[Flexible endoscopic treatment for Zenker's diverticulum: preliminary results in a single center experience in a public hospital in Argentina.] / Tratamiento del divertículo de Zenker con endoscopio flexible: experiencia en us hospital público de la Arfgentina.

Zenker's diverticulum (ZD) is an acquired protrusion of the esophageal wall. Treatment is reservedfor symptomatic cases. In Argentina, ZD has historically managed exclusively by surgical intervention. In 1995, Ishioka, et al and Mulder, et a1published their experience using flexible endoscopes for diverticulotomy. Since then, a wide variety ofdifferent techniques have been published. Objetive. To present technique modifications and results ofour center. MATERIAL AND METHODS: We reviewed the database of57patients (36 men), with a mean age of 71.9 years (range 37-98), with symptomatic Zenker ' diverticulum, who underwent endoscopic myotomy, from December 1997 to April 2015. All procedures were performed in our center, by the same endoscopist (HM). The most common symptom was dysphagia (94.7%), which was recorded by a 0-4 score (0=no dysphagia, 1 =solids, 2=semisolids, 3=liquids, 4=saliva). The first nine cases were done exposing the septum with a nasogastric tube, and the others with a soft diverticuloscope. Allprocedures were carried out with the patient under deep sedation, adminis- tered by an anesthesiologist. A myotomy was done in all cases with a needle-knife, using a coagulation current, to prevent bleeding. Clips were placed to close mucosalilaps, decrease the risk of unsuspected perforation and postprocedure bleeding. RESULTS: Seventy procedures were performed, in 56 patients. One patient was excluded because of incomplete myotomy due to a severe adverse event. Ninety-eight percent ofpatients had resolution or improvement of the dysphagia score, at 30 days. Three patients with regurgitation as their sole complaint completely resolved their symptom. Median follow-up was 25 months (1-99). Thirty-seven patients were followed for at least 1 year and 97.3% showed a favorable outcome. In 13 cases (22.8%) a reintervention was needed, with positive results in all cases. Bleeding occurred in one patient (1.4%), who required surgery. Another patient required surgical intervention due to technical issues. There were no perforations or infections. CONCLUSION: Treatment of ZD with flexible endoscope is a safe and effective option, with good long-term results. We need randomized clinical trials comparing different therapeutic options to be able to recommend a definitive strategy. Until then, we suggest using the technique with which each center has the most experience and feels most comfortable performing.

Expression Pattern of Fatty Acid Binding Proteins in Celiac Disease Enteropathy.

Celiac disease (CD) is an immune-mediated enteropathy that develops in genetically susceptible individuals following exposure to dietary gluten. Severe changes at the intestinal mucosa observed in untreated CD patients are linked to changes in the level and in the pattern of expression of different genes. Fully differentiated epithelial cells express two isoforms of fatty acid binding proteins (FABPs): intestinal and liver, IFABP and LFABP, respectively. These proteins bind and transport long chain fatty acids and also have other important biological roles in signaling pathways, particularly those related to PPARγ and inflammatory processes. Herein, we analyze the serum levels of IFABP and characterize the expression of both FABPs at protein and mRNA level in small intestinal mucosa in severe enteropathy and normal tissue. As a result, we observed higher levels of circulating IFABP in untreated CD patients compared with controls and patients on gluten-free diet. In duodenal mucosa a differential FABPs expression pattern was observed with a reduction in mRNA levels compared to controls explained by the epithelium loss in severe enteropathy. In conclusion, we report changes in FABPs' expression pattern in severe enteropathy. Consequently, there might be alterations in lipid metabolism and the inflammatory process in the small intestinal mucosa.

[Intraparenchymal hepatic haematoma after endoscopic retrograde cholangiopancreotography overinfected by Citrobacter freundii and Klebsiella pneumoniae BLEE]. / Hematoma intraparenquimatoso hepático post- colangiopancreatografía retrógrada endoscópica sobreinfectado por Citrobacter freundii y Klebsiella pneumoniae BLEE.

