Fatal outcome of a corticosteroid resistant IgG4-related autoimmune hepatitis and IgG4-primary sclerosing cholangitis.

33-year-old woman, previously hospitalized for self-limited migratory bile duct strictures, presented with jaundice three months after giving birth. Blood analysis revealed elevated levels of aspartate aminotransaminase 1064U/L, alanine aminotransaminase 1097U/L, gamma-glutamyl transferase 194U/L, alkaline phosphatase 284U/L, bilirubin 27mg/dL and prothrombin time of 19.3s. Magnetic resonance-cholangiopancreatography revealed intrahepatic bile duct dilation with a stenosis in the common hepatic duct, not detected on endoscopic retrograde cholangiopancreatography. Additionally, diffuse signal abnormalities were observed in the liver parenchyma on T2 sequences. An early liver biopsy showed moderate-severe interface hepatitis with IgG4-positive plasma cell infiltration (IgG4-PPC) of 8-20cells/HPF, hepatocellular ballooning and focal rosette formation, yielding 6 points of the simplified-score for autoimmune hepatitis and treatment with methylprednisolone was initiated. Despite treatment, there was no improvement after two weeks and the patient received rituximab as a rescue treatment, but three days later, developed candida sepsis with rapid progression to multiorgan failure, ultimately resulting in death.

Adenoma serrado gástrico / Gastric serrated adenoma

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Gastric serrated adenoma.

A 51 years-old male with several family history of gastric cancer, who was studied one year before for dyspepsia. A new gastroscopy was done that objectified in the greater curvature, a sessile polyp with slightly depressed center and a villous crypt pattern with Narrow Band Imaging. The histopathology study shown a horizontalization of the basal glands and basal dysplasia, compatible with serrated adenoma. A 51 year-old male with a family history of gastric cancer was studied for one year due to dyspepsia. A new gastroscopy was performed that identified a sessile polyp with a slightly depressed center and a villous crypt pattern in the greater curvature via narrow band imaging. The histopathology study showed horizontal basal glands and basal dysplasia, which was compatible with serrated adenoma.

Ulcerative colitis with gastric and duodenal involvement.

Ulcerative colitis is one of the forms of presentation of the inflammatory bowel disease. UC yypically affects the large bowel but in the last few years more cases with proximal involvement have been described (diffuse gastritis, focally enhanced gastritis and duodenitis). We present the case of gastric and duodenitis involvement in the context of a moderate-severe ulcerative pancolitis which showed a good evolution and resolution of symptoms with corticoid treatment.

Caso de pancreatitis aguda tóxica por infusiones de cola de caballo / Case of drug-induced acute pancreatitis produced by horsetail infusions

Introducción: las causas más frecuentes de pancreatitis aguda son las litiasis biliares, el consumo de alcohol, el tabaquismo o los tumores. Hay un porcentaje de ellas que quedan sin causa establecida, catalogándose de pancreatitis idiopática. Caso clínico: presentamos el caso de una mujer de 56 años con antecedente de suprarrenalectomía bilateral de las glándulas suprarrenales en tratamiento hormonal sustitutivo con corticoides, que presenta episodios de pancreatitis aguda leve de repetición con estudio etiológico (analítico y pruebas de imagen) sin hallazgos. Se sospecha el origen tóxico, por lo que se retiran los corticoides y se modifica el tratamiento antihipertensivo, pero la clínica persiste. Posteriormente se detecta el consumo habitual de infusiones de cola de caballo. Tras su suspensión la paciente se queda asintomática y no vuelve a presentar nuevos episodios. Discusión: la pancreatitis aguda tóxica es una causa rara de pancreatitis que con cierta frecuencia queda sin diagnosticar por la dificultad de establecer una relación entre el agente tóxico y la pancreatitis. Los fármacos relacionados con las pancreatitis agudas son múltiples, mientras que la información disponible es escasa con los productos de herboristería. Se suelen presentar como episodios leves y recurrentes, sin objetivar la causa en el estudio tanto analítico como por pruebas complementarias (ecografía de abdomen, tomografía computarizada [TC] de abdomen, colangiopancreatografía por resonancia magnética [RMN] y ecoendoscopia). Es importante detectar el origen de estas pancreatitis para evitar su recurrencia (AU)

Introduction: The most frequent causes of acute pancreatitis are biliary stones, alcohol consumption, smoking and tumors. Some of them do not have any established cause, and they are catalogued as idiopathic pancreatitis. Case report: We report the case of a 56-year-old woman with a history of bilateral adrenalectomy on hormone replacement therapy with corticosteroids, who has recurrent episodes of mild acute pancreatitis with an etiologic study (laboratory and imaging tests) without significant findings. A drug-induced etiology was suspected, so corticosteroids were removed and antihypertensive treatment was modified, but the clinical manifestations persisted. Later regular consumption of horsetail infusions was detected, and after their suspension the patient became asymptomatic and has not presented new episodes. Discussion: The drug-induced acute pancreatitis is a strange cause of pancreatitis that is frequently underdiagnosed because of the difficulty to establish a relationship between the drugs and the pancreatitis. Lots of drugs have been related with acute pancreatitis, while the information available for herbal products is limited. They usually present like mild and recurrent episodes, without significant findings in both laboratory and imaging tests (abdominal ultrasound, abdominal computed tomography [CT], cholangiography and endoscopic ultrasound). It is important to detect the origin of this type of pancreatitis to prevent recurrence (AU)

Case of drug-induced acute pancreatitis produced by horsetail infusions.

INTRODUCTION: The most frequent causes of acute pancreatitis are biliary stones, alcohol consumption, smoking and tumors. Some of them do not have any established cause, and they are catalogued as idiopathic pancreatitis. CASE REPORT: We report the case of a 56-year-old woman with a history of bilateral adrenalectomy on hormone replacement therapy with corticosteroids, who has recurrent episodes of mild acute pancreatitis with an etiologic study (laboratory and imaging tests) without significant findings. A drug-induced etiology was suspected, so corticosteroids were removed and antihypertensive treatment was modified, but the clinical manifestations persisted. Later regular consumption of horsetail infusions was detected, and after their suspension the patient became asymptomatic and has not presented new episodes. DISCUSSION: The drug-induced acute pancreatitis is a strange cause of pancreatitis that is frequently underdiagnosed because of the difficulty to establish a relationship between the drugs and the pancreatitis. Lots of drugs have been related with acute pancreatitis, while the information available for herbal products is limited. They usually present like mild and recurrent episodes, without significant findings in both laboratory and imaging tests (abdominal ultrasound, abdominal computed tomography [CT], cholangiography and endoscopic ultrasound). It is important to detect the origin of this type of pancreatitis to prevent recurrence.

Endometriosis en el músculo recto anterior del abdomen sobre cicatriz de cesárea / Rectus abdominal endometriosis on cesarean scar

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Tumor sólido pseudopapilar de páncreas con diagnóstico preoperatorio por ecoendoscopia / Solid pseudopapillary tumor of the pancreas diagnosed by preoperative endoscopic ultrasound

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