Efficacy of octreotide in bleeding recurrence from small bowel angioectasia: A comparative study.

INTRODUCTION: Fifty percent of small bowel bleeding is caused by angioectasia and the rebleeding rate due to small bowel angioectasia (SBA) is 80%. Its endoscopic treatment is difficult. Beneficial effects of octreotide on gastrointestinal angioectasia have been described, but no studies have reported its efficacy in SBA. AIM: Our aim was to investigate the effectiveness of octreotide in the prevention of rebleeding due to SBA. MATERIAL AND METHODS: Sixteen patients with bleeding caused by SBA were assigned to treatment with octreotide 100 µg/24 h SC, for at least 6 months, and compared with a non-treatment group of 36 patients. The primary outcome was the rebleeding rate, and the secondary outcomes were the number of hospital readmissions, bleeding-related death, and adverse effects. RESULTS: Octreotide was administered for 10.5 ± 8.4 months. Follow-up was 12.9 ± 17.3 months and 15.3 ± 17.7 months, in the treatment and non-treatment groups, respectively (p = 0.09). At the end of follow-up, 4 (25%) treatment group patients and 26 (72.2%) non-treatment group patients presented with rebleeding (p = 0.002). In the treatment group and non-treatment group, the cumulative probability of remaining rebleeding-free at one year was 79% vs 44.2%, and 79% vs 34.6% at 2 years, respectively (p = 0.05). Through the multiple logistic regression analysis, treatment was the protective variable. Six patients presented with adverse events. One of those patients (6.25%) had a major adverse event. CONCLUSIONS: Our results suggest that treatment with octreotide could be efficacious in the prevention of rebleeding due to SBA.

Octreótido de liberación prolongada para el tratamiento de hemorragia digestiva alta en Pediatría / Long-acting Release Octreotide for Pediatric Upper Gastrointestinal Bleeding

Resumen: Introducción: La hemorragia digestiva por hipertensión portal, sin alternativa de tratamiento endos- cópico o quirúrgico por localizaciones ectópicas, no identificadas del sitio de sangrado o caracterís ticas anatómicas, constituye un desafío terapéutico en Pediatría. El tratamiento habitual incluye la infusión de octreótido endovenoso. En los últimos años, la presentación de octreótido de liberación prolongada (OCT-LAR) para administración mensual intramuscular, resulta una alternativa tera péutica atractiva. Objetivo: Reportar el caso de un lactante con hemorragia digestiva por hiperten sión portal que recibió tratamiento exitoso con OCT-LAR. Caso Clínico: Paciente de 8 meses de vida, con malformación de vena porta extrahepática y episodios reiterados de sangrados digestivos con re querimientos transfusionales e infusiones de octréotido, sin posibilidad de tratamiento endoscópico o quirúrgico. Indicamos OCT-LAR intramuscular mensualmente. Después de diez meses de iniciado el tratamiento, el paciente no repitió sangrados digestivos y no presentó efectos adversos relacionados a la medicación. Conclusión: Consideramos que el reporte de este caso puede resultar de utilidad al presentar una nueva alternativa para el tratamiento de pacientes pediátricos con sangrado digestivo por hipertensión portal sin posibilidades terapéuticas convencionales.

Abstract: Introduction: Upper gastrointestinal bleeding (UGIB) secondary to portal hypertension (PHT), without endoscopic or surgical treatment options due to an ectopic or unidentified bleeding site or the patient's anatomic characteristics, is challenging in pediatric hepatology. The usual treatment in these cases includes intravenous Octreotide. Recently, the availability of long-acting release Octreo tide (OCT-LAR) for monthly intramuscular administration has become an interesting therapeutic alternative. Objective: To report the case of an infant with UGIB due to PHT who was successfully treated with OCT-LAR. Clinical Case: Eight-month-old patient with repeated episodes of UGIB due to extrahepatic portal vein malformation, requiring blood transfusions, and intravenous octreotide infusions. As neither endoscopic nor surgical treatment were feasible, we decided to start IM OCT- LAR monthly. After ten months of treatment, the patient did not present bleeding episodes. No medication-related events were observed. Conclusion: We consider that this report could help in the management of similar pediatric patients with UGIB due to PHT without conventional therapeutic possibilities.

