Utility of ultrasound in the diagnostic approach to lymphoma with splenic involvement.

This paper describes the clinical case of a patient diagnosed with diffuse large B-cell lymphoma with splenic involvement, focusing on the role of abdominal ultrasound (US) in this context. The patient experienced dyspepsia and progressive asthenia over several months so an abdominal US was performed. The US showed multiple heterogeneous and hypoechogenic focal splenic lesions together with a moderate left pleural effusion. Lymphoma was suspected due to these findings and the diagnosis was then confirmed with the performance of a CT scan and a biopsy that revealed the presence of a diffuse large B-cell lymphoma with metastatic disease. Chemotherapy containing rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone was administered and the patient is currently on clinical remission. This study highlights the role of abdominal ultrasound as a useful technique in the non-invasive assessment of this entity, considering an appropriate clinical context and mainly after detecting multiple hypoechogenic splenic lesions in the US.

Recertification of the specialty. Recognition of the professional prestige of the doctor.

The recertification of the specialist doctor is the individualized recognition of the level reached by the doctor in terms of knowledge, experience in healthcare, teaching and research tasks.

Intestinal amyloidosis: a diagnostic challenge.

Amyloidosis is a disease caused by extracellular deposition of abnormally folded proteins. While gastrointestinal involvement is relatively frequent in its systemic form, isolated gastrointestinal disease is rare. We present the case of a 62-year-old man assessed for iron deficiency anemia and abdominal pain after starting antiplatelet therapy with acetylsalicylic acid and ticagrelor for ischemic heart disease. An esophagogastroduodenoscopy was performed as part of the study, showing thickened folds with pseudopolypoid morphology and nodular mucosa with a preserved crypt pattern in the duodenal bulb and second duodenal portion.

From metastasis to the primary tumor: Giant liver metastasis from a pancreatic neuroendocrine tumor.

We present the case of a 37-years old male, who consulted for an extended history of intermittent nausea and vomiting. Laboratory tests showed moderate elevated bilirubin (1.30 mg/dL) and GGT (106 U/L). An abdominal CT scan performed showed a solid 18-centimetres (cm) mass located in the right liver lobe. A biopsy of the lesion was performed, revealing metastastic cells of a well-differentiated neuroendocrine tumour (NET, G3 (Ki-67: 25%). Further study was performed with MRI, and SPECT-CT, showing a 2-cm lesion in the pancreatic tail suggestive of being the primary NET. Chromogranin A levels were high (114.100 ng/ml). In our case, despite the large size of the liver metastasis a full resection of the tumours was achieved.

Pedunculated mucosa-associated lymphoid tissue (MALT) lymphoma causing gastric outlet obstruction.

An 86-year-old female presented with anemia and dyspepsia. She underwent esophagogastroduodenoscopy, which revealed a giant pedunculated polyp located in the gastric corpus, protruding into the duodenal bulb, causing gastric outlet obstruction (GOO). Thus, an endoscopic resection was scheduled.

Molecular analysis of pancreatic cystic neoplasm in routine clinical practice.

