Resección endoscópica mucosa o mucosectomía (EMR) en pólipos complejos del colon. Experiencia clínica en un centro de referencia en Perú (2004-2018)

Antecedentes: La detección y resección de lesiones colónicas elevadas (pólipos) sésiles o planas, con polipectomía clásica o compleja detiene la secuencia adenoma-cáncer. La mucosectomía endoscópica (EMR) fue introducida en los setentas y perfeccionada en los ochentas como un procedimiento avanzado para el tratamiento de pólipos grandes o complejos. Una adecuada realización de la técnica puede evitar procedimientos quirúrgicos mayores. Objetivos: Evaluar los resultados y complicaciones de la técnica de mucosectomía (EMR) realizada por gastroenterólogos-endoscopistas en un centro de referencia del Perú. Revisión de indicaciones, éxito, complicaciones y seguimiento. Material y método: Se realizó un análisis descriptivo, retrospectivo y observacional de pacientes tratados con técnica de mucosectomía endoscópica en un centro de endoscopia de referencia nacional en Lima, Perú, desde enero de 2004 a diciembre de 2018. Se aplicó la técnica de elevación y corte controlado en lesiones polipoideas mayores a 1 cm. Se realizó la resección en bloque en lesiones hasta 3 cms y técnica de "piecemeal" o sacabocado en mayores de 3 cms. Se evaluaron resultados, eventos adversos y recurrencia. Resultados: Se analizaron 756 lesiones en el mismo número de pacientes. Hombres 46.8 % (298) y mujeres 53.2 % (338). La edad promedio fue de 61.9 (rangos 37-91). El tamaño promedio de las lesiones fue de 20,3 mm (10 - 50 mm). El tiempo promedio por procedimiento fue de 46 minutos (rango 20-123 minutos). Se logró resección en bloque en 78.04 % de pólipos (590 lesiones). Se realizó técnica sacabocado en 166 (21.96 %) lesiones. La tasa de complicaciones en nuestra serie fue del 6.74 %, todos manejados endoscópicamente más tratamiento conservador médico sin cirugía. El seguimiento promedio fue de 18 meses (3 - 24 meses) y la tasa global de recidiva local fue de 2.49 %. El tratamiento quirúrgico post procedimiento y con pieza analizada se indicó en 15 casos por adenomas avanzados con adenocarcinoma intramucoso bien diferenciado (ADCA-IM). A los 12 meses, 13 de 15 recidivas fueron tratadas endoscópicamente y 2 casos refractarios fueron operados. Conclusiones: La mucosectomía (RME ó EMR) es un procedimiento que, realizado por endoscopistas-gastroenterólogos bien entrenados muestra baja tasa de recurrencia y complicaciones aisladas permitiendo la obtención de adecuado material para el estudio anátomo-patológico y reduciendo necesidad de cirugía abierta o laparoscópica.

Background: Detection and resection of colonic polypoid sessile and flat lesions, prevents the development of colon cancer. Endoscopic mucosal resection (EMR) has emerged in the 70´s and improved in the 80´s, as an alternative treatment of this lesions and is considered the procedure of choice nowadays, being able to avoid major surgical procedures. Objectives: Evaluation of the results and complications of the technique by endoscopists of a reference center. Review of indications and limitations of the technique. Material and methods: Descriptive, retrospective and observational analysis of patients treated with endoscopic mucosal resection technique at a referral center in Lima, Peru, between January 2004 and December 2018. EMR Technique was used in polypoid lesions greater than 1 cm. The bloc resection and the piecemeal resection technique was used for those lesions up to 3 cm and more. We evaluated complications and results according to the technique as recurrence rate, performing tracking in all cases with endoscopic follow up. Results: 756 lesions and patients (338 women and 298 men) The average age was 61.9 years (37-91 years) and the average lesion size of 20.3 mm (10-50 mm). En bloc or one-piece resection was performed in 78.04 %(590) and piece meal in 21.96%(166) achieving endoscopic and pathological resection. The complication rate in our series was 6.74% and managed endoscopically and with conservative measures and no surgery. Mean follow-up was 18 months (3-24 months) and overall local recurrence rate was 2.49%. After-procedure, additional surgical treatment was performed in 15 cases with pathologic piece report and intramucous adenocarcinoma (IM-ADCA). 13 of 15 local recurrences at 12 months follow up were treated endoscopically and 2 had surgical treatment. Conclusions: Endoscopic mucosal resection (EMR) or Mucosectomy is a technique performed by experts endoscopists and shows low rates of recurrence and complications with suitable material for pathologic examination. It reduces open and laparoscopic surgery.

