Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group from the Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines.

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past years, the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques, such as endoscopic ultrasound guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group from the Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) have the purpose to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions.

This document summarizes the contents of the Clinical Guidelines for the Endoscopic Mucosal Resection of Non-Pedunculated Colorectal Lesions that was developed by the working group of the Spanish Society of Digestive Endoscopy (GSEED of Endoscopic Resection). This document presents recommendations for the endoscopic management of superficial colorectal neoplastic lesions.

Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions. / Guía clínica para la resección mucosa endoscópica de lesiones colorrectales no pediculadas.

This document summarizes the contents of the Clinical Guidelines for the Endoscopic Mucosal Resection of Non-Pedunculated Colorectal Lesions that was developed by the working group of the Spanish Society of Digestive Endoscopy (GSEED of Endoscopic Resection). This document presents recommendations for the endoscopic management of superficial colorectal neoplastic lesions.

Gastroduodenal lesions detected during small bowel capsule endoscopy: incidence, diagnostic and therapeutic impact.

BACKGROUND: Capsule endoscopy was primarily designed for the investigation of the small bowel. However, it may also identify lesions in other segments of the gastrointestinal tract. The aim of the current study was to evaluate the incidence of gastroduodenal abnormalities during small bowel capsule endoscopy and its impact on patient diagnosis and management. PATIENTS AND METHODS: This study is a retrospective analysis of data from 2,217 consecutive capsule endoscopy procedures performed at a single tertiary-care center between January 2008 and February 2016. Patient baseline characteristics, gastroduodenal lesions, diagnosis and management before and after capsule endoscopy were recorded and a descriptive analysis was performed. RESULTS: Two thousands and two hundred seventeen patients were finally included in the analysis. One thousand and seventy patients were male (48.2%) and the mean age was 56.1 ± 19.5 years (range: 12-93). Obscure gastrointestinal bleeding (52.3%) and inflammatory bowel disease (18.3%) were the main procedure indications. Gastroduodenal abnormalities were detected by capsule endoscopy in 696 (31.4%) of 2,217 patients. The most common types of missed gastric and duodenal lesions found were gastric erosions (35.4%), findings suggestive of chronic gastritis (22.9%), duodenal erosions (28.1%) and duodenal erythema (23.5%). This information had a clinical or diagnostic impact of 26.2% and a therapeutic impact of 15.5%. CONCLUSION: Capsule endoscopy detects not only small bowel lesions but also some gastroduodenal lesions that may be overlooked during an initial gastroscopy. Therefore, all gastroduodenal images should be read during small bowel capsule endoscopy as it may provide relevant information that result in changes in patient management.

Duodenal hematoma caused by endoscopic hemostatic procedures (sclerotherapy).

Endoscopic hemostatic procedures such as local injection of epinephrine are commonly used for the treatment of bleeding ulcers. Although the risks are usually considered to be minimal, there are reports describing that duodenal intramural hematomas may develop as a complication after endoscopy especially in patients susceptible to hemorrhage such as those with anticoagulants therapy or blood dyscrasia.

Colonic lesions in patients undergoing small bowel capsule endoscopy: incidence, diagnostic and therapeutic impact.

BACKGROUND: Nowadays, capsule endoscopy is the first-line procedure to assess the small bowel. During small bowel procedures, other segments of the gastrointestinal tract may be visualized. The aim of the current study was to evaluate the incidence of colonic abnormalities in patients undergoing small bowel capsule and its impact on patient management. PATIENTS AND METHODS: This study is a retrospective analysis of data from 526 consecutive capsule endoscopy procedures performed at a single tertiary-care centre between 2008 and 2011. Patients with incomplete procedures were excluded from the analysis. Patient baseline characteristics, colonic lesions, diagnosis and management before and after capsule endoscopy were recorded and a descriptive analysis was performed. RESULTS: Four hundred and sixty four patients were finally included in the analysis. Two hundred and ninety three patients were male (57.3%) and the mean age was 61.3 ± 20.03 years (18-86). Obscure gastrointestinal bleeding (59%) and inflammatory bowel disease (19%) were the main indications for the procedure. Colonic abnormalities were detected by capsule endoscopy in 47 (9%) of 464 patients. The most common types of missed lesions were vascular lesions (34%) and colonic ulcers (32%). This information had a clinical or diagnostic impact of 7.55% and a therapeutic impact of 6.03%. CONCLUSION: All images of the colon should be evaluated during small bowel capsule endoscopy as they may provide relevant information that may result in changes in patient management.

Asymptomatic bronchial aspiration of capsule endoscope: a significant complication.

Capsule endoscopy is a safe and well-tolerated procedure allowing the direct, non-invasive mucosal investigation of the small bowel. There are, however, few limitations.

[Rituximab as rescue therapy in refractory esophageal lichen planus]. / Rescate con rituximab en paciente con liquen plano esofágico refractario.