This case report describes a 37-year-old woman who develops an intraparenchymal hepatic haematoma after an endoscopic retrograde cholangiopancreatography with papillotomy and stone extraction. The procedure requires the passage of a guidewire. The patient develops acute abdominal pain 72 hours later and a magnetic resonance shows a hematoma of 124 x 93 mm. She remains under observation. Twenty one days later she complains of upper right abdominal pain and fever. Consequently, a percutaneous drainage is performed isolating Citrobacter freundii and Klebsiella pneumoniae BLEE. The patient has a good evolution.

Role of CXCR3/CXCL10 axis in immune cell recruitment into the small intestine in celiac disease.

Lymphocytic infiltration in the lamina propria (LP), which is primarily composed of CD4(+) Th1 cells and plasma cells, and increased numbers of intraepithelial lymphocytes (IELs), is a characteristic finding in active celiac disease (CD). Signals for this selective cell recruitment have not been fully established. CXCR3 and its ligands, particularly CXCL10, have been suggested to be one of the most relevant pathways in the attraction of cells into inflamed tissues. In addition, CXCR3 is characteristically expressed by Th1 cells. The aim of this work was to investigate the participation of the chemokine CXCL10/CXCR3 axis in CD pathogenesis. A higher concentration of CXCL10 was found in the serum of untreated CD patients. The mRNA levels of CXCL10 and CXCL11 but not CXCL9 were significantly higher in duodenal biopsies from untreated CD patients compared with non-CD controls or treated patients. The results demonstrate that CXCL10 is abundantly produced in untreated CD and reduced in treated patients, and the expression of CXCL10 was found to be correlated with the IFNγ levels in the tissue. Plasma cells and enterocytes were identified as CXCL10-producing cells. Moreover, the CXCL10 expression in intestinal tissues was upregulated by poly I:C and IL-15. IELs, LP T lymphocytes, and plasma cells, which infiltrate the intestinal mucosa in untreated CD, express CXCR3. The CXCR3/CXCL10 signalling axis is overactivated in the small intestinal mucosa in untreated patients, and this finding explains the specific recruitment of the major cell populations that infiltrate the epithelium and the LP in CD.

Hematoma intraparenquimatoso hepático post- colangiopancreatografía retrógrada endoscópica sobreinfectado por Citrobacter freundii y Klebsiella pneumoniae BLEE / [Intraparenchymal hepatic haematoma after endoscopic retrograde cholangiopancreotography overinfected by Citrobacter freundii and Klebsiella pneumoniae BLEE].

This case report describes a 37-year-old woman who develops an intraparenchymal hepatic haematoma after an endoscopic retrograde cholangiopancreatography with papillotomy and stone extraction. The procedure requires the passage of a guidewire. The patient develops acute abdominal pain 72 hours later and a magnetic resonance shows a hematoma of 124 x 93 mm. She remains under observation. Twenty one days later she complains of upper right abdominal pain and fever. Consequently, a percutaneous drainage is performed isolating Citrobacter freundii and Klebsiella pneumoniae BLEE. The patient has a good evolution.

Hematoma intraparenquimatoso hepático post- colangiopancreatografía retrógrada endoscópica sobreinfectado por Citrobacter freundii y Klebsiella pneumoniae BLEE. / [Intraparenchymal hepatic haematoma after endoscopic retrograde cholangiopancreotography overinfected by Citrobacter freundii and Klebsiella pneumoniae BLEE].

This case report describes a 37-year-old woman who develops an intraparenchymal hepatic haematoma after an endoscopic retrograde cholangiopancreatography with papillotomy and stone extraction. The procedure requires the passage of a guidewire. The patient develops acute abdominal pain 72 hours later and a magnetic resonance shows a hematoma of 124 x 93 mm. She remains under observation. Twenty one days later she complains of upper right abdominal pain and fever. Consequently, a percutaneous drainage is performed isolating Citrobacter freundii and Klebsiella pneumoniae BLEE. The patient has a good evolution.

Broad MICA/B expression in the small bowel mucosa: a link between cellular stress and celiac disease.