Anesthetic management of carcinoid syndrome: is octreotide enough? A case report / Manejo anestésico del síndrome carcinoide: es el octreótido suficiente? Presentación de un caso

Abstract: Carcinoid tumors are rare slow-growing neuroendocrine tissue neoplasms. Their ability to secrete bioactive substances to the systemic circulation is accountable for a clinical presentation known as carcinoid syndrome. Main symptoms include bronchoconstriction, flushing, diarrhea and hemodynamic instability. Octreotide, a somatostatin analogue, is the current mainstay for carcinoid syndrome treatment and perioperative management. However, no regimen has proven to be completely effective in preventing systemic manifestations and recent literature suggests that it might be an insufficient measure. We report a case of a 51-year-old male with a functioning small bowel neuroendocrine tumor and carcinoid syndrome presenting for a primary tumor resection, discussing possible pitfalls and key points in the care of these patients.

Resumen: Los tumores carcinoides son neoplasias de tejido neuroendocrino poco comunes y de crecimiento lento. Su capacidad para secretar sustancias bioactivas a la circulación sistémica es responsable por una presentación clínica conocida como síndrome carcinoide. Los principales síntomas incluyen broncoconstricción, enrojecimiento, diarrea e inestabilidad hemodinámica. Octreótido, un análogo de la somatostatina, es el pilar actual para el tratamiento del síndrome carcinoide y su manejo perioperatorio. Sin embargo, ningún tratamiento ha demostrado ser completamente eficaz para prevenir las manifestaciones sistémicas y estudios recientes indican que puede ser una medida insuficiente. Presentamos un caso de un varón de 51 años con un tumor neuroendocrino funcionante en el intestino delgado y un síndrome carcinoide, sometido a una resección del tumor primario, discutiendo posibles dificultades y puntos clave en la atención de estos pacientes.

Ascitis quilosa postraumática tratada con nutrición parenteral total y octreótido / Post-trauma Chylous Ascites Treated with Total Parenteral Nutrition and Octreotide

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal por ruptura u obstrucción de los conductos linfáticos abdominales. Aunque es infrecuente, se describe mayor probabilidad de aparición después de traumas abdominales. Se presenta un paciente masculino de 46 años que sufre herida por arma blanca tóracoabdominal por lo que requirió tratamiento quirúrgico de urgencia. Luego de varias cirugías se constató la presencia de líquido abdominal blanquecino, con triglicéridos elevados. Se confirmó la ascitis quilosa, que se reabsorbió en 45 días con nutrición parenteral y octreótido(AU)

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity due to rupture or obstruction of the abdominal lymph ducts. Although it is rare, greater probability is described for its onset after abdominal traumas. The case is presented of a 46-year-old male patient who suffers from a thorax-abdomen knife wound and therefore required emergency surgical treatment. After several surgeries, the presence of whitish abdominal liquid was detected, with elevated triglycerides. Chylous ascites was confirmed, which was reabsorbed in 45 days with parenteral nutrition and octreotide(AU)

Ascitis quilosa postraumática tratada con nutrición parenteral total y octreótido / Post-trauma Chylous Ascites Treated with Total Parenteral Nutrition and Octreotide

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal por ruptura u obstrucción de los conductos linfáticos abdominales. Aunque es infrecuente, se describe mayor probabilidad de aparición después de traumas abdominales. Se presenta un paciente masculino de 46 años que sufre herida por arma blanca tóracoabdominal por lo que requirió tratamiento quirúrgico de urgencia. Luego de varias cirugías se constató la presencia de líquido abdominal blanquecino, con triglicéridos elevados. Se confirmó la ascitis quilosa, que se reabsorbió en 45 días con nutrición parenteral y octreótido(AU)