Esophageal lichen planus (ELP) is a rare condition with unknown prevalence that can sometimes be underestimated due to the subtle and nonspecific findings of diagnostic workup. Oral lesions rarely extend to the esophageal mucosa, but when they do, the most frequent symptoms are dysphagia and odynophagia. There is often a significant delay in diagnosis and inadequate treatment. We report the case of a 59-year-old woman diagnosed with ELP, successfully treated with rituximab, a chimeric monoclonal antibody that depletes CD20+B cells. To our knowledge, this is only the second report of this treatment in ELP.

[Pleural effusion secondary to pancreaticopleural fistula following acute pancreatitis]. / Derrame pleural secundario a fístula pancreático-pleuralpospancreatitis aguda.

Pancreaticopleural fistula is a rare complication of acute or chronic pancreatitis, requiring medical (somatostatin), endoscopic or surgical treatment, with medical treatment being the first option. We describe the case of a 64-year-old man who showed complete disruption of Wirsung's duct that was diagnosed through ultrasound endoscopy and was complicated by the development of a subphrenic collection, diaphragm perforation and subsequent empyema. Medical therapy was attempted without success, and anatomical restoration of the duct was achieved after endoscopic treatment. The patient also required surgery to evacuate the pleural collection.

[Jaundice secondary to giant pancreatic serous cystoadenoma]. / Ictericia secundaria a cistoadenoma seroso pancreático gigante.

Serous cystadenoma is the second most frequent pancreatic cystic neoplasm and accounts for 1-2% of exocrine neoplasms of the pancreas. Recently, they have been identified more frequently, due to the improvement in imaging techniques. Differential diagnosis should be performed with mucinous cystoadenoma, due to the latter´s potential for malignant transformation. We present the case of a female patient who underwent examination for painless jaundice and cholestasis, with a final diagnosis of pancreatic serous cystoadenoma.

[Upper gastrointestinal bleeding secondary to Dieulafoy's lesion: differential features]. / Presenta características diferenciales la hemorragia digestiva alta por lesión de Dieulafoy?

OBJECTIVE: To analyze the possible differential features of upper gastrointestinal (GI) bleeding due to Dieulafoy's lesion (DL) compared with bleeding due to gastroduodenal ulcer. MATERIAL AND METHODS: We evaluated variables associated with patient characteristics, hemorrhagic characteristics and clinical severity in 31 cases of bleeding secondary to DL and 31 cases of gastroduodenal ulcer bleeding. Univariate and multivariate statistical analysis were performed. RESULTS: The comorbidity rate was 80% in the DL group and 42% in the ulcer group (OR = 5.54; 95%CI, 1.5-20.7; p < 0.0004). Lesion location was gastric in 87% of DL versus 39% of ulcers (OR = 10.7; 95%CI, 2.6-47.6; p < 0.0003). More than one gastroscopy was required for diagnosis in 30% of DL vs. 3.2% of ulcers (OR = 12.9; 95%CI, 1.4-291; p < 0.01). Endoscopic treatment was required in 97% of DL and 39% of ulcers (OR = 47.5; 95%CI, 5.5-106.1; p < 0.0001). Active bleeding during endoscopy was registered in 81% of DL and in 29% of ulcers (OR = 10.2; 95%CI, 2.7-40.3; p < 0.0005). The remaining variables analyzed showed no significant differences. The mortality rate was 9.7% in the DL group and 3.2% in the ulcer group (p = NS). Multivariate analysis showed that gastric location (p < 0.01), active bleeding (p < 0.01), and comorbidity (p < 0.02) were more frequent in DL. CONCLUSIONS: Active bleeding and gastric location of the lesion were more frequent in the DL group than in the ulcer group. Diagnosis of DL is difficult, requiring a greater number of gastroscopies. Initial hemorrhage severity and the success rate of endoscopic treatment were similar in the two groups. The higher mortality found in DL can be explained by the greater comorbidity in these patients, with a worse bleeding tolerance.

[Gastric plasmacytoma as an uncommon cause of upper gastrointestinal bleeding]. / Plasmocitoma gástrico como causa infrecuente de hemorragia digestiva alta.

Gastric plasmacytoma is an infrequent form of presentation of monoclonal gammopathy that, if ulcerated, can cause upper gastrointestinal bleeding. This entity is usually localized but may progress to multiple myeloma or other forms of monoclonal gammopathy. Differential diagnosis should be performed with other monoclonal gammopathies, based on laboratory and histological criteria, as well as with other gastric tumors such as adenocarcinoma, gastrointestinal stromal tumors, neuroendocrine tumors and lymphomas. Differential diagnosis can be based on radiological and endoscopic characteristics, although definitive diagnosis will undoubtedly be based on histological study and immunohistochemical techniques. We describe the case of a male patient who underwent investigations for upper gastrointestinal bleeding and iron deficiency anemia. The final diagnosis was multiple myeloma associated with gastric plasmacytoma.