Síndrome de superposición autoinmune secuencial (hepatitis autoinmune/colangitis esclerosante primaria) y enfermedad inflamatoria intestinal: a propósito de tres casos clínicos / No disponible

La enfermedad inflamatoria intestinal (EII) se relaciona con distintas manifestaciones hepáticas como compromiso extraintestinal; la colangitis esclerosante primaria (CEP) es la más frecuente de ellas. Durante su evolución, pueden desarrollarse otras hepatopatías autoinmunes en lo que se conoce como síndrome de superposición (SS), entidad de menor asociación a EII que se presenta en forma concomitante o durante su evolución, lo cual se conoce como SS secuencial. Reportamos tres casos de SS secuencial en los cuales la hepatitis autoinmune es la primera manifestación, que tras 7-19 años de evolución desarrollaron una CEP y posteriormente una EII. Las manifestaciones extraintestinales hepáticas pueden preceder en varios años a la EII, por lo que es importante conocer esta asociación

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Autoimmune sequential overlap syndrome (autoimmune hepatitis/primary sclerosing cholangitis) and inflammatory bowel disease: three clinical cases.

Inflammatory bowel disease (IBD) is related to different liver extraintestinal manifestations and occurs with or without a link to disease activity. Primary sclerosing cholangitis (PSC) is the most common hepatobiliary manifestation. Other autoimmune hepatopathies may develop during the evolution of the latter, which is known as overlap syndrome. Sequential overlap syndrome occurs when these conditions appear in subsequent stages, and it is less frequently associated with IBD. We report three cases of sequential overlap syndrome with autoimmune hepatitis as the first manifestation, followed by PSC after 7-19 years and subsequently IBD. Liver extraintestinal manifestations may precede IBD by several years. Therefore, it is crucial to keep this association in mind, thereby reducing the diagnostic delay.

[Acute small bowel diverticulitis in a patient with crohn’s disease]. / Diverticulitis aguda de intestino delgado en un paciente con enfermedad de Crohn: Report of one case.

Diverticular disease of the small intestine is rare, especially when it is located in the jejunum. It is generally asymptomatic, but in some patients it may have complications such as acute diverticulitis with peritonitis, gastrointestinal bleeding or obstruction. In such cases, the recommended treatment is surgery. We report a 77-year-old patient with ileal Crohn’s disease with a long-standing inflammatory phenotype, who developed acute diverticulitis of the jejunum presenting a severe septic shock and secondary multiple-organ failure. It resolved with medical treatment and prolonged antibiotic therapy.

Multi-modality imaging of the leaking ureter: why does detection of traumatic and iatrogenic ureteral injuries remain a challenge?

Ureteral injuries are uncommon in trauma patients, accounting for fewer than 1% of all injuries to the urinary tract. These uncommon, yet problematic, injuries can often be overlooked in the standard search pattern on abdominal and pelvic multi-detector CT (MDCT) images, as radiologists focus on more immediate life-threatening injuries. However, early diagnosis and management are vital to reduce potential morbidity. If there is a high clinical index of suspicion for ureteral injuries with penetrating or blunt trauma, or if there is suspected iatrogenic ureteral injury, delayed-phase/urographic-phase MDCT images are essential for confirming the diagnosis. Moreover, making the distinction between partial and complete ureteral transection is critical, as it will guide management. The aim of this pictorial review is to overview the key imaging findings in blunt and penetrating traumatic and iatrogenic injuries of the ureter, as well as to discuss the advantages and disadvantages of different imaging modalities for accurately and rapidly establishing or excluding the diagnosis of ureteral injuries, with an emphasis on MDCT. The potential causes of missed ureteral injuries will also be discussed.

