The inability to belch: a neglected disease in the era of high-resolution esophageal manometry.

Retrograde upper esophageal sphincter dysfunction (R-UESD) is characterized by the inability to belch. Evidence of using high-resolution manometry (HRM) in diagnosing R-UESD has emerged in recent years. We describe the clinical picture and HRM patterns of two patients with R-UESD. Case 1: A 23-year-old female presented with a two-year complaint of inability to belch. We performed HRM with a belch provocation test for which the patient drank 500 ml of carbonated water. The study revealed increased esophageal pressure, an absence of UES relaxation and secondary peristalsis once the patient mentioned the need to belch. Case 2: A 21-year-old male presented to our medical office with a history of an incapacity to belch during the last three years. We performed HRM with a belch provocation test. During the study, he reported an incapacity to belch and his symptoms coincided with increased esophageal pressure, an absence of UES relaxation, and secondary peristalsis. Retrograde upper esophageal sphincter dysfunction is a rare condition characterized by a lack of UES relaxation during esophageal distension. The incapacity to belch is the hallmark of the disease. We encourage the use of HRM, looking for an increase in esophageal pressure to the level of gastric pressure, failure of UES relaxation with consequently no venting of air across the UES, and secondary peristalsis. In conclusion, diverse R-UESD clinical presentations represent a diagnostic challenge for physicians. This case series highlights the need to actively search for typical HRM findings when encountering patients referring an incapacity to belch.

Comparing fine needle biopsy techniques in solid pancreatic lesions: A prospective randomized study.

INTRODUCTION: Endoscopic ultrasound-guided fine-needle biopsies (EUS-FNB) are the best technique for sampling solid pancreatic lesions. However, the most appropriate biopsy technique has not been standardized using Fine Needle Biopsy (FNB) needles. The aim of this work was to identify the best biopsy technique to achieve the best tissue integrity and cause the least blood contamination. MATERIAL AND METHODS: Patients ≥18 years of age with solid pancreatic lesions who underwent EUS-FNB at our institution from January 2020 to May 2021 were consecutively selected. Three passes were performed with each of the threee techniques to obtain tissue: suction with 10 ml of vacuum, capillary, and wet. An independent pathologist evaluated the received tissue integrity and the degree of blood contamination of each sample according to scales. RESULTS: Seventy-five patients were recruited for our study. A superior tissue integrity was observed using the wet-suction technique in lesions located in the body and/or tail of the pancreas, and an average score of 4.40 (p = 0.027) was assigned for this technique. Regarding the contamination of the sample in the whole cohort, the simple-suction technique shown a higher contamination, 1.55 (p < 0.001). There was no statistically significant difference among the techniques when evaluating tissue integrity or contamination in lesions larger or smaller than 3 cm. CONCLUSION: When performing EUS-FNB for solid pancreatic lesions located in the head/uncinated process, the three methods provided similar diagnostic yields. The wet-suction technique had a higher score in tissue integrity when lesions were located in the body and/or tail of the pancreas.

Acute respiratory failure secondary to megaesophagus: think beyond COVID-19.

A 61-year-old man with a history of progressive dysphagia in the last three years and current COVID-19 diagnosis, presented to our emergency department with sudden dyspnea and loss of consciousness. Initial examination revealed a respiratory rate of 30 bpm with an oxygen saturation of 94% with room air. A venous blood gas exam showed acute hypercapnic respiratory failure; therefore, he was intubated and admitted to the medical intensive care unit.

Glanzmann thrombasthenia: an uncommon cause of acute upper gastrointestinal bleeding.

The major function of platelets is to contribute to hemostasis. If an impairment in their production and/or function occurs, abnormal bleeding can develop. An 18-year-old male presented to our hospital after four episodes of hematemesis. His medical history was relevant for Glanzmann thrombasthenia diagnosed during early childhood. On initial examination, he appeared pale and with normal blood pressure. His complete blood count included a hemoglobin concentration of 11.0 g/dL, additional laboratory tests were within the normal ranges. The initial approach consisted of a high dose of proton pump inhibitors. Hours later, esophagogastroduodenoscopy revealed diffuse oozing bleeding from gastric mucosa with no other visible lesions such as peptic ulcers or varices.

Risk factors for mortality in patients with acute bacterial cholangitis - Type-2 diabetes is a significant clinical predictor.

Acute cholangitis is a life-threatening infection, and several features are associated with a worse prognosis if prompt treatment is not started. Eighty-six subjects with acute cholangitis were included in a retrospective analysis. Patients had a median age of 53 years (range: 34.5 to 70 years) and 55 (64.0 %) were female. Of the entire cohort, 16 patients had a history of diabetes mellitus. Regarding acute cholangitis severity, 17 (19.8 %) cases were classified as severe, 41 (47.7 %) as moderate, and 28 (32.6 %) as mild.

