Granuloma eosinófilo óseo / Eosinophilic granuloma of the bone

El granuloma eosinófilo (GE) es una enfermedad infrecuente que suele afectar de forma predominante a los varones. Se desarrolla con mayor frecuencia durante la infancia y adolescencia, en nuestro caso se trata de una paciente de 31 años cuya circunstancia hace que sea más excepcional. El GE es la afección más benigna de las enfermedades que tradicionalmente se denominaban histiocitosis X, y que actualmente reciben el nombre histiocitosis de células de Langerhans. El GE óseo puede afectar a uno o múltiples huesos, los más frecuentes son los del cráneo, huesos largos, costillas, vértebras y mandíbula. Los hallazgos radiológicos craneales consisten en lesiones osteolíticas redondeadas de bordes marcados y que pueden traspasar las capas óseas. El tratamiento dependerá de la afectación clínica del paciente(AU)

Eosinophilic granuloma (EG) is a rare disease that usually predominantly affects males. It most often develops during childhood and adolescence. The case presented is exceptional in that the patient is 31 years old. EG is the most benign of the diseases that traditionally were designated histiocytosis X, and which are now called Langerhans cell histiocytosis. EG of the bone may affect one or more bones, most common being the skull, long bones, ribs, vertebrae and jaws. The radiological findings at cranial level consist of osteolytic lesions with marked rounded edges and can pass through the layers of bone. Treatment depends on the clinical condition of the patient(AU)

Use of fully covered self-expanding metal stents for the management of benign biliary conditions.

BACKGROUND AND AIM: biliary self-expanding metal stents (SEMS) have the advantage of being inserted undeployed with very small sizes and provide, when fully opened, large diameters for biliary drainage. However, their use in benign conditions has been very limited, mainly because of difficulty in their extraction. We present our initial experience with a fully covered SEMS (Wallflex) for the management of benign problems of the bile duct. PATIENTS AND METHODS: in a prospective study, stents of 8 mm in diameter and 4, 6 or 8 cm long were inserted by means of ERCP. These SEMS were chosen when according to medical judgement it was thought that diameters greater than 10 French (3.3 mm) were needed for proper biliary drainage. Stents were extracted also endoscopically, several months later when deemed clinically appropriate. RESULTS: twenty biliary SEMS were inserted. Reasons for insertion were: large intrahepatic biliary fistula after hydatid cyst surgery (1), perforation of the papillary area following endoscopic sphincterotomy (2), coaxial insertion to achieve patency in obstructed uncovered stents inserted in benign conditions (3), benign strictures (7), multiple and large common bile duct stones that could not be extracted because of tapering and stricturing of the distal common bile duct (7). In all cases, successful biliary drainage was achieved and there were no complications from insertion. Stents were easily extracted after a mean time of 132 days (36-270) in place. Complete resolution of biliary problems was obtained in 14 patients (70%). CONCLUSIONS: in our initial experience, the fully covered Wallflex biliary stent was removed without any complication after being in place in the common bile duct for a mean time of over four months. Therefore, it could be used in the management of benign biliary conditions.

[Palliative management of malignant gastric outlet obstruction with endoscopically inserted self-expanding metal stents].

AIM AND BACKGROUND: the insertion of self-expanding metal stents to palliate malignant gastric outlet obstruction is a minimally invasive procedure that is being increasingly used. We discuss experience with this technique in a level-II hospital in the Spanish National Health System. PATIENTS AND METHODS: a retrospective five-year study (2003-2007) was conducted in 23 patients who underwent 27 procedures aimed at resolving malignant gastric outlet obstruction (mean, 0.45 procedures per month) using endoscopically inserted noncovered stents (Wallstent and Wallflex). RESULTS: insertion was technically feasible in all 27 (100%) attempts, with satisfactory clinical results in 25 cases (92.5%). Endoscopy alone was used 10 times (37%), and both endoscopy and fluoroscopy on 17 (63%) occasions. After stent insertion, one patient was intervened for treatment, and a patient with an unsuccessful prosthesis received a palliative surgical bypass. Four stents became obstructed by tumoral ingrowth, and patency was reestablished by inserting a new stent. Obstructive jaundice caused by stents covering the papilla of Vater occurred in three cases. There were no other complications or mortality due to the procedure. Mean survival was 104 days (range 28-400, SD +/- 94). CONCLUSIONS: in our experience endoscopic insertion of self-expanding metal stents appears to be a safe and efficient palliative method for malignant gastric outlet obstruction, and can be performed successfully in a center with our characteristics.

Long-term follow-up of patients with small-bowel angiodysplasia on capsule endoscopy. Determinants of a higher clinical impact and rebleeding rate.