The MICA/B genes (MHC class I chain related genes A and B) encode for non conventional class I HLA molecules which have no role in antigen presentation. MICA/B are up-regulated by different stress conditions such as heat-shock, oxidative stress, neoplasic transformation and viral infection. Particularly, MICA/B are expressed in enterocytes where they can mediate enterocyte apoptosis when recognised by the activating NKG2D receptor present on intraepithelial lymphocytes. This mechanism was suggested to play a major pathogenic role in active celiac disease (CD). Due to the importance of MICA/B in CD pathogenesis we studied their expression in duodenal tissue from CD patients. By immunofluorescence confocal microscopy and flow cytometry we established that MICA/B was mainly intracellularly located in enterocytes. In addition, we identified MICA/B(+) T cells in both the intraepithelial and lamina propria compartments. We also found MICA/B(+) B cells, plasma cells and some macrophages in the lamina propria. The pattern of MICA/B staining in mucosal tissue in severe enteropathy was similar to that found in in vitro models of cellular stress. In such models, MICA/B were located in stress granules that are associated to the oxidative and ER stress response observed in active CD enteropathy. Our results suggest that expression of MICA/B in the intestinal mucosa of CD patients is linked to disregulation of mucosa homeostasis in which the stress response plays an active role.

[N-butyl-2-cyanoacrylate for the treatment of gastric varices]. / N-butil-2-cianoacrilato en el tratamiento de las várices gástricas.

OBJECTIVE: To evaluate the success of the treatment with cyanoacrylate in primary hemostasis, rebleeding, and gastric varices eradication. MATERIAL AND METHODS: In this retrospective study 65 patients with gastric varices treated with N-butyl-2-cyanoacrylate (Histoacryl) were included from January 1999 to January 2008. We used a solution of 0,5 mL of cyanoacrylate and 0.9 mL of lipiodol, utilizing an average of 3.46 mL of this mixture per session (range 1 to 6 mL). Sclerosing needles of 21 gauge were used. Patients were sedated. Data were analyzed using a chi-squared test. RESULTS: Sixty-five patients were included, 42 men and 23 women with an average age of 53.8 years (range 18 to 76 years). The etiology of the portal hypertension (PH) was cirrhosis in 52 patients (80%), prehepatic PH in 7 (10.8%), and segmentary PH in 3 (4.6%), and non-classified in 3 (4.6%). Cirrhotic patients were classified as Child A in 21 cases, Child B in 25 and Child C in 6. According to the Sarin classification, 7 patients had gastric-oesophageal varices (GOV) type 1, 32 GOV2, 8 GOV1 and 2, and 8 isolated gastric varices (IGV) type 1. Fifty-six patients (86%) presented active bleeding or stigmata of recent bleeding at time of initial endoscopy. Primary hemostasis was achieved in 50 of them (89%) and the remaining 6 required a second session. Eleven patients presented rebleeding within the following 6 weeks and were again treated with cyanoacrylate. Hemostasis was achieved in 8 of them, 2 were referred for surgical management, and 1 received endovascular treatment. Follow-up was able in 53 patients for an average period of 11 months (range 1 to 81 months). During this period, 7 patients presented an episode ofrebleeding and were treated with cyanoacrylate, achieving hemostasis. Eradication of varices was documented on 21 patients (39.6%). The global rate of rebleeding was 37%. One patient developed splenic vein thrombosis as a major complication of treatment. CONCLUSION: Definitive hemostasis was achieved in 94.6% of patients, with primary hemostasis in 89%. The global rate of rebleeding was 37% and the rate of major complications associated with treatment 0.6%. Eradication of gastric varices was achieved in 35.8% of cases. As these data show, it can be concluded that butyl-cyanoacrylate constitutes an effective method for the treatment of gastric variceal bleeding.

Celiac disease serology in patients with different pretest probabilities: is biopsy avoidable?