Diverticulitis aguda de intestino delgado en un paciente con enfermedad de Crohn: Report of one case / Acute small bowel diverticulitis in a patient with crohn’s disease

Diverticular disease of the small intestine is rare, especially when it is located in the jejunum. It is generally asymptomatic, but in some patients it may have complications such as acute diverticulitis with peritonitis, gastrointestinal bleeding or obstruction. In such cases, the recommended treatment is surgery. We report a 77-year-old patient with ileal Crohn’s disease with a long-standing inflammatory phenotype, who developed acute diverticulitis of the jejunum presenting a severe septic shock and secondary multiple-organ failure. It resolved with medical treatment and prolonged antibiotic therapy.

Mesotelioma benigno como causa de dolor abdominal inespecífico en un paciente con Enfermedad de Crohn / Benign multicystic peritoneal mesothelioma in a patient with Crohn disease

Benign multicystic peritoneal mesothelioma is an uncommon lesion arising from the peritoneal mesothelium. It is asymptomatic or presents with unspecific symptoms. Imaging techniques may reveal it, however the final diagnosis can only be made by histopathology. Surgery is the only effective treatment considering its high recurrence rate. We report a 19 years old male with Crohn’s disease. Due to persistent abdominal pain, an abdominal magnetic resonance imaging was performed, showing a complex cystic mass in the lower abdomen. The patient underwent surgery and the lesion was completely resected. The pathological study reported a benign multicystic peritoneal mesothelioma.

[Benign multicystic peritoneal mesothelioma in a patient with Crohn disease]. / Mesotelioma benigno como causa de dolor abdominal inespecífico en un paciente con Enfermedad de Crohn.

Benign multicystic peritoneal mesothelioma is an uncommon lesion arising from the peritoneal mesothelium. It is asymptomatic or presents with unspecific symptoms. Imaging techniques may reveal it, however the final diagnosis can only be made by histopathology. Surgery is the only effective treatment considering its high recurrence rate. We report a 19 years old male with Crohn’s disease. Due to persistent abdominal pain, an abdominal magnetic resonance imaging was performed, showing a complex cystic mass in the lower abdomen. The patient underwent surgery and the lesion was completely resected. The pathological study reported a benign multicystic peritoneal mesothelioma.

Ionizing radiation exposure in patients with inflammatory bowel disease: are we overexposing our patients?

OBJECTIVE: Imaging techniques are accurate and reliable in diagnosing inflammatory bowel disease (IBD). However, the main disadvantage of computed tomography (CT) compared with magnetic resonance imaging (MRI) is radiation exposure and the potential risk of cancer, especially since IBD patients are at increased risk of malignancies. This study aims to quantify and characterize effective radiation exposure of IBD patients. METHODS: A cohort of IBD patients were retrospectively enrolled in the Clínica las Condes IBD registry between 2011 and 2013. High cumulative radiation exposure (CED) was defined as ≥-50 mSv. RESULTS: A total of 325 IBD patients were enrolled in our registry, including 243 (74.8%) with UC and 82 (25.2%) with CD. The patients with CD were more commonly to reach a high CED seen compared with those with UC (19.5% vs 2.5%). Higher exposure to radiation was associated with longer duration of disease, ileal involvement, stricturing behavior, treatments with steroids and biological agents and CD-related hospitalization or surgery. Abdominopelvic CT and enteroclysis CT accounted for 93.6% of total CED. CONCLUSIONS: A high percentage of IBD patients are exposed to high CED. Radiation-free cross-sectional examinations, such as MRI, should be used, especially in young patients, those who have undergone prior surgery and those with severe IBD.

Invaginación intestinal en adultos como manifestación de enfermedad celíaca: Caso clínico / Celiac disease presenting as an intestinal intussusception: Report of one case

Acute abdominal pain caused by perforation, intestinal lymphoma or intussusception is an uncommon manifestation in adult celiac disease. We report a 49 year-old female with history of irritable bowel syndrome and osteoporosis consulting for acute abdominal pain and severe abdominal distention. Abdominal CT scan and magnetic resonance imaging showed a jejunal intussusception and other radiological alterations that suggested the possibility of celiac disease. Serological antibodies (endomysial and transglutaminase antibodies), endoscopy and the pathological study of duodenal biopsies confirmed the diagnosis. With a gluten free diet, the patient remains asymptomatic.