[Difficult or Complex Bile duct stones in ERCP: Large Balloon Dilation and other stone management methods. Accumulated experience in a referral Endoscopic Center 2009- 2018.] / Cálculos complejos o difíciles en la endoscopia de vía biliar (CPRE): dilatación con balones de gran diámetro y otros métodos de manejo. Experiencia acumulada en un centro endoscópico de referencia 2009-2018.

INTRODUCTION: Bile duct stones constitutes 20% of symptomatic gallbladder disease and difficult stones are one third of this. Endoscopic papillary large balloon dilation (EPLBD) with or without prior endoscopic sphincterotomy (EST) produces excellent outcomes for the treatment of complex or difficult common bile duct (CBD) stones, alone or combined with previous therapeutic options as mechanical lithotripsy (ML) and temporary or definitive stenting. OBJECTIVES: Show success rate, complications and adverse events. Show that higher success rates are obtained combining ERCP techniques with no increase in complications. MATERIALS AND METHODS: We evaluated the safety and therapeutic outcomes of EPLBD with vs. without EST and other combinations for the removal of difficult bile duct stones. We described our procedures for a decade and compare them with the previous decade without balloon dilation. Of 865 patients and procedures, 223 (25.78%) had difficult stones. Treatments where EPLBD with EST (n=183), EPLBD alone group (n=40). Additional modalities where required in 15.25% (n=34). These two groups were compared with respect to overall procedure-related adverse events, overall stone removal success rate, number of sessions required for complete stone removal, need for mechanical lithotripsy, temporal or definite stenting and total procedure time. Results Safety removal of stones was achieved in one session on 84.75% of cases with EPLBD. The incidence of adverse events was not significantly different between the groups (EPLBD alone vs. EPLBD with EST: overall adverse events 12.5% vs. 10.38% (including pain); pancreatitis 2.7% vs. 2.5%, p=0.62). Overall success similar, initial success similar, and the need for additional techniques were also similar between groups. Median total procedure time tended to be greater in the EPLBD alone group (20.5 minutes) than in the EPLBD with EST group. Conclusion DPBGD in ERCP allows bile duct stone extraction rates close to 99.65% (90% in previous decade) according to other reports of literature. Adverse events of EPLBD alone or with EST are similar between them and with classic ERCP without statistical difference and similar to other world series.

[Polypectomy and endoscopic management of a giant gastric polyp]. / Polipectomía y manejo endoscópico de lesión gigante gástrica.

Gastric polyps are mainly hyperplastic and benign. They are associated with idiosinchratic factors, genetic or associated to chronic use of pump inhibitors. Endoscopic resection is recommended even though the rate of malignant transformation is very low. The vast majority are encountered as incidental findings in routine endoscopy. When they grow beyond 10mm (they may reach several centimetres in diameter) gastric polyps are a cause of dyspepsia, bleeding or gastric outlet obstruction, if located in the antrum. We report a safe endoscopic resection of a giant gastric polyp combining injection, elevation, endoloop and argon plasma coagulation (APC).

[Migration of gastrostomy button as a cause of duodenal ulcer and upper digestive bleeding]. / Botón de gastrostomía migrado como causa de ulceración duodenal y sangrado digestivo alto.

PEG or Percutaneous endoscopic gastrostomy is a well known and widely used procedure. With adequate methodology of instrumentation and follow up it has very low rate of complications directly related or non-related to the procedure. Such complications include accidental retirement, wound infection, deterioration of tube, migration to sub-cutaneous tissue and others. We present a case in which a patient with long history of PEG shows up at our ER with melena (upper GI bleeding).

Polipectomía y manejo endoscópico de lesión gigante gástrica / Polypectomy and endoscopic management of a giant gastric polyp

Los pólipos gástricos suelen ser hiperplásicos y benignos en su gran mayoría. Se asocian entre otras a factores idiosincráticos, genéticos o al uso prolongado de bloqueadores de bomba. Si bien su grado de malignización es bajo se recomienda su remoción. La mayoría se encuentran incidentalmente en procedimientos de rutina. Cuando superan los 10 mm (pueden incluso llegan a medir varios centímetros) suelen causas dispepsia, pueden sangrar u obstruir el píloro si son ubicados en antro. Reportamos la remoción de un pólipo gástrico gigante con método combinado de inyección, elevación, uso de asa desprendible o endoloop, complementado con aplicación de argón plasma (APC).

