e cálculos do ducto de Wirsung. A derivação Wirsung-jejunal foi realizada por via convencional com boa evolução posterior.

Ansa pancreática: desafio no diagnóstico etiológico em paciente jovem com pancreatite grave / Ansa pancreatica: etiological diagnosis challenge in a young patient with severe pancreatitis

A ansa pancreática é uma variação anatômica rara dos ductos pancreáticos. Consiste numa comunicação entre o ducto pancreático principal (Wirsung) e o ducto pancreático acessório (Santorini). Recentemente, estudos têm demonstrado estar essa variação anatômica implicada como fator predisponente e significativamente associada a episódios recorrentes de pancreatite aguda. A pancreatite é uma entidade clínica pouco frequente na infância. Diferente dos adultos, as causas mais comuns incluem infecções virais, por ascaris, medicamentosas, traumas e anomalias estruturais. O objetivo deste estudo foi relatar um caso de pancreatite aguda grave não alcoólica e não biliar, em um paciente jovem de 15 anos, em cuja propedêutica imagenológica evidenciou-se alça, comunicando com os ductos pancreáticos ventral e dorsal, compatível com ansa pancreática.

Ansa pancreatica is a rare anatomical variation of the pancreatic ducts. It consists of communication between the main pancreatic duct (Wirsung) and the accessory pancreatic duct (Santorini). Recently, studies have shown that this anatomical variation is implicated as a predisposing factor and significantly associated with recurrent episodes of acute pancreatitis. Pancreatitis is a rare clinical entity in childhood. Different from that in the adults, the most common causes include viral and ascaris infections, drugs, traumas, and structural abnormalities. The objective of this study was to report a case of a severe non-alcoholic and non-biliary acute pancreatitis in a 15-year-old patient, whose propedeutic imaging showed a loop communicating with the ventral and dorsal pancreatic ducts, consistent with ansa pancreatica.

Hemosuccus pancreaticus: rara asociación entre pancreatitis aguda, alcoholismo y sesiones vasculares en la circulación esplácnica / Hemosuccus Pancreaticus: an unusual association of acute pancreatitis, alcoholism and vascular abnormalities of the splanchnic circulation

La pancreatitis aguda o crónica puede resultar en lesiones del conducto pancreático, además, la corrosión por el jugo pancreático puede provocar la ruptura de la pared vascular periférica, lo que conduce a hemosuccus pancreático (HP) definido como el sangrado del conducto pancreático a través de la ampolla de Vater. El sangrado suele ser intermitente, repetitivo y, a menudo, no lo suficientemente grave, como para causar inestabilidad hemodinámica. La mayoría de los pacientes tiene antecedentes de enfermedades pancreáticas originales y cuando esto no se cumple, debe incluirse en el diagnóstico diferencial para alcohólicos crónicos con hemorragia digestiva alta intermitente. Presentamos una forma clínica atípica en un paciente masculino de 55 años de edad, con antecedentes de HTA, alcoholismo y aneurisma de la aorta abdominal, quien consultó por dolor tipo cólico en abdomen superior, náuseas y vómitos; luego se asoció disminución del estado de conciencia, alternando con episodios de agitación psicomotriz y primo convulsión generalizada. Una vez ingresado, sucedieron varios episodios de melena. La tomografía abdominal mostró aumento de tamaño y densidad (unidades hounsfield de 58-61) en cabeza y cuerpo del páncreas, por lo que se realizó una angiografía abdominal con protocolo de páncreas y se evidenció doble lesión aneurismática de la arteria esplénica y la arteria gástrica. Falleció en el postoperatorio(AU)

Acute or chronic pancreatitis can result in lesions of the pancreatic duct; in addition, corrosion by the pancreatic juice can cause the rupture of the peripheral vascular wall, which leads to pancreatic hemosuccus defined as bleeding from the pancreatic duct through the Vater ampulla. Bleeding is often intermittent, repetitive, and often not severe enough to cause hemodynamic instability. Most of the cases have a history of strictly pancreatic original diseases, when this is not the case, the PH should be included in the differential diagnosis for chronic alcoholics with intermittent upper gastrointestinal bleeding, We report here an atypical presentation in a 55-year-old male patient with a history of hypertension, alcoholism and an abdominal aortic aneurysm. He consulted for colicky abdominal pain in the upper abdomen, nausea and vomiting; subsequently he presented decreased consciousness, alternating with episodes of psychomotor agitation and generalized seizures. Once hospitalized he had several bouts of melena. The abdominal tomography showed an increase in the size and density (hounsfield units of 58-61) of the head and body of the pancreas. An abdominal angiography with a pancreas protocol was performed, which evidenced a double aneurismal lesion of the splenic and gastric arteries. The patient died after surgery(AU)