AIM: To establish the diagnostic performance of several serological tests, individually and in combination, for diagnosing celiac disease (CD) in patients with different pretest probabilities, and to explore potential serological algorithms to reduce the necessity for biopsy. METHODS: We prospectively performed duodenal biopsy and serology in 679 adults who had either high risk (n = 161) or low risk (n = 518) for CD. Blood samples were tested using six assays (enzyme-linked immunosorbent assay) that detected antibodies to tissue transglutaminase (tTG) and deamidated gliadin peptide (DGP). RESULTS: CD prevalence was 39.1% in the high-risk population and 3.3% in the low-risk group. In high-risk patients, all individual assays had a high diagnostic efficacy [area under receiving operator characteristic curves (AU ROC): 0.968 to 0.999]. In contrast, assays had a lower diagnostic efficacy (AU ROC: 0.835 to 0.972) in the low-risk group. Using assay combinations, it would be possible to reach or rule out diagnosis of CD without biopsy in 92% of cases in both pretest populations. We observed that the new DGP/tTG Screen assay resulted in a surplus compared to more conventional assays in any clinical situation. CONCLUSION: The DGP/tTG Screen assay could be considered as the best initial test for CD. Combinations of two tests, including a DGP/tTG Screen, might be able to diagnose CD accurately in different clinical scenarios making biopsy avoidable in a high proportion of subjects.

[Primary hepatic lymphoma: an infrequent cause of focal hepatic lesion]. / Linfoma hepático primario: causa infrecuente de lesión focal hepática.

Primary hepatic lymphoma (PHL) is confined to the liver with no evidence of extrahepatic lymphomatosis. Histopathologically, the PHL belongs to the group of non-Hodgkin's lymphomas and the most common subtype is the diffise large B-cell lymphoma. We present a 72-year-old woman, with no relevant antecedents and the following symptoms: early satiety, abdominal discomfort and rapid weight loss. Liver function tests are normal, erythrocyte sedimentation rate is accelerated and LDH progressively increases during the hospitalization. Imaging studies (ultrasound, CT scan, nuclear magnetic resonance) show a multilobued mass of around 12 cm of diameter in the right hepatic lobe. Tumoral and virological markers are negative. The pathology of an echo-guided biopsy informs a massive infiltration by a diffuse large B-cell lymphoma. The immunohistochemical study shows CD20+, CD45+ and negative CD3, CKAE1, AE3, Hepatocyte and HMB45. The citology of pleural liquid is negative for atypia, peripheral blood smear shows no signs of leukemia, bone marrow biopsy is negative for lymphomatous infiltration, and gallium scintigraphy and body CT scan do not reveal extrahepatic lesions. The patient starts chemotherapy with cyclophosphamide and methylprednisolone but worsens and dies two weeks after beginning treatment. We conclude that our patient had a rare disease with an unresectable lesion, poor prognostic factors and high recurrence risk. Chemotherapy is the treatment of choice in these cases.

A prospective evaluation of endoscopic markers for identifying celiac disease in patients with high and low probability of having the disease.

BACKGROUND/OBJECTIVES: the usefulness of duodenoscopic markers for predicting celiac disease (CD) has been questioned. We assessed the diagnostic efficacy of endoscopic markers of mucosal atrophy in individuals with different pretest probability of CD. METHODS: we prospectively performed endoscopic intestinal biopsies and CD-related serology tests in 661 individuals, including 143 consecutive patients attending a malabsorption clinic (high pretest probability) and 518 subjects randomly selected fom those undergoing routine endoscopy because of upper GI symptoms (low pretest probability). Duodenoscopic markers reported were: mosaic pattern, scalloped folds, and reduction in number or loss of Kerkring's folds. RESULTS: sixty-three (44.1%) and 18 (3.5%) patients were diagnosed with CD in the high and low risk groups, respectively Among high pretest subjects, the presence of any marker had very high sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for the identification of CD (92.1%, 93.8%, 92.1%, 93.8% and 93.0%, respectively). The performance of these parameters for the presence of any marker in the low pretest population were 61.1%, 96.8%, 40.7%, 98.6% and 95.6%, respectively. Sensitivity (p < 0.004) and positive predictive value (p < 0.0001) of markers were significantly higher for the high risk patients. The identification of a reduction in number or loss of Kerkring'sfolds was not a reliable finding unless other signs were also present. CONCLUSIONS: we confirm that endoscopic markers are useful in predicting CD in different clinical scenarios. The high negative predictive value in the low probability group suggests that intestinal biopsy is not required if endoscopic markers are absent.

