Exocrine pancreatic insufficiency and graft-versus-host disease.

We present the case of a 59-year-old man with acute myeloid leukemia treated with allogeneic hematopoietic stem cell transplantation (allo-HSCT). Two years later, he consulted for diarrhea and steatorrhea of 2-3 months of evolution with significant weight loss. Stool cultures and study of parasites were negative. Thyroid and celiac profile, cytomegalovirus viremia and colonoscopy, were normal. Fecal calprotectin and fecal clearance of alpha-1-Antitrypsin were normal but with almost undetectable fecal elastase (<15 ug/g). Pancreatic magnetic resonance reveals a generalized atrophy of the pancreas without other parenchymal or ductal alterations. The patient had no risk factors for chronic pancreatitis and was diagnosed with exocrine pancreatic insufficiency (EPI) associated with chronic graft-versus-host disease (GVHD). GVHD is caused by an immune-mediated reaction by donor T cells recognizing foreign antigens from the recipient. GVHD occurs in 80% of patients after allo-HSCT. Diarrhea is one of the most frequent manifestations, most often due to intestinal damage, opportunistic infections or chemoradiation effects.

Endoscopy-Related Bleeding and Thromboembolic Events in Patients on Direct Oral Anticoagulants or Vitamin K Antagonists.

BACKGROUND & AIMS: Few prospective studies have assessed the safety of direct oral anticoagulants (DOACs) in elective endoscopy. Our primary aim was to compare the risks of endoscopy-related gastrointestinal bleeding and thromboembolic events in patients on DOACs or vitamin K antagonists (VKAs) in this setting. Secondarily, we examined the impact of the timing of anticoagulant resumption on the risk of delayed bleeding in high-risk therapeutic procedures. METHODS: We conducted a multicenter, prospective, observational study from January 2018 to March 2020 of 1602 patients on oral anticoagulants (1004 on VKAs and 598 on DOACs) undergoing 1874 elective endoscopic procedures. Our primary outcomes were 90-day thromboembolic events and 30-day endoscopy-related gastrointestinal bleeding. The inverse probability of treatment weighting propensity score method was used for baseline covariate adjustment. RESULTS: The 2 groups had similar risks of endoscopy-related gastrointestinal bleeding (VKAs vs DOACs, 6.2% vs 6.7%; adjusted odds ratio [OR], 1.05; 95% CI, 0.67-1.65) and thromboembolic events (VKAs vs DOACs, 1.3% vs 1.5%; adjusted OR, 0.90; 95% CI, 0.34-2.38). In high bleeding risk procedures (n = 747), delayed anticoagulant resumption (> 48 hours or 24-48 hours vs < 24 hours) did not reduce the risk of postprocedural bleeding (10.3%, 9%, and 5.8%, respectively; adjusted P = .43). Hot and cold snare polypectomy were the most frequent high-risk interventions (41.8% and 39.8%, respectively). CONCLUSION: In a prospective study of patients on DOACs or VKAs undergoing elective endoscopy, endoscopy-related bleeding and thromboembolic events showed similar risk. Our study suggests that early anticoagulant resumption is safe in most patients, but more data are needed for advanced high-risk therapeutic procedures.

Hemorragia digestiva en paciente con hiperplasia de glándulas de Brunner / Digestive tract hemorrhaging in a patient with Brunner's gland hyperplasia

Resumen Objetivo: analizar las características epidemiológicas, bases etiopatogénicas y presentación clínica, así como el diagnóstico y el tratamiento de la hiperplasia de glándulas de Brunner (HGB). Métodos: describir un caso de HGB diagnosticado de forma incidental durante una endoscopia electiva y realizar una revisión de la literatura disponible hasta el momento. Resultados: esta neoformación consiste en una proliferación glandular localizada preferentemente en el duodeno proximal. Su diagnóstico, normalmente realizado mediante biopsia endoscópica, puede asociarse con complicaciones que, aunque infrecuentes, no deben ser subestimadas. Conclusiones: las neoplasias duodenales representan un porcentaje pequeño dentro del total de las que afectan al tracto gastrointestinal. Debido a que el diagnóstico de estas lesiones suele realizarse de forma casual durante una endoscopia programada, el tratamiento deberá basarse en la sintomatología, así como el tamaño de las mismas, de acuerdo con los estándares de tratamiento de cada centro.

Abstract Objective: This study analyzes the epidemiological characteristics, etiological and pathogenic bases, clinical presentation, diagnosis and treatment of Brunner's gland hyperplasia. Methods: We describe a case of Brunner's gland hyperplasia that was diagnosed incidentally during elective endoscopy and review the available literature. Results: This neoplasm consists of glandular proliferation preferentially located in the proximal duodenum. Its diagnosis, normally made by endoscopic biopsy, can be associated with complications that, although infrequent, should not be underestimated. Conclusions: Duodenal neoplasms are a small percentage of those that affect the gastrointestinal tract. Because diagnosis is usually made by chance during a scheduled endoscopy, treatment should be based on the symptoms and size of the lesion according to the treatment standards of each medical center.