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity due to rupture or obstruction of the abdominal lymph ducts. Although it is rare, greater probability is described for its onset after abdominal traumas. The case is presented of a 46-year-old male patient who suffers from a thorax-abdomen knife wound and therefore required emergency surgical treatment. After several surgeries, the presence of whitish abdominal liquid was detected, with elevated triglycerides. Chylous ascites was confirmed, which was reabsorbed in 45 days with parenteral nutrition and octreotide(AU)

Pre-operative 68Ga-DOTANOC somatostatin receptor PET/CT imaging demonstrating multiple synchronous lesions in a patient with head and neck paraganglioma.

Paragangliomas, or glomus tumors, are neoplasms arising from extra-adrenal chromaffin tissue. They frequently cause symptoms by over-production of catecholamines with known predilection to multicentricity. We describe the case of a patient with bilateral carotid body tumor who underwent a preoperative 68Gallium labeled [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-NaI3-Octreotide (68Ga-DOTANOC) positron emission tomography/computed tomography (PET/CT) imaging for staging. This is a unique case in which multiple paraganglioma and pheochromocytoma were demonstrated in a single patient using 68Ga-DOTANOC PET/CT.

Cytoplasmic expression of SSTR2 and 5 by immunohistochemistry and by RT/PCR is not associated with the pharmacological response to octreotide.

OBJECTIVE: To evaluate expression of somatostatin receptor subtypes 2 and 5 (SSTR 2 and 5) by RT/PCR and immunohistochemistry (IHC) in GH-secreting adenomas, seeking correlations with response to octreotide. METHODS: SSTR2 and 5 expression was tested by IHC (n=37), RT/PCR (n=36) or both (n=13) in GH-secreting adenomas from 60 patients with acromegaly who had undergone pituitary surgery; 36 had been treated preoperatively with octreotide LAR for 3-6 months, and were categorized as responders (achievement of GH <2.5ng/mL and a normal age-adjusted IGF-1), partial responders (GH and IGF-1 reduction >50% and >30%, respectively) or non-responders. IHC was performed on a tissue microarray using specific antibodies directed to the carboxyl terminus of SSTR2 and 5. RESULTS: SSTR5 was the predominantly expressed receptor subtype by both IHC and RT/PCR in all tumors tested, regardless of whether they came from octreotide-naïve, octreotide-responsive, or octreotide-resistant patients. Immunostaining was concentrated in the cytoplasm. Neither SSTR2 nor SSTR5 expression correlated with baseline or post-octreotide GH or IGF-1 levels or tumor volume by either method. The agreement rate between RT/PCR and IHC was 77% in all 13 adenomas in which both methods were used. CONCLUSION: Expression of these receptors does not guarantee an adequate response to somatostatin analogs; other functional aspects of this interaction, such as receptor homo- and heterodimerization, and the resulting signaling cascade, probably play a role in determining whether a patient will respond or not to these agents.