Canulación biliar difícil: precorte precoz tipo fistulotomía para evitar la pancreatitis post CPRE. Un análisis retrospectivo de dos años / Difficult biliary cannulation: early precut fistulotomy to avoid post ERCP pancreatitis. A retrospective analysis for two years

Antecedentes: La canulación biliar difícil es un factor de riesgo para la pancreatitis post-CPRE. En estos casos el precorte es la técnica más usada. Objetivo: Demostrar que el precorte tipo fistulotomía es seguro y eficaz. Materiales y métodos: Se revisaron los datos de mayo de 2016 a mayo de 2018. Se definió canulación difícil como: litiasis impactada, canulación inadvertida del conducto pancreático en tres ocasiones e incapacidad para lograr la canulación en 3 minutos. Las medidas de resultados fueron la canulación biliar exitosa y la pancreatitis post-CPRE. Resultados: Se realizó precorte tipo fistulotomía en 96 casos (67 mujeres, 29 hombres). La tasa de éxito de la canulación biliar fue del 95,8% (92/96). Ochenta pacientes tenían factores de riesgo para pancreatitis post CPRE: 29 tuvieron un solo factor de riesgo, 26 tuvieron dos, 19 tuvieron tres y 6 tuvieron cuatro. Factores de riesgo ampulares de canulación difícil: calculo impactado 9 casos, abultamiento de la papila en 10 casos, ubicación inferior del orificio papilar en 38 casos, localización parcial del poro papilar en 23 y estenosis del orificio papilar en 16 casos. Diez pacientes tuvieron divertículo periampular, 7 pacientes tuvieron conducto biliar normal. Ninguno de los pacientes experimentó pancreatitis. Tres pacientes tuvieron sangrado precoz, una paciente presento sangrado tardío. Un paciente (2%) tuvo fiebre y fue hospitalizado. Conclusiones: En casos de canulación biliar difícil el precorte tipo fistulotomía es seguro y eficaz.

Background: Difficult biliary cannulation is a risk factor for post-ERCP pancreatitis. In these cases, precutting is the most used technique. Objective: To demonstrate that precut fistulotomy is safe and effective. Materials and methods: Data from May 2016 to May 2018 were reviewed. Difficult cannulation was defined as: impacted lithiasis, inadvertent cannulation of the pancreatic duct on three occasions and inability to achieve deep biliary cannulation in 3 minutes. The outcome measures were successful biliary cannulation and post-ERCP Pancreatitis. Results: Precut fistulotomy was performed in 96 cases (67 women, 29 men). The success rate of biliary cannulation was 95.8% (92/96). Eighty patients had risk factors for post-ERCP pancreatitis: 29 had 1 risk factor, 26 had 2 risk factors, 19 had 3 risk factors, and 6 had four risk factors. Ampullary risk factors of difficult cannulation: impacted stone in the papilla: 9 cases, papilla bulging: 10 cases, lower location of the hole papillary 38 cases, partial location of the papillary pore 23 and papillary orifice stenosis 16 cases. Ten patients had periampullary diverticulum, 7 patients had normal bile duct. None of the patients experienced Pancreatitis. Three patients had early bleeding, one patient had late bleeding. One patient (2%) had a fever and was hospitalized. Conclusions: In cases of difficult biliary cannulation, the precut fistulotomy is safe and effective.

Utilidad de la colangiopancreatoscopia directa en el manejo del cálculo pancreático, a propósito de un caso (con video) / Usefulness of Direct Cholangiopancreatoscopy for Management of Pancreatic Calculi: Case Study (with video)

Resumen Se presenta el caso de un paciente con pancreatitis crónica y hallazgo de lesión quística en el ducto pancreático principal, a quien se le realizó colangioscopia directa tipo Spyglass y se encontró un gran cálculo impactado a nivel de la cabeza del páncreas, condicionando una formación pseudoquística. Se realizó litotricia láser y se logró la extracción en su totalidad, con lo cual se logró la remisión sintomática.

