Clinical practice guideline on the use of single-operator cholangioscopy in the diagnosis of indeterminate biliary stricture and the treatment of difficult biliary stones.

BACKGROUND AND AIMS: Single-operator cholangioscopy (SOC) offer a diagnostic and therapeutic alternative with an improved optical resolution over conventional techniques; however, there are no standardized clinical practice guidelines for this technology. This evidence-based guideline from the Colombian Association of Digestive Endoscopy (ACED) intends to support patients, clinicians, and others in decisions about using in adults the SOC compared to endoscopic retrograde cholangiopancreatography (ERCP), to diagnose indeterminate biliary stricture and to manage difficult biliary stones. METHODS: ACED created a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Universidad de los Andes and the Colombia Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network supported the guideline-development process, updating and performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The GRADE approach was used, including GRADE Evidence-to-Decision frameworks. RESULTS: The panel agreed on one recommendation for adult patients with indeterminate biliary strictures and one for adult patients with difficult biliary stones when comparing SOC versus ERCP. CONCLUSION: For adult patients with indeterminate biliary strictures, the panel made a conditional recommendation for SOC with stricture pattern characterization over ERCP with brushing and/or biopsy for sensitivity, specificity, and procedure success rate outcomes. For the adult patients with difficult biliary stones the panel made conditional recommendation for SOC over ERCP with large-balloon dilation of papilla. Additional research is required on economic estimations of SOC and knowledge translation evaluations to implement SOC intervention in local contexts.

Clinical characteristics, treatments, and outcomes of difficult biliary stones in a reference hospital in Colombia.

The local experience and the success rate of different available treatments for difficult biliary stones in Colombia are poorly described. We made an observational study reporting patients treated for difficult biliary stones, at Hospital Universitario San Ignacio in Bogotá, Colombia between January 2015, and November 2021. Clinical characteristics, endoscopic retrograde cholangiopancreatography (ERCP) findings, and outcomes are presented. Additionally, the success rates of Endoscopic Sphincterotomy Plus Large Balloon Dilation (ESLBD), Mechanical Lithotripsy (ML), temporary stenting (TS), cholangioscopy-guided laser lithotripsy (CGLL), and surgery are described. A total of 146 patients were included (median age 69 years, IQR 58.5-78.5, 33.8% men). The median stone diameter was 15 mm (IQR 10 - 18 mm). One stone was presented in 39.9%, two stones in 18.2%, and ≥3 stones in the remaining stone. A 67.6% disproportion rate was observed between the stone and distal common bile duct. Successful stone extraction was achieved in 56.2% in the first procedure, 22.6% in the second, 17.1% in the third, 3.4% in the fourth, and 0.7% in the fifth procedures. The successful extraction rates were 56.8% for ESLBD, 75% for ML, 23.4% for TS, 57.7% for CGLL, and 100% for surgery. Endoscopic management of difficult stones is usually successful, although it usually requires 2 or more ERCPs procedures. The surgical requirements were low. ESLBD is an effective technique unlike TS. Few patients required advanced techniques such as ML or CGLL. Endoscopic procedures are associated with a low rate of complications.

[Acute cholangitis secondary to periampullary duodenal diverticulum. Case report]. / Colangitis aguda severa secundaria a divertículo duodenal periampular. Reporte de un caso.

Background: Periampullary duodenal diverticula are rare and pancreaticobiliary complications infrequent, however, when they are diagnosed and associated with symptoms, they warrant urgent intervention. The aim of this article is to present a clinical case of severe cholangitis secondary to the presence of a periampullary diverticulum successfully treated endoscopically. Clinical case: A 68-year-old man with a history of diabetes and hypertension, was admitted to the emergency room with symptoms of abdominal pain, fever, and tachycardia. With acute kidney injury and alterations in liver function tests, ultrasound with dilated common bile duct and gallstones. Magnetic resonance cholangiography is performed, showing duodenal diverticulum and choledocholithiasis. Antibiotic management is given, and endoscopic retrograde cholangiopancreatography is decided, finding a duodenal diverticulum with stones and pus inside, sphincterotomy, transpapillary dilation and multiple sweeps are performed. Cholecystectomy was performed 7 days later, and the patient was discharged without complications. Conclusions: In patients with signs of severe cholangitis, it is important not to delay endoscopic retrograde cholangiopancreatography, even when infrequent associated pathologies are evidenced, such as a periampullary duodenal diverticulum, since this represents the diagnostic and therapeutic method of choice with high rates of resolution in the case of an obstructive pathology of the bile duct.

