Protocol for acquisition of images and measurement of transabdominal ultrasound pancreatic two-dimensional shear wave elastography (2D-SWE). / Protocolo de adquisición de imágenes y medición de la elasticidad pancreática mediante elastografía por onda de cizallamiento bidimensional (2D-SWE) transabdominal.

INTRODUCTION: Transabdominal ultrasound (TU) pancreatic 2D-SWE elastography is a developing technique that needs to be protocolized. OBJECTIVES: Establish a protocol for image acquisition and measurement of TU pancreatic - 2D-SWE elastography and estimate the minimum number of measurements to be performed. MATERIALS AND METHODS: Ten measurements of pancreatic elasticity were taken in healthy volunteers using TU-2D-SWE, following a strict protocol for image acquisition and measurement. RESULTS: The 70% of the participants were women, with an average age, weight, and BMI of 49.5±15.7 years, 65.9±11.9kg, and 24.5±4.2kg/m2, respectively. Measurements were taken from the body (70%), tail (16.7%), and pancreatic head (13.3%). The median mean velocity and elasticity were 1.46±0.25cm/sec and 6.46±2.87KPa, respectively. The ROI depth was 4.12±1cm and the SP-ROI distance was 5.2mm on average. There were no statistically significant differences between the 10 measurements. The reliability analysis of the measurements showed high internal consistency and repeatability. Taking 5-6 measurements ensured high concordance with the ten reference measurements. The measurements were significantly lower when the SP-ROI values were intermediate (0.3-0.6cm). The measurement accuracy was higher when performed at a depth less than 4.8cm. CONCLUSION: To measure pancreatic elasticity using TU-2D-SWE, we propose a strict protocol for image acquisition and measurement, taking a minimum of 5 measurements in the best visualized and accessible pancreatic portion, and preferably at a depth of less than 4.8cm.

Treatment of severe hypertriglyceridemia through therapeutic plasma exchange in patients with acute pancreatitis or at risk of developing it. / Tratamiento de la hipertrigliceridemia grave mediante recambio plasmático terapéutico en pacientes con pancreatitis aguda o en riesgo de padecerla.

INTRODUCTION AND OBJECTIVES: TPE drastically reduces serum triglyceride (sTG), but its role in the treatment of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) or at risk of developing it, is not well established. The objectives were to assess the effectiveness and safety of TPE in the treatment of severe HTG (sHTG), as well as to evaluate the severity of HTG-AP treated with TPE. MATERIALS AND METHODS: Observational-retrospective-single-center study, in which a descriptive analysis of sHTG treated with TPE was conducted, with the aim of treating HTG-AP or preventing its recurrence. TPE was performed if sTG≥ 1000 mg/dL after 24 hours of admission. RESULTS: 42 TPE were performed to treat 35 sHTG in 23 patients: 29 HTG-AP, and 6 sHTG with previous HTG-AP. Among the patients, 37% (13/55) were women, with 37 ± 14 years-old, 74.3% had normal BMI (25/35), 34% (12/35) were drinking > 40 g/alcohol/day and 54% (19/35) were diabetics. TPE significantly reduced the baseline sTG (4425 ± 2782 mg/dL vs. 709 ± 353 mg/dL, p < 0.001) in a single session, achieving a mean percentage reduction of 79 ± 13%; 20% (7/35) of sHTG cases required two TPE sessions to reduce sTG to < 1000 mg/dL. Adverse effects were reported in 4/42 TPE sessions (9,5%). sHTG-AP was observed in 3% of cases (1/29), and there were no deaths. sTG at 24 hours of admission showed no relation with the severity of APs. CONCLUSION: The treatment of sHTG with TPE, with the aim of treating HTG-AP or preventing its recurrence, reduces sTG quickly and safety.

Sometimes things are what they seem.

Accessory spleen is a frequent congenital abnormality (10-20%) resulting in the fusion failure of splenunculi. We present a case report of a 74 year-old man with a nodule identified in the tail of the pancreas of 1.8 cm x 1.5 cm in size. The CT scan showed soft tissue attenuation and arterial hyperenhancement with a lower uptake in the central area, low 18-FDG affinity and no evidence of 111-In-octretide uptake. A solid, round and well-circumscribed nodule was defined as an intrapancreatic accessory spleen (IPAS) by endoscopic ultrasound (EUS), due to shared ultrasonographic characteristics and a pattern of contrast enhancement with the spleen. The material obtained by EUS guided puncture was consistent with a lymph node. A distal pancreatectomy confirmed the presence of an IPAS.