BACKGROUND: Cystic pancreatic lesions consist of a wide variety of lesions that are becoming increasingly diagnosed with the growing use of imaging techniques. Of these, mucinous cysts are especially relevant due to their risk of malignancy. However, morphological findings are often suboptimal for their differentiation. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) with molecular analysis has been suggested to improve the diagnosis of pancreatic cysts. AIM: To determine the impact of molecular analysis on the detection of mucinous cysts and malignancy. METHODS: An 18-month prospective observational study of consecutive patients with pancreatic cystic lesions and an indication for EUS-FNA following European clinical practice guidelines was conducted. These cysts included those > 15 mm with unclear diagnosis, and a change in follow-up or with concerning features in which results might change clinical management. EUS-FNA with cytological, biochemical and glucose and molecular analyses with next-generation sequencing were performed in 36 pancreatic cysts. The cysts were classified as mucinous and non-mucinous by the combination of morphological, cytological and biochemical analyses when surgery was not performed. Malignancy was defined as cytology positive for malignancy, high-grade dysplasia or invasive carcinoma on surgical specimen, clinical or morphological progression, metastasis or death related to neoplastic complications during the 6-mo follow-up period. Next-generation sequencing results were compared for cyst type and malignancy. RESULTS: Of the 36 lesions included, 28 (82.4%) were classified as mucinous and 6 (17.6%) as non-mucinous. Furthermore, 5 (13.9%) lesions were classified as malignant. The amount of deoxyribonucleic acid obtained was sufficient for molecular analysis in 25 (69.4%) pancreatic cysts. The amount of intracystic deoxyribonucleic acid was not statistically related to the cyst fluid volume obtained from the lesions. Analysis of KRAS and/or GNAS showed 83.33% [95% confidence interval (CI): 63.34-100] sensitivity, 60% (95%CI: 7.06-100) specificity, 88.24% (95%CI: 69.98-100) positive predictive value and 50% (95%CI: 1.66-98.34) negative predictive value (P = 0.086) for the diagnosis of mucinous cystic lesions. Mutations in KRAS and GNAS were found in 2/5 (40%) of the lesions classified as non-mucinous, thus recategorizing those lesions as mucinous neoplasms, which would have led to a modification of the follow-up plan in 8% of the cysts in which molecular analysis was successfully performed. All 4 (100%) malignant cysts in which molecular analysis could be performed had mutations in KRAS and/or GNAS, although they were not related to malignancy (P > 0.05). None of the other mutations analyzed could detect mucinous or malignant cysts with statistical significance (P > 0.05). CONCLUSION: Molecular analysis can improve the classification of pancreatic cysts as mucinous or non-mucinous. Mutations were not able to detect malignant lesions.

Implementation of a peroral endoscopic myotomy program.

INTRODUCTION: the aim of our study was to develop a peroral endoscopic myotomy (POEM) program in our Unit following a two-step sequence: training on animal models and supervision by an experienced endoscopist during the first human cases. METHODS: a single endoscopist experienced in advanced endoscopy was trained in POEM. After observing POEM in referral centers, training was implemented on swine models (preclinical phase). Technical aspects and adverse events were prospectively recorded. A first subset of cases (group A) was compared to a second one (group B) to assess our progression. Finally, POEM was implemented in humans under the supervision of an experienced endoscopist (clinical phase). The outcomes and adverse events were prospectively recorded. RESULTS: during the preclinical phase, 15 POEM procedures were performed on live pigs. Severe adverse events (AE) were less frequent in group B than in group A (12 % vs 57 %, p = 0.07). After nine cases, a plateau of adverse events was reached. During the clinical phase, eleven POEM procedures were performed in patients under expert supervision. Technical and clinical (Eckardt score ≤ 3) success were 100 % and 91 %, respectively (follow-up 3-21 months). In two cases, intervention of an experienced endoscopist was required (cases 2 and 3) because of a difficult orientation at the esophagogastric junction. One mild pneumoperitoneum occurred, with no severe adverse events reported. CONCLUSIONS: training in animal models and supervision by an experienced endoscopist during the first cases could provide the necessary skills to perform POEM safely and effectively.

Follicular non-Hodgkin lymphoma with primary colonic involvement.

We report the case of a 76-year-old female who underwent a colonoscopy for post-polypectomy follow-up. A nodular area was found in the proximal rectum that was suggestive of hyperplastic polyps by location and endoscopic appearance. Biopsies were taken due to its slightly atypical characteristics, with a final histological result of lymphoid aggregates.

Effectiveness of rectal indomethacin in the prevention of acute pancreatitis after endoscopic retrograde cholangiopancreatography in unselected patients.

BACKGROUND AND AIMS: several studies have shown that rectal indomethacin decreases the risk of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, in recent studies, its effectiveness is being questioned, especially in average risk patients. Our principal aim was to evaluate the efficacy of rectal indomethacin prophylaxis in the development of post-ERCP pancreatitis (PEP). METHODS: a retrospective cohort study was conducted at a third-level university hospital. Data was collected from every patients who underwent ERCP between January 2014 and June 2016. After February 2015, all patients received 100 mg of rectal indomethacin prior to ERCP. We analyzed groups, with indomethacin and without indomethacin, in unselected patients. RESULTS: a total of 524 patients were analyzed, with a mean age of 71.1 ± 17.0 (standard deviation [SD]) years. Of the total number of patients, 393 (75%) had an average risk; 277 received rectal indomethacin prior to ERCP, while 247 did not. In the group with indomethacin, 12 patients developed PEP (4.33%) versus ten in the indomethacin-free group (4.04%) (OR 1.33; 95% confidence interval [CI], 0.52-3.40; p = 0.56). Severe-moderate PEP developed in seven patients (2.52%) in the indomethacin group and in two patients (0.81%) in the indomethacin-free group (p = 0.24). Previous sphincterotomy was a protective factor (OR 0.02; 95% CI, 0.02-0.2; p = 0.001) and age < 45 years was a risk factor: (OR 3.43; 95% CI, 1.14-10.32; p = 0.03). CONCLUSIONS: rectal indomethacin does not appear to decrease the risk of developing PEP in unselected patients.