Introducción: los divertículos duodenales periampulares son raros y las complicaciones pancreaticobiliares infrecuentes; sin embargo, cuando se diagnostican y se asocian a sintomatología ameritan intervención urgente. El objetivo de este trabajo es presentar un caso clínico de colangitis severa secundaria a la presencia de un divertículo periampular tratado de manera exitosa por vía endoscópica. Caso clínico: hombre de 68 años con antecedentes de diabetes e hipertensión, quien acude al área de Urgencias con cuadro de dolor abdominal, fiebre y taquicardia. Se identifica lesión renal aguda y alteraciones en las pruebas de función hepática, ultrasonido con colédoco dilatado y litiasis vesicular. Se realiza colangioresonancia magnética que evidencia divertículo duodenal y coledocolitiasis. Se otorga manejo antibiótico y se decide colangiopancreatografía retrógrada endoscópica, encontrándose divertículo duodenal con litos y pus en su interior, se realiza esfinterotomía, dilatación transpapilar y múltiples barridos. Se realiza colecistectomía a los siete días y se egresa a domicilio por mejoría sin complicaciones. Conclusiones: en pacientes con datos de colangitis grave es importante no retrasar la colangiopancreatografia retrógrada endoscópica, aun cuando se evidencien patologías asociadas infrecuentes como un divertículo duodenal periampular, ya que esta representa el método diagnóstico y terapéutico de elección con tasas altas de resolución ante una patología obstructiva de la vía biliar.

[Gallstone ileus: a diagnostic and therapeutic challenge. Presentation of a clinical case]. / Íleo biliar: un reto diagnóstico y terapéutico. Presentación de un caso clínico.

Background: Gallstone ileus represents 4% of the causes of bowel obstruction in general population, but it increases to 25% in patients above 65 years of age. Gallstone ileus does not present with unique symptoms, making diagnosis difficult. It has a high mortality (12 to 27%) due to associated comorbidities and diagnostic delay. The aim of this case report is to communicate the importance of prompt diagnosis and surgical management of gallstone ileus. Clinical case: It is presented the clinical case of a 67-year-old female patient with a history of long-standing diabetes mellitus without medical control, without previous surgical history, who began suffering 2 days prior to admission to the emergency room with signs and symptoms of intestinal occlusion. She was given medical management without improvement and diagnostic delay of mechanical intestinal occlusion that was surgically intervened 7 days after the onset of clinical symptoms, finding gallstone ileus in the exploratory laparotomy, with satisfactory resolution of the pathology despite the diagnostic delay. Conclusions: Gallstone ileus is a difficult clinical entity to diagnose and therefore requires a high index of suspicion. The aim of gallstone ileus treatment is to release the obstruction, which is done through enterolithotomy. It is the recommended technique for gallstone ileus management because of its lower morbidity and mortality, compared with the other techniques.

Introducción: el íleo biliar representa el 4% de las causas de obstrucción intestinal en la población en general, pero incrementa a un 25% en los pacientes de más de 65 años. No presenta síntomas únicos, lo cual hace difícil su diagnóstico. Tiene una alta mortalidad (entre 12 y 27%) debido a las comorbilidades asociadas y al retraso diagnóstico. El objetivo de este caso clínico es comunicar la importancia del diagnóstico oportuno y el manejo quirúrgico del íleo biliar. Caso clínico: se presenta el caso clínico de una paciente de 67 años con antecedente de diabetes mellitus de larga evolución sin control médico, sin antecedentes quirúrgicos previos, cuyo padecimiento comenzó dos días antes de su ingreso a urgencias con signos y síntomas de oclusión intestinal. Se le dio manejo médico sin mejoría y hubo retraso diagnóstico de oclusión intestinal mecánica, la cual fue intervenida quirúrgicamente siete días después del inicio del cuadro clínico. En la laparotomía exploradora se encontró un íleo biliar, con resolución satisfactoria de la patología a pesar del retraso diagnóstico. Conclusiones: el íleo biliar es una entidad clínica de difícil diagnóstico que requiere un alto índice de sospecha. El objetivo del tratamiento del íleo biliar es liberar la obstrucción por medio de la enterolitotomía. Comparada con las otras técnicas, esta es la técnica recomendada para el manejo del íleo biliar, debido a su menor morbimortalidad.