Intraductal papillary neoplasm of the bile duct: a recurring disease.

Intraductal papillary neoplasm of the bile duct (IPNB) is a premalignant disease characterized by a low incidence, a high risk of malignant transformation, and an uncertain prognosis. We hereby present the case of an 8-mm IPNB in the left liver lobe detected by endosonography in a 76-year-old woman followed for a dissociated asymptomatic cholestasis who was treated with a left hepatectomy. The resected IPNB had low-grade dysplasia and no nodal involvement in the surgical piece; however, signs of recurrence of the disease were observed in the right liver lobe a year and a half later. Therefore, given that it can be multifocal and recurrent, IPNB is a disease that requires close follow-up.

A bronchobiliary fistula treated with cyanoacrylate glue in a patient with liver cirrhosis.

A 60-year-old male was operated upon in 2002 for liver hydatidosis, which included partial right hepatectomy with cholecystectomy and bilioduodenal anastomosis. He then developed liver cirrhosis secondary to left hepatic duct stricture. He presents at the emergency room with dry cough, which he had for a month and then became associated with yellowish, bitter-tasting "fluid" expectoration. A chest-abdominal CT scan revealed a 6 x 5-cm collection roughly located somewhere between the middle pulmonary lobe and subphrenic area . A fistula was suspected, which prompted a sputum biochemistry test that was positive for bilirubin. Given the patient's impaired liver function because of his liver disease conservative treatment was initiated with an inner-outer drain under transparietal hepatic cholangiography (TPHC) to promote bile outflow via the duodenum. Subsequently, TPHC was used to locate the point where contrast leaked from the biliary tree into a pleural cavity, and the fistula was sealed using cyanoacrylate glue, which resulted in improved symptomatology.

Ultrasound-guided percutaneous drainage and sclerotherapy in a patient with isolated autosomal dominant polycystic liver disease.

Isolated polycystic liver disease (IPLD) is a rare genetic condition characterized by the presence of multiple liver cysts with no association with polycystic kidney disease. Most patients are asymptomatic and acute complications (cyst torsion, bleeding, infection) are uncommon.Imaging techniques, including abdominal ultrasounds, computerized axial tomography, and magnetic resonance imaging, represent a vital diagnostic modality. They are also useful for therapy support in this disease. Below we report a peculiar case of a female patient recentlydiagnosed with IPLD who, having received treatment with ultrasoundguided percutaneous drainage and sclerotherapy for a giant liver cyst, showed symptom and laboratory improvement.

[Nasogastric enteral nutrition in severe acute pancreatitis]. / Nutrición por sonda nasogástrica en la pancreatitis aguda grave.

BACKGROUND AND OBJECTIVE: To establish the nasogastric enteral nutrition tolerance in patients with severe acute pancreatitis. PATIENTS AND METHOD: A total of 12 patients with severe acute pancreatitis (> or = 3 Ranson criteria; C-reactive protein > 210 mg/dl) and adverse clinical course were included during 2006. When we verified the disease severity, nasogastric (10 F) enteral nutrition was initiated. We used a low fat semi-elemental feed (Dietgrif) in a slow infusion rate. We evaluated the enteral nutrition tolerance and the adverse events. RESULTS: The patient (4 women and 8 men) mean age (standard deviation) was 70 (11) years and the mean hospital stay was 86 days (range: 14-405 days). The etiology of pancreatitis was: gallstones 8, alcohol abuse one and unknown 3. All patients had medical and/or pancreatic complications. Seven had significant pancreatic necrosis detected in the abdominal computed tomography. Three patients were admitted in the critical care unit and 2 died. The nasogastric enteral nutrition was well tolerated in 8 out of 12 patients (67%) regardless of their medical or pancreatic complications. Only in 3 patients we had initially to discontinue the feeding because of ileus and total parenteral nutrition was provisionally necessary. Enteral nutrition was impossible in one patient because of duodenal stenosis. CONCLUSIONS: Nasogastric enteral nutrition is well tolerated in patients with severe acute pancreatitis and it is an alternative to others nutritional routes.