Neuroendocrine tumor of the ampulla of Vater. Review of the literature.

Neuroendocrine tumors (NETs) or carcinoids represent a small percentage of gastrointestinal neoplasms (2%). The ileum (41.8%), rectum (27.4%) and stomach (8.7%) are the most common locations. We present an unusual case of NET due to its origin in the ampulla of Vater, as an extremely rare cause of biliary obstruction. A bibliographic review of the current recommendations of management and treatment for this case, different from other locations of the gastrointestinal tract is carried out. The curative treatment of choice for early-stage Vater ampulla NETs is Whipple surgery with lymphadenectomy due to Its high rate of lymphatic and metastatic dissemination, regardless of size and histological grade, although there are no updated official guidelines.

Early work activities after sedation with propofol in digestive endoscopy. Reply.

We read with interest the letter by Dr. Cerezo-Ruiz and we agree in general with the commentaries and would like to add some information related to the use of propofol in deep sedation by our group.

Balanced by iron. Hereditary hemochromatosis and celiac disease.

We present the case of a healthy 14-year-old adolescent who was referred to our hospital for an incidental alteration of the iron profile (Fe 225 ug/dl, transferrin 186 mg/dl, IST 63.93 %, ferritin 253 ng/ml). The blood count, proteinogram and renal, lipid and liver function tests were in the normal range. Abdominal ultrasound was requested with no findings of interest. The genetic analysis for hereditary hemochromatosis (HH) confirmed that the patient was homozygous for the C282Y mutation.

Acute hepatocellular drug-induced liver injury probably caused by doxazosin.

Drug-induced liver injury (DILI) is a diagnostic challenge, due to the hepatotoxic potential of drugs, herbs and dietary supplements, the variety of pathological phenotypes and the absence of specific biomarkers.

Percutaneous hepatic biopsy under propofol sedation. A safe and effective procedure.

INTRODUCTION: the percutaneous hepatic biopsy is a necessary procedure for the diagnosis of liver diseases which can cause complications and psychological discomfort for the patient. AIMS: to determine the safety profile of propofol in percutaneous hepatic biopsy, the complications of the technique per se and patients satisfaction once completed. METHODS: a retrospective observational study was performed via the acquisition of data of tolerance and perceived quality by the patients using a transversal survey. RESULTS: ninety-seven patients were included with an average propofol dose of 170.46 mg. Of the complications resulting from the sedation, there were six slight desaturations (6.2 %) resolved with a forehead maneuver (50 %) or cessation of the propofol infusion pump (50 %) and eleven hypotension episodes (11.3 %) resolved without intervention (82.82 %) or with fluid replacement (18.18 %). Of the complications resulting from the technique, there were three cases of early-onset pain (3.1 %) and one delayed (1.03 %); all were resolved with 1 g of intravenous paracetamol. All patients were discharged with oral tolerance and without the need for analgesia 24 hours after the procedure. General satisfaction, as well as psychological discomfort, were evaluated as "very good/excellent" in 100 % of the patients. DISCUSSION: propofol demonstrated a favorable safety profile in hepatic biopsy, aiding in the ultimate success of the procedure and tolerance for the patient. We propose the expansion of the use of sedation with propofol to this procedure.

Problems with a prophylactic non-expulsive pancreatic stent.

We appreciate the advice and comment of Drs. García Cano and Viñuelas about the best plastic stent for the prevention of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. We are aware of the benefit of placing a plastic stent in cases where the pancreatic duct is incorrectly and accidentally canalized in an attempt to access the biliary tree, as shown in their original paper.

Spanish online survey on informed consent for the performance of paracentesis. Do we have it? Do we use it?

INTRODUCTION: informed consent is necessary for invasive procedures as a document that guarantees the ethical health relationship and patient safety. AIMS: to analyze whether we have and use informed consent documents for paracentesis in our hospitals and to obtain data on the technique. METHODS: a descriptive observational study was performed during December 2019, via a cross-sectional survey disseminated through social networks, aimed at specialists and residents of gastroenterology. RESULTS: two hundred and three anonymous surveys were included (55.2 % gastroenterologist and 44.8 % residents) from 74 hospitals in 34 Spanish provinces. Ninety respondents (44.3 %) stated that they had the document in their centers. Of these, 29 (32.2 %) always provided it, 31 (34.4 %) provided it sometimes and 21 (23.3 %) never. Seventy-two professionals (35.5 %) answered that they did not have it and 41 (20.5 %) selected "unknown". Of these, 77 (68.1 %) considered it was necessary to create this document, 31 (27.4 %) did not think it was necessary and five (4.4 %) did not answer. With regards to the technique, 173 (85.2 %) performed paracentesis under direct visualization and 30 (14.8 %) were eco-guided on most occasions. One hundred and nine (53.7 %) always applied local anesthetic, 80 (39.4 %) sometimes and 14 (6.9 %) did not. One hundred and sixty-seven respondents (82.3 %) considered it to be a simple technique versus 36 (17.7 %) who thought that it was of intermediate complexity. In terms of risk, 150 (73.5 %) considered it was low and 52 (25.6 %), medium. Ninety-nine (48.8 %) experienced minor complications and 37 (18.2 %) experienced major complications. CONCLUSIONS: paracentesis is a common technique in digestive services and could be associated with complications, even though it is considered to be simple and safe. Due to the important intra- and inter-hospital variability that this technique presents, we consider standardized training in this technique is necessary, as well as the creation, spread and use of informed consents.

Acute pancreatitis secondary to a plastic prophylactic pancreatic prosthesis.

Plastic pancreatic prosthesis are indicated in the prophylactic of post-ERCP pancreatitis. But paradoxically, these prosthesis can cause pancreatitis if they are not expelled in a short period of time.

Hemorrhagic complications following paracentesis.

Paracentesis is a common and well accepted technique for its diagnostic-therapeutic profitability. This procedure is considered rapid, minimally invasive and safe, but we must not forget that it can lead to severe complications. In this letter we present two patients with hemorrhagic complications following paracentesis. Both cases were treated by percutaneous transarterial embolization. Likewise, in the absence of consensus on the prevention of complications and on their optimal management, we make some recommendations.

Tear of the secondary gastric mucous membrane to the extraction of the biliary prosthesis.

The extraction of a biliary prosthesis can be done by various techniques. It is usually simple, but it can be difficult for granulation tissue to adhere to the bile duct or its migration. In our case, it was complicated by an iatrogenic injury from the exit of the instruments for extraction.

The gastro-gastric fistula as a complication of a gastric bypass.

The gastric-gastric fistula is an infrequent complication of bariatric surgery, but one you have to suspect it in cases of weight gain or sickness. For its diagnosis it is necessary to conduct an upper digestive endoscopy or other imaging techniques, such as a barium-based contrast examination or CT with water-soluble contrast.