Ten strategies to improve the efficacy of laparoscopic biliary surgery. / Diez estrategias para mejorar la eficacia de la cirugía biliar laparoscópica.

Laparoscopic surgery is the gold standard treatment of symptomatic gallstones. For some, it is also the treatment of choice for choledocholithiasis. Certain special and rare circumstances regarding the number, size and location of bile duct stones or altered bile duct anatomy (embryonic or acquired), can be challenging to resolve with usual laparoscopic techniques. For these situations, we describe 10 surgical strategies that are relatively simple and inexpensive to apply, making them appropriate to be used in most surgical centers.

Colecistectomía: resultados de una década de experiencia / Cholecystectomy: results. a decade of experience

Introducción: La colecistectomía, sea a través de una incisión subcostal o videolaparoscópica es la intervención quirúrgica por excelencia para remover la vesícula biliar. El objetivo del estudio es presentar la experiencia acumulada en este tipo de cirugía a través de diez años, sus indicaciones, sus modalidades quirúrgicas, la relación con otras patologías así como las complicaciones de las técnicas empleadas. Metodología: Se incluyen todos los casos quirúrgicos de pacientes con enfermedad de la vesícula y vías biliares ingresados del 01 de enero del 2006 al 31 de diciembre del 2016 en el Departamento de Cirugía del Hospital San Vicente. Resultados: Del 2006 al 2016 se intervinieron 985 pacientes de los cuales, 888 (90.15%) corresponden al sexo femenino. La edad promedio fue de 41 años para ambos sexos, no mostrando diferencias 40.78 vs. 40.95. La colecistitis crónica fue la indicación pre operatoria en el 98.7% y su relación con hernia umbilical fue del 2.23%. La técnica quirúrgica abierta se realizó en 702 (70.27%) y la vía laparoscópica en 260 (26.40%). La tasa global de complicaciones fue del 2.33% (23 / 985 pacientes) siendo el sangrado el más observado en 12 pacientes (1.21%) y la lesión de la vía biliar en 5 (0.50%). Conclusiones: La afección de la vesícula sigue afectando principalmente al sexo femenino, su resolución es esencialmente quirúrgica y en la actualidad la colecistectomía video laparoscópica se considera la cirugía por excelencia, sin que ésta anule la vía abierta por múltiples factores. Es un procedimiento de baja morbilidad y en nuestra serie no se acompañó de mortalidad.

Background: Cholecystectomy, performed with open incision or laparoscopically, by excellence it is the surgery to remove the pathological gallbladder. The aim of this study is to present the experience gained in this type of surgery within ten years, showing indicatons, surgical modalites, and the relaton with other pathologies as well as complicatons of the techniques employed. Methods: All surgical cases of patents with diseased gallbladder and bile ducts are admited from January 01, 2006 to December 31, 2016 in the Department of Surgery of San Vicente Hospital. Results: 985 patents were included, 888 (90.15%) are female. Average age was 41 years old for both sexes, showing no diferences 40.78 vs. 40.95. Chronic Cholecystts was the main preoperatve diagnosis in 98.7%, and its relaton with an umbilical hernia was 2.23%. The open technique was performed on 702 patents (70.27%) and laparoscopic approach on 260 patents (26.40%). The overall complicaton rate was 2.33%. Hemorrhage was the most common in 12 patents (1.21%), and bile duct injury in 5 patents (0.50%). Conclusion: Gallbladder disease is stll more common in women. Treatment is essentally surgical and currently laparoscopic cholecystectomy is considered the standard of care. Cholecystectomy has a low incidence of morbidity and in this study there was no mortality

Biliary ileus: case report.

Biliary ileusis a uncommon cause of mechanical bowel obstruction, affecting older adult patients who often have other significant medical conditions. It is caused by intestinal impaction of a gallstone that enters the bowel via a cholecysto-enteric fistula. The mortality rate is considerable, ranging between 12 and 27%. Treatment in most cases is surgical, aimed at the resolution of the intestinal obstruction. We report the case of a 55 year old patient diagnosed with biliary ileus, wich evolved without complications after a enterolithotomy. We have concluded, based on the literature that an early diagnosis associated with appropriate therapy can lead to a better prognosis.