Gastric polyps are mainly hyperplastic and benign. They are associated with idiosinchratic factors, genetic or associated to chronic use of pump inhibitors. Endoscopic resection is recommended eventhough the rate of malignant transformation is very low. The vast majority are encountered as incidental findings in routine endoscopy. When they grow beyond 10mm (they may reach several centimetres in diamater) gastric polyps are a cause of dyspepsia, bleeding or gastric outlet obstruction, if located in the antrum. We report a safe endoscopic resection of a giant gastric polyp combining injection, elevation, endoloop and argon plasma coagulation (APC).

Botón de gastrostomía migrado como causa de ulceración duodenal y sangrado digestivo alto / Migration of gastrostomy button as a cause of duodenal ulcer and upper digestive bleeding

La gastrostomía endoscópica percutánea: PEG o GEP, es una técnica ampliamente difundida. Con una adecuada metodología de colocación y seguimiento tiene pocas complicaciones tanto en el peri-procedimiento como en el seguimiento a largo plazo. Se describen en cifras bajas, retiro accidental, infección, desgaste, migración al tejido sub-cutáneo, entre otras. Presentamos el caso de una paciente con sonda varios meses que acude con Hemorragia Digestiva a la Emergencia de nuestra Institución.

PEG or Percutaneous endoscopic gastrostomy is a well known and widely used procedure. With adequate methodology of instrumentation and follow up it has very low rate of complications directly related or non-related to the procedure. Such complications include accidental retirement, wound infection, deterioration of tube, migration to sub-cutaneous tissue and others. We present a case in which a patient with long history of PEG shows up at our ER with melena (upper GI bleeding).

[Case reports. Endoscopic resection of rectal carcinoid tumors: classical and submucosal resection with band-snare method]. / Resección Endoscópica de Tumor Carcinoide RectaL: Extracción Clásica y con Elevación Submucosa y Banda.

Rectal isolated carcinoid tumor can de treated endoscopically and locally. There is concern about margin involvement due to the fact that there is inward migration of these lessions from the mucosa into deeper layers (submucosa), because of the internal origin in Kutchinsky cells, which are located between mucosa and submucosa (deep in the mucosa). We review and present 6 cases of rectal carcinoid tumors treated endoscopically with polypectomy, polypectomy plus sub mucosal elevation and band -snare-elevation resection. We review current techniques, benefits of elevation, and results from the Endoscopy Unit at the INEN or National Cancer Center (Instituto Nacional de Enfermedades Neoplásicas) in Lima-Perú.

Resección endoscópica de tumor carcinoide rectal: extracción clásica y con elevación submucosa y banda / Endoscopic resection of rectal carcinoid tumors: clasical and submucosal resection with band-snare method

El tumor carcinoide rectal aislado, puede ser resecado localmente. Existe preocupación sobre compromiso de los márgenes al ser estas lesiones mucosas pero con crecimiento hacia la sub-mucosa, al originarse en las células enterocromafines de Kutchinsky que limitan con esta última. Presentamos una serie de 6 casos de tumor carcinoide rectal tratados endoscópicamente con polipectomía, polipectomía con elevación y aplicación de banda elástica. Se revisa la tecnología actual, los beneficios de la elevación y los resultados de la técnica en el área de endoscopia del servicio de gastroenterología del Instituto Nacional de Enfermedades Neoplásicas (INEN).

concern about margin involvement due to the fact that there is inward migration of these lessions from the mucosa into deeper layers (submucosa), because of the internal origin in Kutchinsky cells, which are located between mucosa and submucosa (deep in the mucosa). We review and present 6 cases of rectal carcinoid tumors treated endoscopically with polypectomy, polypectomy plus sub mucosal elevation and band ûsnare-elevation resection. We review current techniques, benefits of elevation, and results from the Endoscopy Unit at the INEN or National Cancer Center (Instituto Nacional de Enfermedades Neoplásicas) in Lima-Perú.