BACKGROUND: the clinical impact of small-bowel angiodysplasia has not been defined. We present a prospective study to determine the features of individuals with a higher risk of rebleeding or a worse clinical outcome. PATIENTS AND METHODS: thirty patients with angiodysplasia found on CE were included and followed for 12 months. Angiodysplasia were classified by their size as small ( 10 mm). We also studied angiodysplasia lesion numbers in each patient. Rebleeding was defined as a hemoglobin drop of more than 2 g/dl in the absence of melena or hematochezia in the case of occult GI bleeding, or with any or both manifestations. RESULTS: a therapeutic procedure was carried out in 13 patients (43.4%). Individuals with large angiodysplasia had higher transfusion requirements, a higher proportion of therapeutic procedure performed after CE, lower hemoglobin concentration, and a lower rebleeding rate. Patients with ten or more angiodysplasia lesions had also higher transfusion requirements and lower hemoglobin levels, but we found no differences in the number of therapeutic procedures or rebleeding rate between both groups. On follow up rebleeding was detected in 5 patients (16.7%), all of them with small angiodysplasias. Rebleeding was more frequent in patients who did not receive further interventions (23.53 vs. 7.69%; p = 0.037). CONCLUSIONS: angiodysplasia size >or= 10 mm determines a worse clinical impact and more possibilities of receiving a therapeutic procedure. Our findings support that patients with large lesions would benefit from therapeutic interventions with a reduction in rebleeding rate.

Extracción de cálculo coledociano de gran tamaño con esfinterotomía biliar seguida de dilatación de la papila con balón hidrostático / No disponible

No disponible

Outcomes of bile duct drainage by means of ERCP in geriatric patients / Resultados del drenaje de la vía biliar por CPRE en pacientes con edad geriátrica.

BACKGROUND AND OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) is usually the procedure of choice for relieving bile duct obstruction. a large number of patients undergoing this intervention are geriatric population (aged 75 years of age and older). Our aim was to assess the efficacy of ERCP in this group of patients as compared to younger ones. PATIENTS AND METHODS: A retrospective study. All patients in whom a therapeutic biliary endoscopy had been performed over a four-year period of time (2002-2005) were included. RESULTS: 178 geriatric patients and 159 younger ones underwent ERCP. No differences were found in successful biliary drainage (97.7 vs. 98.7%), complication number (11.8 vs. 14.4%), or mortality rate (1.1 vs. 0.6%). On the other hand, more common bile duct stones were found in geriatric patients (57.3 vs. 39.6%, p = 0.004), and also more self-expanding metal stents were employed to drain malignant obstructive jaundice (47 vs. 8%, p = 0.0035). In the youngest group, more ERCPs were repeated in the same patients (4 vs. 10%, p = 0.001). CONCLUSIONS: The geriatric population showed similar success and morbidity and mortality rates when compared to younger patients in draining their bile duct by means of ERCP. Common bile duct stones were more frequently found in geriatric patients. No patients needing an ERCP should be excluded only because of their age.

Distensión de la vesícula biliar por obstrucción tumoral coledociana (signo de Courvoisier) / Gallbladder distension caused by tumoral obstruction of the common bile duct (Courvoisier's sign)

No disponible

El aceite de oliva es un excelente lubricante para el dilatador tipo Witzel / Olive oil is a good lubricating agent for the Witzel dilator

No disponible

Coledococele de pequeño tamaño como causa de dolor epigástrico crónico: diagnóstico y tratamiento mediante CPRE / Small size choledochocele as a cause of chronic epigastric pain: diagnosis and treatment by means of ERCP

El coledococele pertenece al tipo III de los quistes biliares según la clasificación de Alonso-Lej, y son considerados los quistes menos frecuentes entre ellos. La definición habitual del coledococele es la de una dilatación quística de la porción distal intramural del colédoco que protruye en la luz duodenal. La CPRE es una de las pruebas de elección tanto para su diagnóstico como para su tratamiento, especialmente cuando son pequeños y la cavidad quística está habitualmente colapsada. La distensión de la papila (“ballooning”) durante la inyección de contraste en la CPRE se considera un signo diagnóstico. Presentamos un paciente con dolor epigástrico crónico a causa de un pequeño coledococele. La Colangiografía por Resonancia Magnética no fue diagnóstica. La CPRE proporcionó el diagnóstico y el tratamiento mediante una esfinterotomía biliar

Choledochocele belongs to type III Alonso-Lej’s classification of biliary cysts and they are considered the less frequent of such cysts. The definition most often given of choledochocele is a cystic dilation of the distal intramural portion of the bile duct, protruding into the duodenal lumen. ERCP is one of the diagnostic and therapeutic procedures of choice, specially when they are small and the cystic cavity is usually collapsed. The ballooning of the papilla during contrast injection in ERCP is thought to be a diagnostic sign. We present a patient suffering from chronic epigastric pain due to a small choledochocele. Magnetic Resonance Cholangiopancreatography failed to diagnose it. ERCP offered both diagnosis and treatment by means of biliary sphincterotomy

[Small size choledochocele as a cause of chronic epigastric pain: diagnosis and treatment by means of ERCP]. / Coledococele de pequeño tamaño como causa de dolor epigástrico crónico: diagnóstico y tratamiento mediante CPRE.

