RESUMEN
Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder characterized by venous malformations predominantly affecting the skin and gastrointestinal tract, commonly the small bowel. Small bowel gastrointestinal bleeding is often the presenting complaint and is difficult to diagnose and treat. Push enteroscopy, capsule endoscopy, and intraoperative enteroscopy are techniques described for the localization and management of small bowel bleeding. We present the case of a 68-year-old male with BRBNS who presented with symptomatic anemia and melena. Initial endoscopic evaluations identified intraluminal vascular blebs, which were injected; however, bleeding continued, prompting intraoperative enteroscopy. During the procedure, multiple small bowel vascular malformations consistent with BRBNS were identified. Cyanoacrylate glue was used endoscopically to treat active bleeding sites. The patient developed a rare postoperative complication of small bowel ischemia and obstruction secondary to cyanoacrylate glue, necessitating surgical resection. Small bowel bleeding in BRBNS poses diagnostic and therapeutic challenges. Intraoperative enteroscopy together with cyanoacrylate glue offers a valuable approach to localization and intervention. While cyanoacrylate glue is generally considered safe, rare complications, including ischemic events, have been reported. This case highlights the utility of intraoperative enteroscopy and endoscopic cyanoacrylate glue in managing small bowel bleeding associated with BRBNS. While effective, clinicians must be vigilant regarding potential complications, including ischemic events, associated with endoscopic hemostatic agents.
RESUMEN
INTRODUCTION: In acute cholangitis (AC), monitoring treatment response to antimicrobial therapy allows for making timely decisions on early biliary decompression. The aims of this study were to compare the discriminating powers of traditional blood inflammatory markers and propose new inflammatory markers that have a better ability to distinguish between patients with and without biliary tract infection. METHODS: This was a retrospective cohort study. Patients who underwent endoscopic retrograde cholangio-pancreaticography for AC and those without biliary tract inflammation were randomly selected in the 4:3 ratio of their hospital admissions from our hospital endoscopic retrograde cholangio-pancreaticography database. The exclusion criterion was the absence of C-reactive protein (CRP) measurements. RESULTS: The discriminating powers of the neutrophil count, lymphocytes, albumin, neutrophil-to-lymphocyte ratio, and CRP were superior to that of white blood cell (P1 < 0.005; P2 = 0.004; P3 < 0.0005; P4 < 0.0005; P5 < 0.0005). In monitoring treatment response in AC, lymphocyte count, albumin, neutrophil-to-lymphocyte ratio, and CRP were better than neutrophil count (P6 = 0.037, P7 < 0.005, P8, 9 < 0.0005). The area under the receiver operating characteristic curve (AUC) of CRP was higher than the AUC for lymphocytes, 96% (95% confidence interval [CI]: 94-98%) versus 81% (95% CI: 76-86%) (P < 0.0005), and larger than the AUC for albumin, 88% (95% CI: 84-92%) (P < 0.0005), indicating a greater discriminating power of CRP. However, the discriminating power of CRP-to-lymphocyte ratio (CLR) was more than that for CRP (P = 0.006) but equal to CRP-to-(lymphocytes∗albumin) ratio (CLAR) (P = 0.249). The AUCs of CLR and CLAR were both 98% (95% CI: 96-99%). CONCLUSIONS: CLR and CLAR have superior discriminating powers than traditional inflammatory markers used for monitoring treatment response in AC.