Endoscopic mucosal resection for cap poliposis treatment.

Cap-polyposis is a rare benign condition characterized by inflammatory colorectal polyps covered by a "cap" of fibrinopurulent exudate. Mucous diarrhea and rectal bleeding are frequent symtoms. It can be difficult to diagnose and it is necessary to make a differential diagnosis from other entities. Its pathogenesis is unknown and it has a variable clinical course. The optimal treatment has not been established.

Hemosuccus pancreaticus: a rare cause of gastrointestinal bleeding.

The term 'hemosuccus pancreaticus' was first coined in 1970 by Sandblom (1). It refers to bleeding that occurs through the pancreatic duct and is a rare cause of gastrointestinal hemorrhage.

Neoplasias quísticas pancreáticas: enfoque diagnóstico / Diagnostic Approach to Cystic Pancreatic Neoplasms

Resumen Los quistes pancreáticos comprenden una amplia variedad de lesiones cada vez más frecuentemente diagnosticadas debido tanto al empleo creciente de técnicas de imagen como al envejecimiento de la población. Entre ellas, las neoplasias quísticas mucinosas son especialmente relevantes por su potencial de malignización. Aunque la ecografía abdominal, la tomografía axial computarizada y la resonancia magnética suelen ser las pruebas diagnósticas de imagen iniciales, muchas veces los hallazgos morfológicos no son suficientes para su diferenciación. La ecoendoscopia se ha convertido en la mejor prueba para su caracterización ya que permite realizar estudio morfológico y también del líquido obtenido mediante punción, aunque su precisión diagnóstica para la detección de quistes de estirpe mucinosa y de malignidad sigue siendo baja. La importancia de la adecuada caracterización radica tanto en la detección precoz de las lesiones preneoplásicas y malignas como en evitar cirugías innecesarias. La indicación de ecoendoscopia, de tratamiento quirúrgico y de seguimiento varía entre las distintas guías de práctica clínica estando actualmente en duda especialmente el tratamiento y seguimiento de las neoplasias quísticas mucinosas papilares intraductales de rama lateral por el menor riesgo de degeneración y su asociación con el cáncer de páncreas.

Abstract Cystic pancreatic lesions comprise a wide variety of lesions that are being increasingly diagnosed due to the more frequent use of imaging techniques and the aging of the population. Among these lesions, mucinous cystic neoplasms are especially relevant because of their malignant potential. Although abdominal ultrasound, computerized tomography and magnetic resonance imaging are usually the initial diagnostic imaging tests, morphological findings are often not enough for their differentiation. Endoscopic ultrasound has become the best test for their characterization because it allows morphological study and fluid analysis obtained by puncture of the lesion, although its diagnostic accuracy for the detection of mucinous and malignant cysts remains low. The importance of proper characterization is the early detection of preneoplastic as well as malignant lesions and to avoid unnecessary surgery. Clinical practice guidelines differ about the indications for endoscopic ultrasound, surgical treatment and follow-up of these lesions. Questions specially remains in the management of side-branch intraductal papillary neoplasm because of their lower risk of degeneration and their association with pancreatic cancer.

Per-oral endoscopic myotomy (POEM): a new endoscopic treatment for achalasia.