Choledochocele belongs to type III Alonso-Lej's classification of biliary cysts and they are considered the less frequent of such cysts. The definition most often given of choledochocele is a cystic dilation of the distal intramural portion of the bile duct, protruding into the duodenal lumen. ERCP is one of the diagnostic and therapeutic procedures of choice, specially when they are small and the cystic cavity is usually collapsed. The ballooning of the papilla during contrast injection in ERCP is thought to be a diagnostic sign. We present a patient suffering from chronic epigastric pain due to a small choledochocele. Magnetic Resonance Cholangiopancreatography failed to diagnose it. ERCP offered both diagnosis and treatment by means of biliary sphincterotomy.

Cytochrome P450 expression in rat gastric epithelium with intestinal metaplasia induced by high dietary NaCl levels.

Drug metabolizing enzymes like cytochrome P450 (CYP) play an important role in determining the susceptibility of organs or tissue to the toxic effects of drugs or other xenobiotics. There is some evidence indicating that individual isoforms of CYPs are over-expressed in different types of malignant tumors including that of oesophagus, pancreas, breast, lung, colon and stomach. Nevertheless, it is not clear if this change in expression is previous or after the appearance of malignancy. This is important in order to clarify the possible role of xenobiotics in the development of gastric cancer. On the other hand, it has been reported that a high salt ingestion leads to histological changes in rat stomach mucosa including enhanced cell proliferation, lipid peroxidation and intestinal metaplasia. The aim of this study is to explore the expression and activity of CYP families involved in the metabolism of carcinogens in normal rat stomach mucosa and intestinal metaplasia induced by high NaCl ingestion. Male Wistar rats were exposed to diets containing different NaCl concentrations (0.6% control group, 6%, 12%, 18% and 24%) for 12 weeks and histological changes as well as CYP modulation were monitored in gastric mucosa. Chronic gastritis, regenerative hyperplasia and focal metaplasia were noted in animals receiving the 12%, 18% and 24% NaCl diets. In the same groups, induction of CYP1A1 and CYP3A2 was produced, mainly in areas of metaplasia. The expression of xenobiotic metabolizing enzymes in the gastric mucosa might contribute to chemical activation in the stomach, metabolizing both exogenous and endogenous compounds implicated in the development of gastric cancer.

[Treatment of malignant colorectal obstruction by means of endoscopic insertion of self-expandable metallic stents]. / Tratamiento de la obstrucción neoplástica del colon meciante la inserción endoscópica de prótesis metálicas autoexpandibles.

BACKGROUND AND AIM: Self-expandable metallic stents are being used increasingly to treat the obstruction of different segments of the digestive tract and biliary tree. We present our centre experience on the initial resolution of malignant colorectal obstruction by means of this type of stents. PATIENTS AND METHODS: During a 18-month period, 13 patients patients suffering from malignant obstruction at the level of rectum, sigmoid or descending colon tried to be initially treated by means of endoscopic insertion of stents (non covered enteral Wallstents). Ten procedures were performed with both endoscopy and fluroscopy and three with only endoscopy. RESULTS: In 12 of the 13 patients (92,3%) the obstruction was solved by means of correct stent insertion. All the exclusively endoscopic procedures (without fluoroscopy) were successful. Six (50 %) patients with tumours at the rectosigmoid underwent later scheduled surgery. In the remaining six ones (a patient with an ovarian carcinoma and five with colonic adenocarcinoma) the stents were considered to be a palliative definitive treatment. Stent migration was observed in two of these patients and both were extracted endoscopically. Only one patient needed to have another stent inserted. A tumoural colo-vesical fistula developed in another patient in the palliative group, inside the previous inserted stent, and was treated by coaxial insertion of an esophageal Ultraflex. There were no other complications or mortality related to the endoscopic procedures. CONCLUSIONS: Self-expandable metallic stents might be considered, in general, as the initial treatment for the malignant obstruction at the level of rectum, sigmoid and descending colon

Thrombin is present in the lungs of patients with primary extremity osteosarcoma and pulmonary metastases.

Osteosarcoma is a rare cancer, which metastasizes to the lung in up to 80% of cases. Thrombin is involved in metastasis and is present in the lungs of patients with pulmonary metastases (PM). To identify its role in PM and osteosarcoma, we measured thrombin levels in the bronchoalveolar lavage fluid (BALF) of 15 patients. BALF was collected at different stages of the disease and correlated with the diagnosis of PM. We also assessed fibrinogen overexpression in the tumors. We found that 11/15 (73%) patients with high thrombin levels in the lungs developed PM within the first 12 months from primary surgery. The median thrombin concentration in the BALF of these patients increased up to 8x10(-9) M (range, 3x10(-9)M-15x10(-9)M), which represents a more than 100-fold increase compared to patients without PM (p<0.0001). Eight of 15 (53%) primary and 11/15 (73%) metastatic samples showed fibrinogen overexpression. A significant difference between high thrombin levels, fibrinogen overexpression and PM was found compared to patients without PM (p=0.00073 and p=0.025). These results show that thrombin levels are increased in the lungs of patients with primary osteosarcoma and a high risk of developing PM. They suggest that thrombin may be involved in the development of PM.