Enteroclisis por tomografía computarizada en niños: experiencia inicial, técnica y utilidad / Computed tomography enteroclysis in children: initial experience, technical and profit

Objetivo: Evaluar la técnica de enteroclisis por tomografía computarizada (ETC ) y revisar sus indicaciones y hallazgos en niños. Materiales y métodos: Revisión retrospectiva de todas las ETC realizadas por los autores en pacientes menores de 18 años de edad entre enero de 2005 y marzo de 2009. Además, se relacionan los resultados con otros métodos de imagen, cirugía o patología. Resultados: Se revisaron 30 ETC (edad media 14,6 años, rango 8-18 años). Las indicaciones más comunes fueron: enfermedad inflamatoria intestinal (55%), dolor abdominal (25%), posquirúrgico (7%), hemorragia digestiva (5%), síndrome de Peutz-Jeghers (4%) y emésis (4%). No hubo complicaciones. El 10% de los estudios fue normal. El hallazgo más común fue enfermedad de Crohn (37%) y obstrucción parcial del intestino delgado (26%). Conclusión: La ETC es fácil y certera en la pesquisa de la patología de intestino delgado en niños. Esta técnica es de gran utilidad en pacientes con enfermedad de Crohn con afectación del intestino delgado.

Objective: To evaluate CT enteroclysis technique (CT E) and to review their indications and findings in children. Materials and Methods: We retrospectively reviewed all CT enteroclysis studies in younger than 18 years performed between January 2005 and March 2009. We correlated the results with other abdominal imaging studies and surgical and pathological findings. Results: Thereview revealed 30 CTE studies performed (mean age 14.6 years, range 8–18 years). CTE study wasperformed most commonly for evaluation of suspicious intestinal inflammatory disease (55%), abdominal pain (25%), post-operative (7%) digestive hemorrhage (5%) Peutz Jeghers syndrome (4%) and vomiting (4%). No complications of CTE were reported. The findings were normal in 10% of the CT E studies. The most common small bowel diagnoses were Crohn’s disease (37%) andpartial small bowel obstruction (26%). Conclusion: CTE is safe, feasible, and accurate in depicting small-bowel pathology in children. This technique can be particularly useful in children with Crohn’s disease involving the small bowel.

[Celiac disease presenting as an intestinal intussusception: report of one case]. / Invaginación intestinal en adultos como manifestación de enfermedad celíaca: Caso clínico.

Acute abdominal pain caused by perforation, intestinal lymphoma or intussusception is an uncommon manifestation in adult celiac disease. We report a 49 year-old female with history of irritable bowel syndrome and osteoporosis consulting for acute abdominal pain and severe abdominal distention. Abdominal CT scan and magnetic resonance imaging showed a jejunal intussusception and other radiological alterations that suggested the possibility of celiac disease. Serological antibodies (endomysial and transglutaminase antibodies), endoscopy and the pathological study of duodenal biopsies confirmed the diagnosis. With a gluten free diet, the patient remains asymptomatic.

[Intraductal papillary mucinous neoplasm of the pancreas]. / Neoplasia mucinosa intraductal del páncreas.

Intraductal papillary mucinous neoplasm of the pancreas is characterized by a dilatation of the main pancreatic duct and/or secondary ducts, mucin production and the absence of ovarian-like struma. The symptoms are non-specific and often the diagnosis is incidental. The treatment of choice is surgery, since these tumors may become malignant. The prognosis depends on the type of lesion, whether the excision is complete and lymph node involvement. The aim of this review is to analyze the clinical, diagnostic, therapeutic and pathological characteristics of this disease.