Performance of serum procalcitonin as a biochemical predictor of death in hematology patients with febrile neutropenia.

INTRODUCTION: Historically, the measurement of serum procalcitonin (PCT) levels in patients with leukopenia has been rejected without sufficient prospective evidence to justify this argument. On the other hand, the accumulated use of broad spectrum antibiotics in these patients and their consequences make the use of PCT attractive in an effort to reduce its use. PATIENTS AND METHODS: We conducted a prospective study between 2016 and 2018, recruiting newly diagnosed FN patients, evaluating them with PCT levels during the first 24 h. After this we evaluate them with overall survival throughout the follow-up. RESULTS: A total of 81 episodes of FN in 72 patients were included. We report a mortality of 27.2% in our cohort. The mean serum PCT in these patients was 4.01 ng/mL compared to 0.42 ng/mL in the survivors group (p < 0.01). Using ROC curves, we determined a cut-off point to predict septic shock/death at 0.46 ng/mL. Patients with a procalcitonin >0.46 ng/mL had an increased risk of death, with a HR of 4.43, (p = 0.048). CONCLUSION: In conclusion, in our trial a single PCT on admission at a cut-off value of 0.46 ng/mL was able to predict the occurrence of septic shock and death in FN patients.

The Heart in Diabetic Ketoacidosis: A Narrative Review Focusing on the Acute Cardiac Effects and Electrocardiographic Abnormalities.

Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus. Hyperglycemia, acidosis, and electrolyte imbalances can directly affect the heart by inducing toxicity, impairing myocardial blood flow, autonomic dysfunction, and altering activation and conduction of electrical impulses throughout the heart, increasing the risk of arrhythmias and ischemia. The electrocardiogram is useful in monitoring patients during and after an episode of DKA, as it allows the detection of arrhythmias and guides metabolic correction. Unfortunately, reports on electrocardiographic abnormalities in patients with DKA are lacking. We found two electrocardiographic patterns that are frequently reported in the literature: a pseudo-myocardial infarction and a Brugada Phenocopy. Both are associated with DKA metabolic anomalies and they resolve after treatment. Because of their clinical relevance and the challenge they represent for clinicians, we analyzed the clinical characteristics of these patients and the mechanisms involved in these electrocardiographic findings.

A case of round pneumonia due to Enterobacter hormaechei: the need for a standardized diagnosis and treatment approach in adults.

Round pneumonia is an unusual radiological manifestation of a bacterial lung infection. We present the case of an elderly male patient who arrived at the emergency room with a productive cough and exertional dyspnea. His chest x-ray and CT showed a round opacity and air bronchograms in the right upper lobe. Taken together, the patient's symptoms and images strongly suggest a pulmonary infection. Empirical antibiotic therapy with ceftriaxone and clarithromycin was started. The sputum culture was positive for Enterobacter hormaechei and the bacterium was sensitive to levofloxacin; therefore, the antibiotic therapy was changed. Despite the treatment, the patient progressed to respiratory failure and septic shock, dying six days after admission. Although round pneumonia is uncommon, it is a potentially curable disease and clinicians should always consider it in their differential diagnosis.

Tumor of the epididymis: an uncommon presentation of disseminated coccidioidomycosis.

Coccidioidomycosis is an endemic disease of arid regions in the Western hemisphere. Its clinical presentation varies from asymptomatic nodules on chest x-rays to disseminated disease. We present the case of a 48-year-old man with a hard and heterogeneous tumor in the posterior aspect of the right testis. Color flow doppler testicular ultrasonography was performed and two nodular masses in the tail of the right epididymis were identified. An epididymectomy was performed and histopathological examination revealed coccidioidomycosis. After diagnosis, the patient was successfully treated with fluconazol.

Clinical outcomes and biochemical characteristics of a Hispanic cohort of patients with diabetic ketoacidosis: 10-Year experience in an emergency department / Resultados clínicos y características bioquímicas en una cohorte hispana de pacientes con cetoacidosis diabética: experiencia de una década en el departamento de emergencias

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Toluene toxicity presenting with hypokalemia, profound weakness and U waves in the electrocardiogram.

We present the case of a 25-year-old man with progressive limb weakness. His electrocardiogram showed prominent U waves which made us consider hypokalemia. The final diagnosis was toluene intoxication with severe hypokalemia and metabolic acidosis. Intravenous potassium administration and hydration effectively corrected the electrolyte and acid-base alterations; weakness resolved and the patient was discharged. The approach to a patient with acute weakness can be challenging. This case reminds us that the electrocardiogram can be a valuable tool in the evaluation and differential diagnosis of patients presenting to the emergency department with these conditions.