Gallstone ileus: An overview of the literature. / El íleo biliar: una revisión de la literatura médica.

INTRODUCTION: Gallstone ileus represents 4% of the causes of bowel obstruction in the general population, but increases to 25% in patients above the age of 65 years. Gallstone ileus does not present with unique symptoms, making diagnosis difficult. Its management is surgical, but there is no consensus as to which of the different surgical techniques is the procedure of choice. At present, there is no recent review of this pathology. AIM: To conduct an up-to-date review of this disease. MATERIALS AND METHODS: Articles published within the time frame of 2000 to 2014 were found utilizing the PUBMED, EMBASE, and Cochrane Library search engines with the terms "gallstone ileus" plus "review" and the following filters: "review", "full text", and "humans". RESULTS: The results of this review showed that gallstone ileus etiology was due to intestinal obstruction from a gallstone that migrated into the intestinal lumen through a bilioenteric fistula. The presence of 2 of the 3 Rigler's triad signs was considered diagnostic. Abdominal tomography was the imaging study of choice for gallstone ileus diagnosis and the surgical procedures for management were enterolithotomy, one-stage surgery, and two-stage surgery. Enterolithotomy had lower morbidity and mortality than the other 2 procedures. CONCLUSIONS: The aim of gallstone ileus treatment is to release the obstruction, which is done through enterolithotomy. It is the recommended technique for gallstone ileus management because of its lower morbidity and mortality, compared with the other techniques.

A New Paradigm in Gallstones Diseases and Marked Elevation of Transaminases: An Observational Study

ABSTRACT Background. In clinical practice, it is assumed that a severe rise in transaminases is caused by ischemic, viral or toxic hepatitis. Nevertheless, cases of biliary obstruction have increasingly been associated with significant hypertransaminemia. With this study, we sought to determine the true etiology of marked rise in transaminases levels, in the context of an emergency department. Material and methods. We retrospectively identified all patients admitted to the emergency unit at Centro Hospitalar e Universitário de Coimbra between 1st January 2010 and 31st December 2010, displaying an increase of at least one of the transaminases by more than 15 times. All patient records were analyzed in order to determine the cause of hypertransaminemia. Results. We analyzed 273 patients - 146 males, mean age 65.1 ± 19.4 years. The most frequently etiology found for marked hypertransaminemia was pancreaticobiliary acute disease (n = 142;39.4%), mostly lithiasic (n = 113;79.6%), followed by malignancy (n = 74;20.6%), ischemic hepatitis (n = 61;17.0%), acute primary hepatocellular disease (n = 50;13.9%) and muscle damage (n = 23;6.4%). We were not able to determine a diagnosis for 10 cases. There were 27 cases of recurrence in the lithiasic pancreaticobiliary pathology group. Recurrence was more frequent in the group of patients who had not been submitted to early cholecystectomy after the first episode of biliary obstruction (p = 0.014). The etiology of hypertransaminemia varied according to age, cholestasis and glutamic-pyruvic transaminase values. Conclusion. Pancreaticobiliary lithiasis is the main cause of marked hypertransaminemia. Hence, it must be considered when dealing with such situations. Not performing cholecystectomy early on, after the first episode of biliary obstruction, may lead to recurrence.

A New Paradigm in Gallstones Diseases and Marked Elevation of Transaminases: An Observational Study.