Neoplasia mucinosa intraductal del páncreas: [revisión] / Intraductal papillary mucinous neoplasm of the pancreas: [review]

Intraductal papillary mucinous neoplasm of the pancreas is characterized by a dilatation of the main pancreatic duct and/or secondary ducts, mucin production and the absence of ovarian ¡ike struma. The symptoms are non-specific and often the diagnosis is incidental. The treatment of choice is surgery, since these tumors may become malignant. The prognosis depends on the type of lesion, whether the excision is complete and lymph node involvement. The aim of this review is to analyze the clinical, diganostic, therapeutic and pathological characteristics of this disease.

Impact of preoperative ultrasonographic staging of the neck in papillary thyroid carcinoma.

OBJECTIVE: To determine the frequency of occult macroscopic metastasis detected by preoperative US evaluation of the neck in patients with PTC. Papillary thyroid carcinoma (PTC) is a malignancy with a high rate of lymph node metastasis. The findings of routine thyroid ultrasonography (US) and physical examination may underestimate metastatic disease. Thus, we propose that patients diagnosed as having PTC undergo preoperative US staging of the neck. DESIGN: This prospective study included 60 patients diagnosed as having PTC from January 1 through June 30, 2006. Patients had undergone previous thyroid US evaluation with no palpable adenopathy. Lymph nodes were deemed suspicious by US findings with a minor axis greater than 10 mm, a minor axis greater than 50% of the major axis, or hyperechogenicity with or without microcalcifications. Metastasis was confirmed by fine-needle aspiration biopsy or frozen section analysis. Patients with confirmed metastasis underwent a neck dissection. The location of adenopathy reported by US was correlated with the pathological report. RESULTS: The US evaluation identified 12 of 60 patients (20%) with adenopathy suggestive of metastasis. Metastasis was confirmed in 11 of 12 patients (92%). Metastasis was found in 1 of 48 patients who had a negative US finding. Overall, sensitivity, specificity, and positive and negative predictive values were 92%, 98%, 92%, and 98%, respectively. All neck levels with suspicious adenopathy detected by US evaluation, with 1 exception, were confirmed by pathological findings. Nine patients had additional neck levels involved with microscopic disease undetected by the US evaluation. CONCLUSIONS: In patients with PTC, preoperative US evaluation of the neck is effective in detecting nonpalpable metastasis. Therefore, routine preoperative neck US evaluation is recommended to optimize primary surgical planning.

Cryptogenic organizing pneumonitis during oxaliplatin chemotherapy for colorectal cancer: case report.

The patient presented here is a 30-year-old woman who underwent anterior resection for the initial treatment of rectal cancer. A postoperative study showed a single liver metastasis. The patient received adjuvant pelvic radiotherapy with concomitant 5-fluorouracil (5-FU) treatment followed by liver metastasectomy 6 weeks after the completion of radiation therapy and chemotherapy. Adjuvant therapy with 5-FU, leucovorin, and oxaliplatin (FOLFOX 4 regimen) was continued. The initial five cycles were well tolerated with the occurrence of only paresthesia that did not interfere with function. After the sixth cycle of the treatment, progressive dyspnea and persistent cough developed in the patient, although her clinical history was negative for lung disease. A chest radiograph revealed diffuse bilateral interstitial infiltrates, and a chest CT scan showed bilateral alveolar infiltrates predominant in the right lung. Lung biopsy by video-assisted thoracoscopy was performed, and the histologic report showed cryptogenic organizing pneumonitis (COP). Prednisone therapy (1 mg/kg/d) resulted in a very good clinical response. In fact, the patient had complete remission of respiratory symptoms including cough and dyspnea after 4 days of treatment, and the chest CT scan showed complete resolution of lung infiltrates after 4 weeks. One month later, the patient continued adjuvant treatment with six cycles of 5-FU, leucovorin, and irinotecan (ie, the FOLFIRI regimen) without complications. Thus, oxiplatin was implicated as the likely cause of this drug-induced lung toxicity, which is a very rare complication associated with platins. Diffuse interstitial lung disease, particularly COP, has been described following the administration of the cytotoxic agents bleomycin and busulfan, but a connection to oxaliplatin has not been reported before this case.