Malignant gastroenteric obstruction: therapeutic options.

Malignant gastric outlet obstruction is a complication of advanced pancreatic cancer, manifesting endoscopically or radiographically as a stricture of the proximal duodenum. Until recently, management consisted of surgical gastroenteric bypass with or without associated biliary bypass. Over the past decade, the endoscopic deployment of self-expanding metal stents (SEMS) emerged as a new option for restoration of enteric patency. Compared with surgical bypass, SEMS placement is less invasive with good clinical outcomes. Aside from SEMS placement and surgical bypass, recent reports of magnetic gastroenteric anastamosis have emerged. This article critically examines each of the different therapeutic options for malignant gastric outlet obstruction, defines their clinical utility, and provides the exact recommendations as to how they may be usefully employed.

Diagnóstico y tratamiento del cáncer periampular / Diagnosis and treatment of periampullar cancer

Antecedentes: Los tumores periampulares constituyen una unidad anatómica, embriológica y clínica permitiendo la aplicación de procedimientos diagnósticos y terapéuticos comunes. Objetivos: Este estudio ha sido diseñado para evaluar retrospectivamente: 1 - La incidencia de sintomatoloía clínica en relación a las distintas localizaciones. 2 - La utilización de los métodos diagnósticos. 3 - Análisis de la estadificación y tratamiento, según su localización y estadio. 4 - Análisis de los resultados del tratamiento quirúrgico resectivo, paliativo y el mini-invasivo. 5 - Incidencia de las variables histopatológicas (grado de diferenciación) como factores pronósticos de sobrevida. 6 - Estudio comparativo de la sobrevida corregida por estadio y método de tratamiento. 7 - Evaluación de la morbimortalidad observada en nuestra serie. 8 - Efectuar una actualización bibliográfica del tema. Lugar de aplicación: Los pacientes fueron estudiados y tratados en dos centros hospitalarios universitarios de referencia de la ciudad de La Plata y en práctica privada. Diseño: Estudio retrospectivo observacional. Población: 460 pacientes tratados entre 1990 y 2005. Métodos: 252 pacientes pertenecían al sexo masculino, con una media etárea de 55.8 años, con un rango entre 34 - 83 años. La localización topográfica fue de 283 en páncreas, 113 en la ampolla de Vater, 56 en vía biliar distal y 8 en duodeno...

Diagnóstico y tratamiento del cáncer periampular / Diagnosis and treatment of periampullar cancer

Antecedentes: Los tumores periampulares constituyen una unidad anatómica, embriológica y clínica permitiendo la aplicación de procedimientos diagnósticos y terapéuticos comunes. Objetivos: Este estudio ha sido diseñado para evaluar retrospectivamente: 1 - La incidencia de sintomatoloía clínica en relación a las distintas localizaciones. 2 - La utilización de los métodos diagnósticos. 3 - Análisis de la estadificación y tratamiento, según su localización y estadio. 4 - Análisis de los resultados del tratamiento quirúrgico resectivo, paliativo y el mini-invasivo. 5 - Incidencia de las variables histopatológicas (grado de diferenciación) como factores pronósticos de sobrevida. 6 - Estudio comparativo de la sobrevida corregida por estadio y método de tratamiento. 7 - Evaluación de la morbimortalidad observada en nuestra serie. 8 - Efectuar una actualización bibliográfica del tema. Lugar de aplicación: Los pacientes fueron estudiados y tratados en dos centros hospitalarios universitarios de referencia de la ciudad de La Plata y en práctica privada. Diseño: Estudio retrospectivo observacional. Población: 460 pacientes tratados entre 1990 y 2005. Métodos: 252 pacientes pertenecían al sexo masculino, con una media etárea de 55.8 años, con un rango entre 34 - 83 años. La localización topográfica fue de 283 en páncreas, 113 en la ampolla de Vater, 56 en vía biliar distal y 8 en duodeno...(AU)

Cáncer temprano rectocolónico: seguimiento luego de la terapéutica endoscópica / Early colorectal cancer: follow-up after endoscopic therapy