BACKGROUND: In clinical practice, it is assumed that a severe rise in transaminases is caused by ischemic, viral or toxic hepatitis. Nevertheless, cases of biliary obstruction have increasingly been associated with significant hypertransaminemia. With this study, we sought to determine the true etiology of marked rise in transaminases levels, in the context of an emergency department. MATERIAL AND METHODS: We retrospectively identified all patients admitted to the emergency unit at Centro Hospitalar e Universitário de Coimbra between 1st January 2010 and 31st December 2010, displaying an increase of at least one of the transaminases by more than 15 times. All patient records were analyzed in order to determine the cause of hypertransaminemia. RESULTS: We analyzed 273 patients - 146 males, mean age 65.1 ± 19.4 years. The most frequently etiology found for marked hypertransaminemia was pancreaticobiliary acute disease (n = 142;39.4%), mostly lithiasic (n = 113;79.6%), followed by malignancy (n = 74;20.6%), ischemic hepatitis (n = 61;17.0%), acute primary hepatocellular disease (n = 50;13.9%) and muscle damage (n = 23;6.4%). We were not able to determine a diagnosis for 10 cases. There were 27 cases of recurrence in the lithiasic pancreaticobiliary pathology group. Recurrence was more frequent in the group of patients who had not been submitted to early cholecystectomy after the first episode of biliary obstruction (p = 0.014). The etiology of hypertransaminemia varied according to age, cholestasis and glutamic-pyruvic transaminase values. CONCLUSION: Pancreaticobiliary lithiasis is the main cause of marked hypertransaminemia. Hence, it must be considered when dealing with such situations. Not performing cholecystectomy early on, after the first episode of biliary obstruction, may lead to recurrence.

Gallstone disease and obesity: a population-based study on abdominal fat distribution and gender differences.

BACKGROUND: Existing evidence suggests the visceral fat is more metabolically active than subcutaneous fat. We aimed to investigate the value of subcutaneous (SAT) and visceral adipose tissue thickness (VAT) for prediction of gallstone disease (GSD) in general population by focus on gender differences and comparison with body mass index (BMI), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR). MATERIAL AND METHODS: In this cross-sectional survey, 1,494 subjects (51.4 % men), aged above 50, randomly selected from Golestan Cohort Study residing in Gonbad City, Iran, underwent anthropometric measurements and abdominal ultrasonography. RESULTS: Prevalence of GSD was 17.8% (95% CI 15.9-19.8). Following adjustment for age and then other potential risk factors, all obesity indices, except for SAT, were associated with GSD in women with the highest odds ratio observed in WHtR (OR 1.52, 95% CI 1.22-1.89). In contrast, WHR was the only associated index in men (OR 1.49, 95% CI 1.08-2.06). The trend of increasing obesity measures across the quartiles with the risk of GSD was significant in subgroups of WHtR and BMI in women and WHR in men. No significant association was found between SAT and GSD in men or women. CONCLUSIONS: The best anthropometric indicators of the risk of GSD may differ by gender. In men, WHR might be the only preferred index to estimate risk of GSD. WHtR, WHR, VAT and BMI are associated with GSD risk in women, although WHtR might better explain this risk. SAT is the poor indicator for identifying subjects with GSD in both genders.

[Acute pancreatitis in childhood by choledocal stone in a choledocal cyst. Case report]. / Pancreatitis en la infancia por litiasis coledociana en quiste de colédoco complicado. Reporte de caso.

Acute pancreatitis is a known complication of choledochal cysts. It is associated with changes in the biliopancreatic junction and with intra-cystic gallstones. We describe a case of pancreatitis and biliary obstruction caused by choledochal cyst type IVa complicated with obstruction by biliary stones in a 2 year old infant.

[Spontaneous cholecystocutaneous fistula]. / Fístula colecistocutánea espontánea.

BACKGROUND: Spontaneous cholecystocutaneous fistula is defined as a gallbladder communication with the external environment through the abdominal wall rupture; the first reports were written in the seventeenth century by Thilesus. During the past 50 years 25 cases have been reported. CLINICAL CASE: We report a case of a 30-year-old woman presented with a five-year history of biliary colic, six months prior to medical assessment presents outlet of biliary material and gallstones spontaneously in the right upper quadrant. Fistulogram was performed without evidence of obstruction, subsequently cholecystectomy and resection of the fistula was performed. DISCUSSION: The biliary fistulas are an abnormal communication from the gallbladder into another surface, is a rare condition in our day as it only occurs in 10% of patients with gallbladder lithiasis; while spontaneous cholecystocutaneous fistula clinic is more than evident. It is imperative perform studies like ultrasound, tomography, and fistulogram. The mainstay of treatment is cholecystectomy, resection of the fistula and repair of abdominal wall defect. CONCLUSION: The incidence of cholecystocutaneous fistula today is minimal and it seems that the current trend is to become an entity anecdotal, the approach subcostal abdominal examination remains as the first choice. The laparoscopic approach is an option reserved for the experienced surgeon.

Influence of ApoE and FABP2 polymorphisms and environmental factors in the susceptibility to gallstone disease.