[Multiple carcinoid tumors of the small bowel. Report of one case]. / Carcinoide intestina múltiple. Análisis de un caso y revisión de la literatura.

Small bowel carcinoid tumors are more common in the distal ileum and they are multiple in 30% of cases. The most common clinical manifestation is abdominal pain and the treatment of choice is surgical excision. We report a 63 years old female consulting for abdominal pain. An intestinal transit by computed axial tomography revealed multiple images compatible with small bowel carcinoid tumors. She had a surgical excision of the involved intestinal segment and the pathological study confirmed the imaging diagnosis. In the follow up, this patients has been asymptomatic.

[Advances in radiography of the small intestine: computed tomography enteroclysis]. / Avances en radiología del intestino delgado: enteroclisis por tomografía computarizada.

Computed tomography (CT) enteroclysis is a new technique consisting of helical CT of the abdomen and pelvis after administration of water through a nasojejunal tube and intravenous contrast, resulting in adequate distension and visualization of the small bowel wall. The use of this technique is especially recommended in patients with gastrointestinal bleeding of unknown etiology, possible neoplastic processes of the small bowel, partial small bowel obstruction, and inflammatory bowel disease. One-hundred consecutive patients underwent CT enteroclysis (multiple detectors; 8, 16, or 64) over a 1-year period for suspected lesions of the small bowel. Of these, 31 were positive: Crohn's disease (17), tumors (8), partial obstruction (2), radiation enteritis (1), sprue (1), pneumatosis cystoids (1), and dilatation of bowel loops (1). In 28 of the 31 patients, the findings were confirmed by pathology, endoscopy or clinical follow-up.

Avances en radiología del intestino delgado: enteroclisis por tomografía computarizada / Advances in intestinal radiology: computed tomography enteroclysis

La enteroclisis por tomografía computarizada (TC) es una nueva técnica que consiste en una TC helicoidal con múltiples detectores realizada tras la administración de agua a través de una sonda nasoyeyunal y medio de contraste intravenoso, lo que permite una adecuada distensión y visualización del intestino delgado. El uso de esta técnica está especialmente indicado en pacientes con enfermedad inflamatoria intestinal, hemorragia digestiva de causa no precisada, obstrucción parcial de intestino delgado y sospecha de neoplasia intestinal. Un total de 100 pacientes consecutivos se sometieron a una enteroclisis por TC (multiples detectores: 8, 16 o 64) debido a la sospecha de lesión en el intestino delgado. De ellos, 31 presentaron lesiones en esa localización: enfermedad de Crohn (n = 17), tumores (n = 8), obstrucción intestinal (n = 2), enteritis actínica (n = 1), enfermedad celíaca (n = 1), neumatosis cistoide (n = 1) y dilatación de asas (n = 1); 28 de los 31 casos fueron confirmados por anatomía patológica, hallazgos endoscópicos o seguimiento clínico

Computed tomography (CT) enteroclysis is a new technique consisting of helical CT of the abdomen and pelvis after administration of water through a nasojejunal tube and intravenous contrast, resulting in adequate distension and visualization of the small bowel wall. The use of this technique is especially recommended in patients with gastrointestinal bleeding of unknown etiology, possible neoplastic processes of the small bowel, partial small bowel obstruction, and inflammatory bowel disease. One-hundred consecutive patients underwent CT enteroclysis (multiple detectors; 8, 16, or 64) over a 1-year period for suspected lesions of the small bowel. Of these, 31 were positive: Crohn's disease (17), tumors (8), partial obstruction (2), radiation enteritis (1), sprue (1), pneumatosis cystoids (1), and dilatation of bowel loops (1). In 28 of the 31 patients, the findings were confirmed by pathology, endoscopy or clinical follow-up