Abstract We present the case of a patient with chronic pancreatitis. After finding a cystic lesion in the main pancreatic duct, the patient underwent direct cholangioscopy using the SpyGlass DS System. A large impacted calculus and pseudocyst formation was found in the head of the pancreas. Laser lithotripsy was used to extract the entire calculus and symptomatic remission was achieved.

Gene expression profiling reveals upregulated FUT1 and MYBPC1 in children with pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is associated with high risk of epithelial atypical growth and malignant transformation of the bile duct or gallbladder. However, overall changes in genetic expression have not been examined in children with PBM. Genome-wide expression was analyzed using peripheral blood samples from 10 children with PBM and 15 pediatric controls. Differentially expressed genes (DEGs) were identified using microarray. Bioinformatics analysis was conducted using Gene Ontology and KEGG analyses. The top 5 in the up-regulated genes in PBM were verified with qRT-PCR. Receiver operator characteristic curve analysis was conducted to evaluate the predictive accuracy of selected genes for PBM. The microarray experiments identified a total of 876 DEGs in PBM, among which 530 were up-regulated and the remaining 346 were down-regulated. Verification of the top 5 up-regulated genes (TYMS, MYBPC1, FUT1, XAGE2, and GREB1L) by qRT-PCR confirmed the up-regulation of MYBPC1 and FUT1. Receiver operating characteristic curve analysis suggested that FUT1 and MYBPC1 up-regulation could be used to predict PBM, with the area under the curve of 0.873 (95%CI=0.735−1.000) and 0.960 (95%CI=0.891−1.000), respectively. FUT1 and MYBPC1 were up-regulated in children with PBM, and could be used as potential biomarkers for PBM.

Variantes anatómicas de la vía biliar derecha y de la trayectoria del ducto pancreático en una cohorte de 1159 pacientes / Anatomical variants of the right bile duct and the path of the pancreatic duct in a cohort of 1159 patients

La Colangiopancreatografia por Resonancia Magnética (CPMR), es la modalidad de elección para la evaluación no invasiva del tracto biliar. La identificación incorrecta de la anatomía biliar puede resultar en complicaciones perioperatorias y posquirúrgicas. Las anomalías congénitas y las variantes anatómicas del conducto pancreático no se detectan hasta la edad adulta y se descubren a menudo en pacientes asintomáticos. El objetivo de este estudio fue la evaluación de la frecuencia de variantes anatómicas de la vía biliar derecha y trayectoria del conducto pancreático usando CPRM. Materiales y Métodos. Se realizó un estudio descriptivo, retrospectivo de corte transversal de 1159 pacientes, entre los meses de febrero del 2017 hasta mayo del año 2018 del Hospital Carlos Andrade Marín, los pacientes incluidos son aquellos que se sometieron a estudios de CPRM para valoración de la vía biliar tanto para patologías neoplásicas y no neoplásicas gastrointestinales. Resultados: El 54,6% de pacientes presenta una anatomía del árbol biliar normal catalogada como variante tipo 1, el conducto pancreático sigmoide se identificó con mayor frecuencia.

Magnetic Resonance Cholangiopancreatography (MRCP) is the modality of choice for the non-invasive evaluation of the biliary tract. Incorrect identification of the biliary anatomy can result in perioperative, and postoperative complications. Congenital anomalies and anatomical variants of the pancreatic duct are not detected until adulthood and are often discovered in asymptomatic patients. The objective of this study was to evaluate the frequency of the anatomical variants of the right bile duct and the trajectory of the pancreatic duct using MRCP. Materials and methods: A descriptive, retrospective, cross-sectional study of 1159 patients was carried out between February 2017 and May 2018 of the Carlos Andrade Marín Hospital, including patients who underwent MRCP studies for the assessment of the bile duct for neoplastic and non-neoplastic gastrointestinal pathologies. Results: 54.6% of patients presented an anatomy of the normal biliary tree classified as a type 1 variant; the sigmoid pancreatic duct is more frequently identified.