BACKGROUND: Gallstone disease (GSD) is a common chronic disease in the Western hemisphere, yet environmental and genetic factors may be responsible for the variations in the prevalence of GSD among populations. AIM: To analyze the relationship of the ApoE and FABP2 polymorphisms with diet, physical activity and emotional health in patients with GSD from West Mexico. MATERIAL AND METHODS: A total of 120 patients with GSD and 370 healthy subjects were enrolled. Anthropometric, biochemical, nutritional, clinical and physical activity parameters were measured. ApoE and FABP2 genotypes were assesed by PCR-RFLPs assays. RESULTS: ApoE E3/E4 genotype and the ApoE E4 allele was highly prevalent among the GSD patients compared to the controls (32% vs. 12.0% and 22% vs. 8.4% respectively p < 0.01). Patients with the Apo E4 allele showed an upward trend of cholesterol levels compared to non-Apo E4 allele carriers (E4 186 ± 30 mg/dL; E3 143 ± 37 mg/dL; E2 129 ± 34 mg/dL). High triglyceride levels were associated with patients that were FABP2 Thr54 allele carriers (p < 0.05) but lacked association with GSD. This may be due to changes in dietary fats after GSD diagnosis, masking the clinical course of the disease. Sedentary lifestyle and negative emotions were detected in 83% and 63% of patients, respectively. CONCLUSION: These data suggest that the Apo E4 allele could confer genetic susceptibility for the development of GSD among the Mexican population. The Ala54Thr polymorphism of FABP2 was associated with high triglycerides levels, but not to GSD; suggesting that environmental factors modulate such susceptibility.

Identification of cholesterol gallstone with two-dimensional gel electrophoresis and mass spectrometry.

BACKGROUND AND RATIONALE: We aimed to provide novel information to better understand the molecular mechanisms underlying gallstones formation and explore the potential protein markers for gallstones progression. The gallbladder tissues were collected from 20 patients with cholesterol gallstone and 10 liver transplant donors from November 2010 to April 2011. The proteomics were compared between gallstone patients and controls by two-dimensional gel electrophoresis (2-DE). The differentially expressed proteins were identified and validated by western blotting and real-time PCR. RESULTS: Total 19 protein spots were found to be different between two groups and 11 proteins were identified, among which 4 ones (such as Peroxiredoxin 3/Prdx3) were down-regulated and 7 (such as Tropomyosin 4/TPM4, Transgelin/SM22, Transthyretin/ TTR) were up-regulated in gallstone group. Results of western blotting and RT-PCR were consistent with the 2-DE results. CONCLUSION: The differentially expressed proteins of TTR, TPM4, SM22 and Prdx3 may play key roles in gallstone formation and may be markers for gallstone progression.

Síndrome de Bouveret: reporte de un caso / Bouveret Syndrome: case report

El síndrome de Bouveret es un tipo infrecuente de íleo biliar, caracterizado por el paso de un cálculo de la vesícula al intestino a través de una fístula colecistogastroduodenal produciendo obstrucción del tracto gastrointestinal. Se reportaron poco más de 200 casos en la literatura médica, con una mortalidad aproximada de un 25% y un pronóstico determinado por: comorbilidad, edad avanzada y retraso en el diagnóstico debido a su inespecificidad. Para el diagnóstico son útiles: radiografía simple, ecografía, tomografía computarizada, resonancia magnética y la endoscopía como medio más sensible que también es usado como forma terapéutica además de la cirugía. Se presenta el caso de una paciente de 49 años, que consultó por epigastralgia, nauseas, vómitos postprandiales, intolerancia alimentaria, en mal estado general, con diagnóstico de colecistitis aguda procediendo a colecistectomía abierta donde se evidencio un cálculo impactado en el trayecto de una fístula colecistogástrica correspondiente a un Síndrome de Bouveret.

Bouveret syndrome is a rare type of gallstone ileus, characterized by the step of calculating the gallbladder into the intestine through a fistula colecistogastroduodenal producing gastrointestinal tract obstruction. Just over 200 cases were reported in the medical literature, with an estimated mortality of 25% and a specific prognosis: comorbidity, advanced age and delay in diagnosis due to its specificity. For diagnostic they are useful: plain radiography, ultrasound, computed tomography, magnetic resonance and endoscopy as more sensitive means is also used as therapeutically addition to surgery. Patient 49, who complained epigastric pain, nausea, postprandial vomiting, food intolerance, poor general condition, diagnosed with acute cholecystitis proceeding to open cholecystectomy where impacted stone was evident in the way of a corresponding cholecystogastric fístula to Bouveret syndrome.