Caso inusual de síndrome de cushing

Objetivo: discutir las dificultades en el diagnóstico y manejo terapéutico de un caso poco frecuente de Síndrome de Cushing (SC). Caso Clínico: se reporta el caso de un paciente femenino, de 24 años, con hipercortisolismo y patrón bioquímico sugestivo de SC dependiente de corticotropina (ACTH). Estudios imagenológicos mostraron agrandamiento de la glándula hipófisis, extensión supraselar y una lesión lateral izquierda, sugestiva de microadenoma. Sometida a cirugía transesfenoidal en dos oportunidades, sin obtenerse la remisión del cuadro. Tomografía computarizada (TC) de tórax demostró la presencia de nódulo pulmonar único izquierdo, hipercaptante en el gammagrama con octreotido. Fue removido quirúrgicamente en forma satisfactoria produciéndose un abrupto descenso en los niveles de ACTH y cortisol pero nuevamente se incrementaron 24 horas después, permaneciendo elevados desde entonces. La inmunohistoquímica fue positiva para ACTH y cromogranina; el estudio anatomapatológico reportó tumor carcinoide típico sin invasión a ganglios linfáticos; sin embargo, la evolución clínica sugirió enfermedad residual. Se inició tratamiento con análogos de somatostatina (octreotido), el cual se ha mantenido por once meses, obteniéndose mejoría significativa del cuadro clínico y control parcial del hipercortisolismo. TC de tórax y gammagrama con octreotido recientemente practicados, revelaron pequeño foco, el cual correspondió a adenopatía mediastinal derecha. Se plantea la hipótesis de que el tumor producía simultáneamente ACTH y hormona liberadora de corticotropina (CRH, por sus siglas en inglés), explicándose de esta manera la hiperplasia hipofisaria. Conclusión: En pacientes con SC dependiente de ACTH hay que tener presente la existencia de incidentalomas que pueden confundir el diagnóstico. Considerar que la hiperplasia hipofisaria puede ser secundaria a una fuente ectópica productora de CRH y aunque en este caso no pudo realizarse inmunohistoquímica para CRH en las células tumorales, es posible suponer que dichas células secretaban conjuntamente CRH y ACTH lo cual explica la hiperplasia hipofisaria.

Objective: to discuss the diagnostic and therapeutic difficulties of a rare case of Cushing´s syndrome. Case Report: we describe a case of a 24-year-old female patient who developed symptoms compatible with hypercortisolism; the biochemical pattern was suggestive of ACTH dependent Cushin´s Syndrome. Imaging studies showed pituitary enlargement with suprasellar extension and a lesion suggestive microadenoma on the left side. Transsphenoidal surgery was performed in two occasions without remission. Subsequent explorations showed the presence of a single left lung nodule, positive to octreoscan. It was successfully operated and, a sharp decline on ACTH and cortisol levels was seen immediately after operation, increasing again 24 hours later and, remained elevated since then. Inmunohistochemestry studies were positive for ACTH and chromogranin and although the pathology was compatible with typical carcinoid, and no lymph node invasion was seen, the clinical evolution suggested the presence of residual disease. Treatment with somatostatin analogues (Octreotide) was started and has being maintained for eleven months, up to the present. A significant improvement of the clinical picture and partial control of the hypercortisolism has being obtained. Chest CT and octreoscan recently performed, revealed small focus, which corresponded to a right mediastinal adenopathy. We hypothesize that the tumor was simulta-neously producing ACTH and CRH, explaining in this way the pituitary hyperplasia. Conclusion: In patients with ACTH dependent Cushing the existence of incidentalomas could confuse the diagnosis and should be ruled out. Pituitary hyperplasia might be secondary to an ectopic CRH source. Although in our case immunohistochemostry for CRH was not performed, we assume that tumor cells secreted both, CRH and ACTH, explaining the pituitary hyperplasia.

Síndrome Carcinoide: Presentación de caso y revisión de la literatura / Carcinoid syndrome: case report and literature review

Se presenta el caso de una mujer de 63 años de edad, con cuadro clínico crónico de un año de evolución caracterizado por diarrea esteatorreica, asociado a episodios de dolor abdominal difuso, tipo cólico, “sensación de bochornos” y enrojecimiento en cara y tronco superior. El abordaje diagnóstico de la diarrea crónica es un reto para los médicos generales y especialistas, más aún, cuando se acompaña de manifestaciones inespecíficas como dolor abdominal y la presencia de “bochornos”. La coexistencia de varios de los anteriores síntomas, obliga a descartar diversas patologías que representan alta morbimortalidad para el paciente. El síndrome de intestino irritable, el feocromocitoma, el hipertiroidismo, el síndrome carcinoide, entre otras, son patologías a excluir en todo caso. El presente artículo pretende brindar el diagnóstico diferencial de las patologías que presentan dichos síntomas, buscando conducir al lector hasta el diagnóstico definitivo de la paciente.