Drenaje endoscópico transgástrico de pseudoquiste pancreático en paciente pediátrico / Transgastric endoscopic drainage of pancreatic pseudocyst in a pediatric patient

Resumen Un pseudoquiste pancreático es una acumulación de líquido casi siempre estéril, rico en enzimas digestivas y jugo pancreático encapsulado en una pared de tejido fibroso y de granulación sin revestimiento epitelial, generalmente de forma ovalada o redondeada. Los pseudoquistes se pueden desarrollar por complicaciones en el páncreas que generan obstrucción o ruptura de un conducto pancreático. Se presenta el caso de un paciente masculino de 9 años con diagnóstico de pseudoquiste pancreático con crecimiento progresivo, debido a trauma abdominal cerrado. Se realizó un manejo multidisciplinario para determinar el tratamiento. Por las características del pseudoquiste, se definió realizar un drenaje endoscópico transgástrico. El procedimiento llevado a cabo es descrito en el presente texto. El paciente evolucionó satisfactoriamente.

Abstract A pancreatic pseudocyst is an accumulation of fluid that is almost always sterile and is rich in digestive enzymes and pancreatic juice that is encapsulated in a wall of fibrous tissue and granulation tissue without an epithelial lining. They are generally oval or rounded. Pseudocysts can develop from complications in the pancreas that lead to obstruction or rupture of a pancreatic duct. We present the case of a 9-year-old male patient diagnosed with a pancreatic pseudocyst with progressive growth due to closed abdominal trauma. Multidisciplinary management determined treatment. Due to the characteristics of the pseudocyst, transgastric endoscopic drainage was used, and the procedure was carried out as described herein. The patient evolved satisfactorily.

Determinación de la frecuencia de hiperamilasemia y pancreatitis en pacientes llevados a colangiopancreatografía retrógrada endoscópica / Determining Frequency of Hyperamylasemia and Pancreatitis in Patients after Endoscopic Retrograde Cholangiopancreatography

Resumen Hemos visto con preocupación que, en el postquirúrgico de la colangiopancreatografía retrógrada endoscópica (CPRE), existe confusión en cuanto a la aparición de pancreatitis y a la elevación transitoria de las amilasas (hiperamilasemia sin repercusión clínica), por lo que nos dimos a la tarea de realizar esta investigación, cuyo objetivo principal era determinar la prevalencia del incremento de niveles séricos de amilasas y de pancreatitis en los pacientes sometidos a colangiopancreatografía retrógrada endoscópica, según variables demográficas, clínicas y procedimentales. Es un estudio descriptivo, prospectivo, analítico y observacional, la población de estudio estuvo integrada por 98 pacientes atendidos en Unión de Cirujanos SAS, quienes requirieron colangiopancreatografía retrógrada endoscópica. Resultados: la frecuencia de pancreatitis aguda después de la CPRE fue del 2%, en 2 de los 98 casos estudiados; el 30% presentó hiperamilasemia (30 pacientes); la canulación del conducto pancreático mostró asociación con pancreatitis post-CPRE, con un valor de p<0,05. De los 2 pacientes que presentaron pancreatitis post-CPRE, a uno de ellos se le realizó contraste del conducto pancreático. La dilatación con balón se asoció con la hiperamilasemia (p<0,041). Conclusiones: la pancreatitis post-CPRE se presentó en un 2% de los pacientes, y este porcentaje se encuentra incluido dentro de los pacientes que presentaron hiperamilasemia, uno de los criterios para el diagnóstico de pancreatitis. Nuestro grupo se encuentra en el rango inferior del promedio internacional (1,8% al 7,2%). La hiperamilasemia asintomática se presentó en un 30%. Recomendamos que, si después de la CPRE, el paciente no presenta dolor, no se midan las amilasas, porque estas van a estar elevadas en gran número de los casos y, entonces, solo causaría confusión.