Aspectos atuais no manejo dos pacientes com íleo biliar / Current aspects in the management of patients with biliary obstruction

Íleo biliar é uma complicação rara da colelitíase que, quando não diagnosticada precocemente, pode cursar com altos índices de complicações. Apesar de infrequente, deve ser lembrado pelos médicos que trabalham em serviços de urgência. O tratamento é cirúrgico, podendo variar conforme o local de atendimento, o estado geral do paciente e a experiência da equipe.

Gallstone ileus is a rare complication of biliary lithiasis that, when not diagnosed early, can be associated with high complication rates. Although infrequent, this condition should be considered by physicians working in emergency departments. Treatment is mainly surgical and may vary by location of care, patient's general condition and experience of staff.

Rendimiento diagnóstico del marcador tumoral CA 19-9 en la diferenciación entre patología bilio-pancreática benigna y maligna / Accuracy of the tumor marker CA 19-9 in the differentiation of benign and malignant bilio-pancreatic diseases

Introduction: CA 19-9 has been identified as a derivative of sialic Lewis blood group A and is expressed in 95 percent of the population. Several studies have documented an overproduction of CA 19-9 in malignant pancreatic and biliary tree diseases. The objective of this study is to determine the accuracy of the tumor marker CA 19-9 differentiating benign and malignant bilio-pancreatic diseases. Material and Methods: diagnostic test study. We reviewed the records of all patients with malignant bilio-pancreatic diseases and benign biliary calculous diseases evaluated in Hospital Base Osorno between august 2007 and december 2011, with CA 19-9 as part of their study. Results: 71 patients met the inclusion criteria, 17 men and 54 women, with a mean age of 60.7 +/- 15.3 years old. Twenty nine (40.8 percent) cases were benign and 42 (59.2 percent) cases malignant. For a cutoff level of 37 U/ml the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to differentiate benign from malignant disease was 81 percent, 72.4 percent, 81 percent and 72.4 percent, respectively. For a cut off level of 130 U/ml specificity and PPV increased to 96.6 percent and 96.4 percent, respectively. Conclusions: the use of CA 19-9 is useful in the diagnosis of patients with suspected bilio-pancreatic malignant disease. The optimization of the normal published value can help to improve accuracy.

Introducción: El CA 19-9 se ha identificado como un derivado siálico del grupo sanguíneo Lewis A y se expresa en el 95 por ciento de la población. Numerosos estudios han documentado una sobreproducción de CA 19-9 en tumores malignos del árbol biliar y páncreas. El objetivo de este estudio es determinar la utilidad del marcador tumoral CA 19-9 en la diferenciación de patología bilio-pancreática benigna y maligna. Material y Métodos: estudio de pruebas diagnósticas. Se revisaron los antecedentes de todos los pacientes con patología bilio-pancreática maligna y enfermedad litiásica biliar benigna, evaluados en el Hospital Base de Osorno entre agosto de 2007 y diciembre de 2011, a los que se les haya solicitado CA 19-9 como parte de su estudio. Resultados: 71 pacientes cumplieron los criterios de inclusión, 17 hombres y 54 mujeres, con una media de 60,7 +/- 15,3 años de edad. Veintinueve (40,8 por ciento) casos correspondieron patología benigna y 42 (59,2 por ciento) casos a patología maligna. Para un valor de corte de 37 U/ml la sensibilidad, especificidad, valor predictivo positivo (VPP) y valor predictivo negativo (VPN) para diferenciar enfermedad benigna de maligna fue de 81 por ciento, 72,4 por ciento, 81 por ciento y 72,4 por ciento, respectivamente. Para un valor de corte de 130 U/ ml la especificidad y el VPP aumentaron a 96,6 por ciento y 96,4 por ciento, respectivamente. Conclusiones: el uso del Ca 19-9 es útil en el proceso diagnóstico de pacientes con sospecha de patología bilio-pancreática maligna. La optimización de los valores sobre el valor de normalidad publicado puede ayudar a mejorar su rendimiento.