Eventos adversos esperados e inesperados en la endoscopia terapéutica de la vía biliar (CPRE): 311 experiencia en un centro privado nacional con 1356 casos consecutivos (1999-2008) / Expected and unexpected adverse events in the therapeutic endoscopy of the bile duct (ERCP) 311 experience of a private national center in 1356 consecutive cases (1999-2008)

Reportamos nuestra experiencia de 10 años en procedimientos terapéuticos de la vía biliar (CPRE), describiendo los eventos adversos o complicaciones mayores y menores. Con descripción de posibles factores asociados, manejo, grupos etáreos y de riesgo. Comentamos también sobre las medidas a tomar para prevenirlos y tratarlos. Las complicaciones descritas son pancreatitis, perforacion, enfisema sub-cutáneo, neumoperitoneo, neumomediastino, neumotórax y excepcionalmente hematoma subcapsular hepático. Se reporta las indicaciones de los procedimientos.El total de complicaciones fué de 54 casos (3.98 por ciento de 1356 intervenciones). La Pancreatitis aguda PA fué la complicación más común con 39 casos(2.88 por ciento del total y 72 por ciento de las complicaciones) . El 79.49 por ciento de la PA fué leve. El 82 por ciento de la PA ocurre en mujeres. La mortalidad relacionada al procedimiento fué de 1 caso (0.007 por ciento).

We report our experience of 10 years in therapeutic procedures of the bile duct (ERCP), describing adverse events or major and minor complications.We describe the associated factors, management, and risk age groups. We comment on the measures taken to prevent and treat them. The reported complications are pancreatitis, perforation, sub-cutaneous emphysema, pneumoperitoneum, pneumomediastinum, pneumothorax and exceptionally sub capsularliver hematoma. We report the particulars of the proceedings.The total number of complications was 54 cases (3.98 percent of 1356 interventions). The Acutepancreatitis PA was the most common complication in 39 cases (2.88 percen of the total and 72 percen of complications). The 79.49 percen of the PA was mild. 82 percen of the PA occurs in women. The procedure related mortality was 1 case (0.007 percen).

[Expected and unexpected adverse events in the therapeutic endoscopy of the bile duct (ERCP): experience of a private national center in 1356 consecutive cases (1999-2008)]. / Eventos Adversos Esperados e Inesperados en la Endoscopía Terapéutica de la Vía Biliar(CPRE): Experiencia en un Centro Privado Nacional con 1356 casos consecutivos (1999-2008).

We report our experience of 10 years in therapeutic procedures of the bile duct (ERCP), describing adverse events or major and minor complications. We describe the associated factors, management, and risk age groups. We comment on the measures taken to prevent and treat them. The reported complications are pancreatitis, perforation, sub-cutaneous emphysema, pneumoperitoneum, pneumomediastinum, pneumothorax and exceptionally sub capsular liver hematoma. We report the particulars of the proceedings. The total number of complications was 54 cases (3.98% of 1356 interventions). The Acute pancreatitis PA was the most common complication in 39 cases (2.88% of the total and 72% of complications). The 79.49% of the PA was mild. 82% of the PA occurs in women.The procedure related mortality was 1 case (0.007%).

[Intrapancreatic mechanical lithotripsy: report and review of the literature of a case in a patient with chronic pancreatitis and lithiasis of Wirsung's duct]. / Litotripsia mecánica intrapancreática en un paciente con pancreatitis crónica y litiasis del conducto de Wirsung: reporte de un caso y revisión de la literatura.

The case of a 34 year-old woman with multiple lithiasis of Wirsung's duct who underwent a modified Puestow's operation is presented. Two (2) months after the surgery, the patient entered with a severe pain chart compatible with acute pancreatitis as a result of chronic pancreatitis. A very large lithiasis is observed in the head of the pancreas. Therapeutic procedure, pancreatic sphincterotomy and mechanical lithotripsy are performed. The procedure is described and the literature is reviewed.

Litotripsia Mecánica Intrapancreática en un paciente con Pancreatitis Crónica y Litiasis del Conducto de Wirsung: Reporte de un Caso y Revisión de la Literatura / Intrapancreatic Mechanical Lithotripsy in a patient with chronic pancreatitis and lithiasis of the conduit Wirsung: Case Report and Literature Review

Presentamos el caso de una paciente mujer de 34 años con litiasis múltiple del Wirsung sometida a cirugía modificada de Puestow. Dos meses después de la cirugía la paciente ingresa con cuadro de dolor severo compatible con pancreatitis aguda sobrepuesta en pancreatitis crónica. Se observa litiasis gigante de cabeza de páncreas. Se realiza procedimiento terapéutico esfinterotomía de páncreas y litotripsia mecánica. Se describe el procedimiento y se revisa la literatura.