BACKGROUND/AIMS: Per-oral endoscopic myotomy (POEM) is a new minimally invasive technique to treat achalasia. METHODS: We performed a review of the literature of POEM with a special focus on technical details and the results obtained with this technique in patients with achalasia and other esophageal motility disorders. RESULTS: Thousands of POEM procedures have been performed worldwide since its introduction in 2008. The procedure is based on the creation of a mucosal entry point in the proximal esophagus to reach the cardia through a submucosal tunnel and then perform a myotomy of the muscular layers of the cardia, esophagogastric junction and distal esophagus, as performed in a Heller myotomy. The clinical remission rate ranges from 82 to 100%. Although no randomized studies exist and available data are from single-center studies, no differences have been found between laparoscopic Heller myotomy (LHM) and POEM in terms of perioperative outcomes, short-term outcomes (12 months) and long-term outcomes (up to three years). Procedure time and length of hospital stay were lower for POEM. Post-POEM reflux is a concern, and controversial data have been reported compared to LHM. The technique is safe, with no reported deaths related to the procedure and an adverse event rate comparable to surgery. Potential complications include bleeding, perforation, aspiration and insufflation-related adverse events. Thus, this is a complex technique that needs specific training even in expert hands. The indication for this procedure is widening and other motor hypercontractil esophageal disorders have been treated by POEM with promising results. POEM can be performed in complicated situations such as in pediatric patients, sigmoid achalasia or after failure of previous treatments. CONCLUSIONS: POEM is an effective treatment for achalasia and is a promising tool for other motor esophageal disorders. It is a safe procedure but, due to its technical difficulty and possible associated complications, the procedure should be performed in referral centers by trained endoscopists.

Practical aspects of high resolution esophageal manometry.

High resolution esophageal manometry (HRM) is currently under development as can be seen in the various Chicago classifications. In order to standardize criteria in certain practical aspects with limited scientific evidence, the First National Meeting for Consensus in High Resolution Manometry of the Spanish Digestive Motility Group took place, bringing together a wide group of experts. The proposals were based on a prior survey composed of 47 questions, an exhaustive review of the available literature and the experience of the participants. Methodological aspects relating to the poorly defined analysis criteria of certain new high resolution parameters were discussed, as well as other issues previously overlooked such as spontaneous activity or secondary waves. Final conclusions were drawn with practical applications.

[Relationship between dysphagia and malnutritition in patients over 65 years of age]. / Malnutrición asociada a disfagia orofaríngea en pacientes mayores de 65 años ingresados en una unidad médico-quirúrgica.

AIMS: The main objective of this study was to understand the relationship between oropharyngeal dysphagia, nutritional risk factors and functional impairment in the elderly (>65y) admitted to a medical-surgical hospital unit. Secondary objectives were to determine the prevalence of oropharyngeal dysphagia, the nutritional status and their functional capacity. METHODS: A cross-sectional observational study was performed. It included patients over 65 years of age admitted to the Gastroenterology-Urology Department in La Princesa University Hospital (Madrid, Spain) during the months of February and March. The following variables were recorded: age, sex, body mass index, family support, diagnosis, comorbidity, oropharyngeal dysphagia (EAT-10 and volume-viscosity evaluation method), malnutrition (Mininutritional Assessment) and functional capacity (Barthel index). RESULTS: A total of 167 patients were recruited, with 30.8% and 15.4% prevalence of dysphagia and malnutrition, respectively. Prevalence of malnutrition increased to 75% in patients with oropharyngeal dysphagia. The logistic regression analysis showed how conditions as low score on the Barthel index (OR 0.97 [95% CI, 0.95-0.99]), comorbidity (OR 7.98 [CI 95%, 3.09-20.61]) and dysphagia (OR 4.07 [CI 95%, 1.57-10.52]) were associated with a greater likelihood of suffering malnutrition. DISCUSSION: Oropharyngeal dysphagia is one of the most underdiagnosed and underestimated conditions among elderly patients and one that has a greater effect on their nutritional status. Accordingly, we suggest using established diagnostic methods with a multidisciplinary team collaboration for its early detection.

[Schönlein-Henoch purpura with intestinal involvement: a clinic exposure]. / Púrpura de Schönlein-Henoch con afectación intestinal: exposición clínica.

Vasculitides are a group of diseases characterized by inflammation of the blood vessels and can affect any type of blood vessel in the body. Schönlein-Henoch purpura is a type of vasculitis secondary to hypersensitivity that affects the small blood vessels. Due to the rarity of this association, we present the case of a male patient with cutaneous purpura and intestinal involvement.