Aproximadamente el 90% de las polipectomías endoscópicas, correctamente indicadas, para los cánceres correctales tempranos, ya sean "invasivas" o no, son "curativas", siempre que se adopte un criterio estricto en el estudio patológico de la muestra resecada. La vigilancia por tiempo ilimitado de los pacientes es obligatoria, dado que tumores benignos (más frecuentemente) o recurrencias malignas aparecen en un 30-40%

Cáncer temprano rectocolónico: seguimiento luego de la terapéutica endoscópica / Early colorectal cancer: follow-up after endoscopic therapy

Aproximadamente el 90% de las polipectomías endoscópicas, correctamente indicadas, para los cánceres correctales tempranos, ya sean "invasivas" o no, son "curativas", siempre que se adopte un criterio estricto en el estudio patológico de la muestra resecada. La vigilancia por tiempo ilimitado de los pacientes es obligatoria, dado que tumores benignos (más frecuentemente) o recurrencias malignas aparecen en un 30-40% (AU)

Valoración de la esfinteropapilotomia endoscopica (EPE) mediante radiocolangiodebitometria operatoria (RCDM)

Con resultados iniciales de un estudio prospectivo, 5 pacientes con descompresión mediante EPE y posterior cirugía a cielo abierto complementaria son evaluados por RCDM seriada, con débito x = 18.6 cc/minuto ñ 2.3 (V.N. > ou =), el análisis comparativo con 24 EPDT amplios a cielo abierto demuestra comportamientos debitométricos similares (x = 18.3 ñ 2.0 cc/minuto). Se realizan algunas consideraçciones fisiopatológicas de acuerdo a las curvas evolutivas promedio, a verificar con muestras más amplias

Valoración de la esfinteropapilotomia endoscopica (EPE) mediante radiocolangiodebitometria operatoria (RCDM)

Con resultados iniciales de un estudio prospectivo, 5 pacientes con descompresión mediante EPE y posterior cirugía a cielo abierto complementaria son evaluados por RCDM seriada, con débito x = 18.6 cc/minuto ñ 2.3 (V.N. > ou =), el análisis comparativo con 24 EPDT amplios a cielo abierto demuestra comportamientos debitométricos similares (x = 18.3 ñ 2.0 cc/minuto). Se realizan algunas consideraþciones fisiopatológicas de acuerdo a las curvas evolutivas promedio, a verificar con muestras más amplias (AU)

Pancreas divisum: diagnóstico y tratamiento / Pancreas divisum: diagnosis and treatment

Investigando la frecuencia de páncreas divisum en nuestro medio, hallamos 9 casos entre 296 pancreatografías canaliculares, obtenidas entre 488 colangiopancreatografía retrógradas endoscópicas efectuadas en el Instituto del Diagnóstico de La Plata, en el lapso comprendido entre marzo de 1981 y agosto de 1985, o sea un 3,04% de las pancreatografías realizadas. Identificamos signos ecotomográficos compatibles con la presencia de la malformación, aunque utilizamos como elemento diagnóstico de certeza la colangiopancreatografía retrógrada endoscópica. Encontramos una prevalencia significativa de la detección de páncreas divisum, en los pacientes que fueron estudiados por presentar una pancreatitis aguda sin causa evidente, sobre los que fueron estudiados por otras causas, y tratamos quirúrgicamente a 2 de ellos con papiloplastia de la papila accesoria y drenonasopancreático con buenos resultados, llevando en la actualidad 10 y 19 meses de seguimiento respectivamente. Si bien los autores consultados se conforman con la papiloplastia de la carúncula menor o dejan un drenaje a lo Leger, consideramos que nuestro aporte, la utilización del drenonasopancreático, evita aún más la posibilidad de la reestenosis sin las complicaciones de exteriorizar un drenaje a través de la pared duodenal. Estos hallazgos avalarían la certeza de la hipótesis por la cual la pancreatitis aguda recidivante, se produciría en el páncreas divisum como expresión del obstáculo al flujo excretorio de la casi totalidad del páncreas exocrino, causada por el pequeño orificio de la papila accesoria