Abstract We have seen with concern that there is confusion regarding the appearance of pancreatitis and the transient elevation of amylases (hyperamylasemia without clinical repercussions) in the postoperative period following ERCP (endoscopic retrograde cholangiopancreatography). For this reason, we embarked on the task of determining the prevalence of increased serum amylases and pancreatitis in patients who have undergone endoscopic retrograde cholangiopancreatography according to demographic, clinical and procedural variables. This is a descriptive, prospective, analytical and observational study. The study population consisted of 98 patients treated in the Union of SAS Surgeons who required endoscopic retrograde cholangiopancreatography. Results: Acute pancreatitis was found in 2% of the patients who had undergone ERCP (Two of the 98 cases studied). Thirty patients (30%) presented hyperamylasemia. Cannulation of the pancreatic was associated with post-ERCP pancreatitis (p <0.05). Pancreatic duct contrast had been used in one of the two patients who presented post-ERCP pancreatitis. Balloon dilation was associated with hyperamylasemia (p <0.041). Conclusions: Post-ERCP pancreatitis was found in two patients (2%), both of whom also presented hyperamylasemia which is one of the criteria for diagnosis of pancreatitis. The rate in our group is at the lower end of the international range of averages from 1.8% to 7.2%. Asymptomatic hyperamylasemia was present in 30% of our group. Following ERCP, we recommend that there is no need to measure amylases in patients who do not present pain. Amylase levels will be elevated in a large number of cases and will only cause confusion.

Causa rara de distensión abdominal aguda: apertura del conducto pancreático en un quiste hidatídico / A rare cause of acute abdominal distention: opening of the pancreatic duct into hydatic cyst

Introducción. El quiste hidatídico, causado por Echinococcus granulosus, se observa mayormente en el hígado y los pulmones, aunque raramente también puede localizarse en cualquier órgano o tejido blando. En este artículo se presenta el caso de un paciente con quiste hidatídico pancreático con apertura del conducto pancreático en el quiste. A propósito de un caso: Se atendió en nuestra clínica a un niño de 10 años de edad con distensión abdominal significativa y dolor en el epigastrio de 10 días de evolución. La concentración de amilasa sérica era de 3709 U/l y la inhibición de la hemaglutinación para hidatidosis era de 1/160. En la tomografía computarizada de abdomen se observaron dos lesiones separadas y ascitis, un quiste hidatídico de tipo CE2 en la región de la cola del páncreas y un quiste hidatídico de tipo CE1 en el lóbulo izquierdo del hígado. Se realizó el drenaje percutáneo del quiste ubicado en la cola del páncreas y se inició tratamiento con albendazol. Se retiró la sonda de drenaje, y desde ese momento se ha realizado el seguimiento del paciente sin que se observen complicaciones.

Introduction. Hydatid cyst, which is caused by Echinococcus granulosus, is mostly seen in the liver and lungs although it may also rarely be found in any organ or soft tissue. This study presents an interesting case of pancreatic hydatid cyst in which the pancreatic duct opened into this cyst. Case report. A 10-year-old boy presented to our clinic with significant abdominal distension and pain in the epigastric region which had started 10 days previously. Serum amylase level was 3709 U/L and hemagglutination inhibition for hydatid disease was 1/160. At abdominal computed tomography, two separate lesions and ascites were determined, a CE2 hydatid cyst in the region of the tail of the pancreas and a CE1 hydatid cyst in the left lobe of the liver. Percutaneous drainage was applied to the cyst in the pancreatic tail, and the patient was started on albendazole. The drainage catheter was removed, and the patient has since been followed-up on an outpatient basis with no complications.

Recurrent acute pancreatitis caused by pancreatic biliary maljunction due to long common channel / Pancreatitis aguda recurrente causada por deficiente unión pancreático-biliar debido a un colédoco largo

The pancreatic biliary maljunction is a rare anomaly that affects mainly females, defined as an anatomical maljunction of the pancreatic duct and the biliary duct confluence, and may be a rare cause of recurrent acute pancreatitis. In order to early diagnosis and prompt treatment, ERCP has an important role in it

La Malformación de la unión biliopancreática es una afección rara y ocurre más en mujeres jóvenes. Es una causa de pancreatitis aguda de causa no conocida. CPRE es una herramienta eficiente para el diagnóstico y también para ser de la terapéutica

Papel da ranitidina como meio de aprimorar a qualidade do exame de colangiopancreatografia por ressonância magnética / The role of ranitidine in the enhancement of imaging quality in magnetic resonance cholangiopancreatography