[Acute liver ischaemia after gastro-oesophageal variceal bleeding]. / Isquemia hepática aguda tras hemorragia digestiva alta por varices esofagogástricas.

INTRODUCTION: Variceal upper gastrointestinal bleeding (UGIB) can trigger acute hypoxic hepatitis (AHH). The aim of this study was to analyse the incidence, associated risk factors and mortality of AHH after variceal UGIB. PATIENTS AND METHODS: Retrospective study of cirrhotic patients with variceal UGIB, classified into 2 groups according to the development of AHH. AHH was diagnosed when AST and ALT reached levels 10 times above the upper limit of normal, after ruling out other causes of hepatitis. The standard initial treatment consisted of haemodynamic support, emergency endoscopy with rubber band ligation, somatostatin and antibiotics. In the case of failure of primary haemostasis, a transjugular intrahepatic portosystemic shunt (TIPS) was implanted. Both groups (AHH and non-AHH) were compared. RESULTS: Sixty-eight cirrhotic patients with variceal UGIB admitted to the gastroenterology department of Hospital Ramón y Cajal between January 2007 and March 2012 were analysed. Eleven of these patients (16.2%) developed AHH. Univariate analysis showed the following items as risk factors: diabetes (OR: 7.5; CI: 1.9-29), shock (OR: 8.5; CI: 2.06-34) and persistent bleeding (OR: 9.0, CI: 1.6-49, P=.03). However, multivariate analysis confirmed only diabetes (OR: 8.61; CI: 1.4-52.5) and shock (OR: 7.58; CI: 1.26-45.51) as risk factors. Mortality rate in the AHH group was 45%, compared to 10.5% in the non-HAA group (P=.012). CONCLUSIONS: AHH after variceal UGIB occurred in 16.2% of cirrhotic patients and was associated with a poorer prognosis, with a mortality rate of 45%. Our findings suggest that diabetes and shock are risk factors for the development of AHH. Early identification of at-risk patients could therefore help prevent AHH.

[Autoimmune pancreatitis]. / Pancreatitis autoinmune.

Autoimmune pancreatitis is a benign fibroinflammatory disease of the pancreas of probable autoimmune origin, which includes 2 different phenotypes: type 1 (lymphoplasmacytic sclerosing pancreatitis) and type 2 (idiopathic duct-centric pancreatitis). Its clinical presentation as obstructive jaundice in patients with a pancreatic mass is common and therefore it must be included in the differential diagnosis of pancreatic neoplasia. Many diagnostic criteria have been described throughout history. The most famous are the HISORT criteria of the Mayo Clinic and the international consensus criteria of 2011. One of the main features of autoimmune pancreatitis is its dramatic response to steroid therapy, without the need for surgical treatment. Knowledge of this disease can dramatically change the management of patients with obstructive jaundice, who would otherwise be subjected to a pancreaticoduodenectomy.

[Acute hypertrygliceridemic pancreatitis]. / Pancreatitis aguda por hipertrigliceridemia.

Acute hypertriglyceridemic pancreatitis is the third cause of acute pancreatitis in the Western population. There is usually an underlying alteration in lipid metabolism and a secondary factor. Clinical presentation is similar to that of pancreatitis of other etiologies, but the course of acute hypertriglyceridemic pancreatitis seems to be worse and more recurrent. Some laboratory data can be artefacts, leading to diagnostic errors. This is the case of amylase, which can show false low levels. Treatment is based on intense fluidotherapy and analgesia. When there is no response to conservative management, other methods to lower triglyceride levels should be used. Several options are available, such as plasmapheresis, insulin, and heparin. The present article provides a review of the current literature on this entity.

[An exceptional cause of acute hepatitis in an adult: parvovirus B19]. / Una causa excepcional de hepatitis aguda en el adulto: parvovirus B19.

There are multiple causes of hepatitis. The most frequent etiologies are viral, usually hepatitis A, B and C viruses. However, other, non-hepatotropic viruses can cause this disease, including parvovirus B19. We present a case of acute hepatitis due to parvovirus B19, as well as a review of the epidemiological, clinical, diagnostic and therapeutic features of this entity.

[Octreotide treatment for postoperative chylous ascites in an adult]. / Ascitis quilosa posquirúrgica en un adulto tratada con octreótida.

Chylous ascites is infequent after abdominal surgery. We describe the case of a 43-year-old man with portal cavernomatosis who underwent surgery to insert a splenorenal shunt, which was not placed due to the absence of signs of portal hypertension. On postoperative day 20, the patient developed abdominal distension and mild dyspnea and was diagnosed with chylous ascites, which was related to the surgery. The patient was initially treated with diet and diuretics, with no clinical response, and consequently octreotide therapy was started. Four days later, the ascites was almost resolved and an ultrasound scan at 4 months showed its complete disappearance. This article demonstrates the effectiveness of octreotide in the treatment of postsurgical chylous ascites.