The case of a 34 year-old woman with multiple lithiasis of Wirsung's duct who underwenta modified Puestow's operation is presented. Two (2) months after the surgery, the patiententered with a severe pain chart compatible with acute pancreatitis as a result of chronicpancreatitis. A very large lithiasis is observed in the head of the pancreas. Therapeuticprocedure, pancreatic sphincterotomy and mechanical lithotripsy are performed. Theprocedure is described and the literature is reviewed.

Colitis isquémica. Presentación de tres casos y revisión de la literatura / Ischemic colitis. Presentation of three cases and literature review

La colitis isquémica se ha asociado a edad avanza, enfermedades cardiovasculares, medicamentos y ciertos tipos de cirugía. Es una entidad poco frecuente, pero creemos que no todos los casos están siendo reconocidos. Presentamos tres casos, en pacientes mayores de 70 años, que iniciaron su enfermedad en forma brusca, con dolor abdominal y sangrado digestivo bajo. El diagnóstico se pudo lograr gracias a la sospecha clínica y el uso temprano de la colonoscopía. La evolución de estos pacientes fue favorable, pero se han descrito complicaciones graves y alta mortalidad en los casos severos.

Ischemic colitis has been associated with advanced age, cardiovascular disease, drug therapy and vascular surgery. It is an uncommon condition in the general population, but we think thatnot all cases are being recognized. These three patients, over 70 years old, were admitted with abdominal cramps and mild lower digestive bleeding. Clinical suspicion and early use ofcolonoscopy was helpful to establish the diagnosis. In these cases the recovery was uneventful, but in some others, severe complications and mortality can occur.

[Alterations in laboratory tests as predictors of choledocholithiasis in patients who underwent ERCP: experience in a national private center]. / Pruebas de laboratorio como predictores de coledocolitiasis en pacientes sometidos a cpre: experiencia en un centro privado nacional.

INTRODUCTION: ERCP is very important in the management of common bile duct stones but it has associated morbidity. METHODS: We analyze retrospectively records of 293 patients with suspected CBD stones to determine laboratory predictors of the pathology and improve the selection of patients for the examination. Sensitivity, specifity, predictive positive value and predictive negative value were calculated for alkaline phosphatase (FA), Total Bilirrubin (BT), TGO(AST) and TGO(ALT). We also compared values between patients with and without gallbladder suffering CBD stones confirmed by ERCP. RESULTS: 293 patients had ERCP. 247 had CBD stones and 46 had no stones. OF the CBD stones group 58(23%) didn't have gallbladder and 187(77%) had gallbladder. Hepatic function tests FA, TGP y BT where all pronostic factors for CBD stones on univariate analysis with statistical value of p<0.01. Clinical presentation was not included in analysis. Age, TGO(AST) and GGTP didn't showed statistical significance. CONCLUSIONS: The predictors of CBD stones have better results when combined. The use of stricter selection criteria can reduce the number of normal exams and complications.

[Management of obstructed metallic biliary stent in pancreatic cancer: stent within a stent. Case report and review of the literature]. / Manejo de Stent Metálico biliar obstruido en cáncer de páncreas: stent dentro de stent . reporte de caso y revisión de la literatura.

Pancreatic cancer producing obstructive jaundice can be handled temporarily or permanently if it is inoperable with stents placed endoscopically by means of an endoscopic retrograde cholangio-pancreatography, or ERCP. These can be made of teflon plastic of relatively short duration (average 2 months) or permanent metallic ones. The metallic stents are made of non-covered metallic mesh that can be obstructed by the growth of the neoplasia and invasion of the lumen. We present the case of a patient with a metallic stent suffering from cholangitis due to tumoral growth. A salvaging procedure was performed.