A 63-year-old woman reported a chronic clinical evolution of one year characterized by steatorrhea, associated with episodes of diffuse abdominal pain, cramping and “hot flashes” also redness on the face and upper trunk . The diagnostic approach of chronic diarrhea is a challenge for physicians and specialists, especially, when accompanied by nonspecific manifestations such as abdominal pain and the presence of “hot flashes”. The coexistence of several of these symptoms must be ruled various pathologies that represent high morbidity and mortality for the patient. Irritable bowel syndrome, pheochromocytoma, hyperthyroidism, carcinoid syndrome, among others, are conditions to exclude in any case. This article aims to provide the differential diagnosis of the diseases that have these symptoms, seeking to lead the reader to the definitive diagnosis of the patient.

Octreotide en quilotórax secundario a corrección de hernia diafragmática congénita / Octreotide for treatment of chylothorax after repair of congenital diaphragmatic hernia

La presencia de quilo en la cavidad pleural es una situación rara cuya causa puede ser adquirida (trauma quirúrgico) o congénita (anomalías del sistema linfático), con manifestaciones clínicas variables dependientes de la cantidad y pérdida de quilo (desnutrición, alteración hidroelectrolítica e inmunosupresión). Se presenta una recién nacida con diagnóstico prenatal de hernia diafragmática izquierda con quilotórax de etiología traumática, a quien se realiza tratamiento médico mediante soporte nutricional y octreotide, con resolución y sin necesidad de optar por manejo quirúrgico...

Chyle effusion in the pleural cavity is a rare situation. It may be acquired (surgical injuries) or congenital (abnormalities of the lymphatic system). Clinical manifestations are varied and depend on the amount of chyle loss (malnutrition, fluid and electrolyte imbalance and immune suppression). This article reports the case of a female newborn infant diagnosed with left diaphragmatic hernia who presented postoperative chylothorax. Medical management included nutritional support and octreotide. Resolution of chylothorax was obtained with no additional surgical treatment...

¿Son útiles la somatostatina y sus análogos (octreótido y lanreótido) en el manejo del paciente con fístula entero-cutánea?: revisión sistemática de la literatura / Are somatostatin and its analogues (octreotide and lanreotide) useful in the management of patients with enterocutaneous fistulae?: systematic literature review

Introducción. Las fístulas entero-cutáneas son una complicación infrecuente pero catastrófica para el paciente quirúrgico. En su manejo, el uso de la somatostatina y de sus análogos (octreótido/ lanreótido) se indica con frecuencia pero los resultados han sido variables en diversos experimentos clínicos.El objetivo de este estudio fue evaluar la eficacia clínica de la somatostatina y de sus análogos en el manejo de fístulas entero-cutáneas. Métodos. Se hizo una revisión sistemática de los experimentos clínicos que compararon la somatostatina y sus análogos con el placebo u otras terapias en fístulas entero-cutáneas. El análisis de la calidad metodológica se efectuó según las recomendaciones de la Colaboración Cochrane. Los resultados primarios fueron: la tasa de cierre, el tiempo de cierre y la reducción del gasto; los secundarios, la morbilidad, la mortalidad, la estancia hospitalaria, los costos y la calidad de vida. Resultados. Se identificaron 8 estudios, 172 pacientes con somatostatina o sus análogos y 134 pacientes con placebo u otros tratamientos. Los estudios son de baja calidad metodológica. El tiempo promedio de cierre fue de 10 días con somatostatina o sus análogos y la tasa de cierre fue superior que con el placebo. La somatostatina más nutrición parenteral total demostró la mayor eficacia clínica (85%). El gasto de la fístula entero-cutánea disminuyó de forma estadísticamente significativa con el uso de somatostatina o de sus análogos. Los resultados de morbilidad y mortalidad fueron variables. No existe información sobre la calidad de vida.Conclusiones. La somatostatina y sus análogos pueden utilizarse en el paciente con fístula entero-cutánea dentro de los primeros 10 días de instauración del evento; sin embargo, la información sobre su eficacia es heterogénea entre los diferentes estudios evaluados. El perfil de seguridad farmacológica en el paciente con fístula entero-cutánea debe evaluarse en estudios complementarios.