OBJETIVO: Avaliar o impacto da ranitidina por via oral na qualidade do exame de colangiopancreatografia por ressonância magnética (CPRM).MATERIAIS E MÉTODOS: Trinta e dois pacientes realizaram CPRM com aquisições 3D e 2D, com três estratégias de supressão do sinal líquido gastrintestinal: a) apenas em jejum; b) 12 horas após ingerir 300 mg de ranitidina; c) após a ingestão de solução de gadolínio. Três observadores avaliaram os estudos, atentos para o grau de visualização da árvore biliopancreática. Foi medida a concordância interobservador com o teste kappa. A diferença entre técnicas e formas de aquisição foi avaliada pela média da soma dos escores de graduação.RESULTADOS: As três estratégias de supressão do sinal líquido gastrintestinal apresentaram elevada reprodutibilidade. A supressão do sinal líquido gastrintestinal com a ranitidina foi semelhante ao jejum e ambas foram piores do que a solução de gadolínio. As aquisições 3D superaram a 2D apenas na visualização do ducto cístico e da vesícula biliar, sendo inferior ou equivalente nos demais segmentos ductais biliopancreáticos.CONCLUSÃO: O uso da ranitidina não parece justificado para aprimorar a avaliação da árvore biliopancreática em exames de CPRM. A CPRM 2D apenas em jejum permite a visualização ductal com elevada qualidade e reprodutibilidade na maioria dos casos.

OBJECTIVE: To assess the impact of oral ranitidine on the imaging quality in magnetic resonance cholangiopancreatography (MRCP).MATERIALS AND METHODS: Thirty-two patients underwent MRCP with 3D and 2D acquisitions, and three strategies for suppression of the gastrointestinal fluid signal: a) only at fasting; b) 12 hours after ingestion of 300 mg ranitidine; c) after oral administration of gadolinium solution. Three observers reviewed the images with a focus on the degree of visualization of the biliopancreatic tree. The interobserver agreement was evaluated with the kappa test. The difference between techniques and acquisition modalities were evaluated by means of average grading scores.RESULTS: The three strategies for suppression of the gastrointestinal fluid signal presented high reproducibility. The results with suppression of the gastrointestinal fluid signal with ranitidine where similar to those obtained with fasting, and both were worse than those obtained with gadolinium solution. The 3D acquisitions surpassed 2D only in terms of visibility of the cystic duct and gallbladder, and were inferior or equivalent in the other biliopancreatic ductal segments.CONCLUSION: The use of ranitidine does not seem justified in the evaluation of the biliopancreatic tree at MRCP, since 2D MRCP with fasting allows the visualization of ductal structures with high quality and reproducibility in the majority of cases.

EUS-Guided access to dorsal pancreatic duct in a patient with pancreas divisum

Se reporta un caso de acceso del conducto pancreatico dorsal por medio de ayuda de ultrasonografía endoscópica en un paciente con cuadro de Páncreas divisum que producía sintomas dolorosos; y que no fué posible su abordaje por PCRE.

Case report of pancreas divisum dorsal pancreatic duct access with endoscopic ultrasonography help to relief pain in a patient with not possible access by PCRE.

Insuficiência exócrina do pâncreas: etiologias / Exocrine pancreatic insufficiency: etiology

Insuficiência exócrina do pâncreas tem sido revisitada em vários compêndios médicos internacionais e suas novas etiologias avaliadas e reconfirmadas. Neste artigo abordamos as causas mais comuns e tradicionais, pancreatite crônica e fibrose cística, bem como as recentemente mais enfatizadas como doença celíaca e diabetes mellitus. Comentamos a clínica e o diagnóstico precoce e o tratamento com reposição enzimática

Pancreatic exocrine insufficiency has been broadly discussed in international medical literature. New aetiologies have been studied and reaffirmed. In this paper we describe common and traditional causes such as chronic pancreatitis and cystic fibrosis as well as the most recently emphasised celiac disease and diabetes. We also review clinical features, early diagnosis and pancreatic enzyme replacement therapy

Adenoma da papila de Vater associado a tumor carcinoide em papila duodenal menor / Adenoma of the papilla of Vater associatedwith carcinoid tumor in the minor duodenal papilla