Pruebas de laboratorio como predictores de coledocolitiasis en pacientes sometidos a CPRE: experiencia en un centro privado nacional / Alterations in laboratory tests as predictors of choledocholithiasis in patients who underwent CPRE: experience in a national private center

INTRODUCCIÓN: la CPRE es de valor en el manejo de la coledocolitiasis pero tiene morbilidad no despreciable. MATERIAL Y MÉTODOS: Analizamos 293 pacientes sometidos a CPRE por sospecha de coledocolitiasis para determinar predictores laboratoriales de coledocolitiasis y mejorar nuestra selección de casos para el procedimiento. Se calculó la sensibilidad, especificidad, valor predicitivo positivo(VPP) y valor predictivo negativo(VPN) para Fosfatasa alcalina (FA), Bilirrubina Total(BT) y transaminasas TGP y TGO. Comparamos también valores de laboratorios entre pacientes con coledocolitiasis sin y con vesícula.RESULTADOS: 293 pacientes sometidos a CPRE; 247(84%) con coledocolitiasis y 46(16%) sin litiasis. En el grupo con coledocolitiasis 187(77%) tenían vesícula y 58(23%) no. Las pruebas de función hepática FA, TGP y BT fueron todas factores pronósticos para coledocolitiasis en análisis univariado con niveles de p<0.01. No se incluyo a la historia de presentación clínica. No lograron valor estadístico la edad, TGO y GGTP. CONCLUSIONES: Los predictores de coledocolitiais tienen mejores resultados combinados. El uso de criterios de selección estrictos puede reducir el número de exámenes normales y sus complicaciones.

INTRODUCTION: ERCP is very important in the management of common bile duct stones but it has associated morbidity.METHODS: We analyze retrospectively records of 293 patients with suspected CBD stones to determine laboratory predictors of the pathology and improve the selection of patients for the examination. Sensitivity, specifity, predictive positive value and predictive negative value were calculated for alkaline phosphatase(FA), Total Bilirrubin (BT), TGO(AST) andTGO(ALT). We also compared values between patients with and without gallbladder suffering CBD stones confirmed by ERCP. RESULTS: 293 patients had ERCP. 247 had CBD stones and 46 had no stones. OF theCBD stones group 58(23%) didn´t have gallbladder and 187(77%) had gallbladder. Hepatic function tests FA, TGP y BT where all pronostic factors for CBD stones on univariate analysis with statistical value of p<0.01. Clinical presentation was not included in analysis. Age, TGO(AST) and GGTP didn´t showed statistical significance.CONCLUSIONS: The predictors of CBD stones have better results when combined. The use of stricter selection criteria can reduce the number of normal exams and complications.

Manejo de stent metálico biliar obstruido en cáncer de páncreas: stent dentro de stent. Reporte de caso y revisión de la literatura / Management of obstructed metallic biliary stent in pancreatic cancer: stent within a stent. Case report and review of the literature

El cáncer de páncreas que produce ictericia obstructiva puede manejarse de manera temporal o definitiva si es inoperable con stents colocados endoscópicamente mediante colangio pancreatografía retógrada endoscópica o CPRE . Estos pueden ser plásticosteflonados de relativa corta duración (2 meses promedio) o definitivos metálicos. En el caso de los stents metálicos, los mismos son de malla metálica no cubierta y que pueden obstruirse por crecimiento de la neoplasia e invasión al lumen. Presentamos el caso de un paciente con stent metálico que cursa con colangitis por crecimiento tumoral. Se realiza un procedimiento de salvataje.

Pancreatic cancer producing obstructive jaundice can be handled temporarily orpermanently if it is inoperable with stents placed endoscopically by means of an endoscopic retrograde cholangio-pancreatography, or ERCP. These can be made of teflon plastic of relatively short duration (average 2 months) or permanent metallic ones. The metallicstents are made of non-covered metallic mesh that can be obstructed by the growth of the neoplasia and invasion of the lumen. We present the case of a patient with a metallic stentsuffering from cholangitis due to tumoral growth. A salvaging procedure was performed.

[Ischemic colitis. Presentation of three cases and review of literature]. / Colitis isquémica. Presentación de tres casos y revisión de la literatura.

Ischemic colitis has been associated with advanced age, cardiovascular disease, drug therapy and vascular surgery. It is an uncommon condition in the general population, but we think that not all cases are being recognized. These three patients, over 70 years old, were admitted with abdominal cramps and mild lower digestive bleeding . Clinical suspicion and early use of colonoscopy was helpful to establish the diagnosis. In these cases the recovery was uneventful, but in some others, severe complications and mortality can occur.