Introduction. Enterocutaneous fistulae constitute an infrequent but catastrophic complication in the surgical patient. Somatostatin and its analogues (octeotide and lanreotide) are frequently indicated in the management of these fistulae, but variable results have been reported in published clinical experiments. The aim of this study was to evaluate the efficacy of somatostatin and its analogues in the management of enterocutaneous fistulae. Methods. Systematic review of published clinical experiments comparing somatostatin and its analogues wth placebo or other therapeutic modalities in patients with enterocutaneous fistulae. Analysis of quality was made according to the Cochrane Collaboration recommendations. Primary results were: rate of closure, time until closure and reduction of output; secondary results were: morbidity, mortality, length of hospital stay, costs, and quality of life. Results. Eight studies were identified, 172 patients managed with somatostatin or its analogues and 134 patients with placebo or other treatment modalities. Methodologically the studies appear of low quality. Average elapsed time to closure was 10 days with somatostin or its analogues and the closure rate was superior as compared with placebo. Somatostain plus total parenteral nutrition demonstrated the highest clinical efficacy (85%). In manner statistically significant, the output of the fistulae diminished with the use of somatostatin or its analogues. Mortality and morbidity results were variable. There is no information on quality of life. Conclusions. Somatostain and its analogues can be utilized in the management of patients with enterocutaneous fistulae within the first ten days of presentation; however, the information on efficacy appears heterogenous in the different studies that were reviewed. The profile of pharmacological safety in patients with enterocutaneous fistulae should be evaluated in complementary studies.

Várices esofagogástricas / Gastro-esophageal varices

La hipertensión portal en el paciente cirrótico condiciona no solamente una serie de cambios fisiológicos, humorales y hemodinámicos, sino tambien fenómenos mecánicos asociados a la arquitectura hepática rígida y nodular. La formación de circulación colateral particularmente en la submucosa del esófago distal, conocida como várices esofágicas es una complicación común, cuya importancia radica en la altísima mortalidad asociada a su ruptura. El grado de prominencia de la várice y su probabilidad de ruptura correlacionan con el estadío clínico de la cirrosis. Se cuenta en la actualidad con fármacos eficaces en el escenario de una hemorragia aguda por várices, conjuntamente con técnicas de hemostasia endoscópica como la escleroterapia o endoligadura o derivaciones portosistémicas radiológicas (TIPS) como modalidad de rescate. Por otro lado, la probabilidad de prevenir el primer sangrado o el resangrado del paciente que ya tuvo la primera hemorragia (profilaxis primaria y secundaria respectivamente) son de sumo interés para el médico que se enfrenta al paciente cirrótico. Estos temas serán revisados extensamente en este artículo.

Portal hypertension in the cirrhotic patient is associated not only to physiologic, humoral and hemodynamic changes, but also with mechanical phenomena associated to the rigid and nodular liver architecture. The formation of collateral circulation particularly in the submucosa of the distal esophagus, known as esophageal varices is a common complication, and its importance relies on the very high mortality associated with its rupture. The degree of variceal prominence and the probability of rupture correlates with the clinical stage of cirrhosis. Currently we count with efficacious drugs in the scenario of an acute variceal hemorrhage, along with endoscopic hemostatic techniques like sclerotherapy and variceal ligation or radiologically placed portosystemic shunts (TIPS) as a rescue modality. On the other hand, the probability of preventing the first bleeding or the rebleeding in the patient who already had a first hemorrhage (primary and secondary prophylaxis respectively) are of extreme interest for the physician caring for a cirrhotic patient. This article extensively reviews those important issues.