As neoplasias benignas da ampola de Vater são raras. Essas lesões têm propensão à degeneração maligna de 35 a 55%1 e podem ter tamanho relativamente grande (>5 cm) em diâmetro, em geral sendo notadas por sintomas de hemorragia digestiva, obstrução intestinal ou icterícia obstrutiva. Os tumores carcinoides da papila menor também são extremamente raros e são, a maioria, assintomáticos, porém podem apresentar comportamento agressivo na forma de metástases. Este trabalho apresenta um caso raro de um paciente portador de adenoma viloso em ampola de Vater associado ao carcinoide de papila menor.

Benign neoplasias are rare in the ampulla of Vater, and the likelihood of their degenerating to malign tumor is 35 to 55 %1. Benign neoplasias can have a relatively large size (> 5 cm diameter) and are usually noticed upon such symptoms as gastrointestinal bleeding, intestinal obstruction or obstructive jaundice. Carcinoid tumors in the minor duodenal papilla are also extremely rare and usually asymptomatic, but they can be severe in the metastasis form. This paper reports on a rare case of a patient with villous adenoma in the ampulla of Vater associated with carcinoid tumor in the minor duodenal papilla.

Pancreatite crônica intersticial e caquexia causada por Eurytrema coelomaticum em vaca Nelore / Chronic interstitial pancreatitis and chronic wasting disease caused by Eurytrema coelomaticum in Nelore cow

A euritrematose bovina, causada por Eurytrema coelomaticum, tem sido relatada no Brasil. A doença pode afetar animais domésticos, incluindo ruminantes. Estes parasitos geralmente vivem nos ductos pancreáticos e ocasionalmente nos ductos biliares. Este estudo relata um quadro de caquexia em um bovino parasitado por E. coelomaticum proveniente de um rebanho de gado de corte localizado no Estado de Minas Gerais. O animal acometido apresentou perda progressiva de peso, glicosúria e cetonúria. Na necropsia o pâncreas apresentava-se diminuído de tamanho, brancacento, intensa e difusamente firme (fibrose). Vários ductos apresentavam-se dilatados e repletos de Eurytrema. Microscopicamente foi observada destruição extensa do parênquima pancreático e fibrose, ovos e parasitas intralesionais, hiperplasia ductal e inflamação multifocal crônica. Este relato descreve a perda progressiva de peso e pancreatite crônica associada a E. coelomaticum em bovino de corte no Estado de Minas Gerais.

Pancreatitis aguda necrotizante por cuerpo extraño. Primer caso reportado secundario a un palillo de fósforos / Acute necrotizing pancreatitis by a foreign body. First reported case secondary to a match stick

Cuadros de pancreatitis causada por cuerpo extraño son excepcionalmente raros. Se han descrito: agujas, clips quirúrgicos, suturas, hebillas de cinturón, mondadientes, espinas de pescado, plumas de pollo y bezoares. Este es el primer caso reportado en la literatura mundial causado de un palito de fósforo (cerillo). Se trata de una mujer de 73 años con diagnóstico de pancreatitis aguda necrotizante, puntaje Apache en 12, que desarrollo en las siguientes 36 horas de la admisión, hipotensión refractaria, falla renal aguda y muerte. La autopsia mostró necrosis extensa que comprometía todo el páncreas y un cerillo impactado en el conducto de Wirsung. Microscópicamente se evidenció necrosis coagulativa parenquimal, micro_abscesos y un denso infiltrado inflamatorio agudo rodeando al cerillo.

Pancreatitis caused by foreign bodies is exceptionally rare. It has been described: needles, surgical clips, sutures, belt buckles, toothpicks, spines of fish, chicken feathers and bezoars. This is the first case reported in world literature caused by a match ("cerillo"). A 73-year-old women, admitted with the diagnostic of severe necrotizing pancreatitis, APACHE score 12, during 36 hours following the admission she developed refractory hypotension, acute renal failure and finally died. The necropsy showed: extensive necrosis that compromise the whole pancreas and a match impacted in the duct of Wirsung. Microscopic evaluation revealed coagulative parenchymal necrosis, micro abscesses and a dense accumulation of acute inflammatory cells surrounding the match.