Trombosis y cavernomatosis portal: las claves para el éxito de un TIPS / The keys to successful TIPS in patients with portal vein thrombosis and cavernous transformation

La trombosis venosa portal (TVP) es una complicación frecuente en pacientes cirróticos. Una alternativa al tratamiento anticoagulante, dado el alto riesgo de hemorragia secundaria a hipertensión portal, es la inserción de un shunt portosistémico transyugular intrahepático (TIPS). Se han descrito tres estrategias para la inserción del TIPS: 1) recanalización portal e implantación convencional del TIPS por vía yugular; 2) recanalización portal mediante acceso percutáneo (transhepático/transesplénico), y 3) inserción del TIPS entre una vena suprahepática y una colateral periportal, sin recanalización portal. Describimos varios materiales útiles como diana fluoroscópica para la aguja del TIPS y para la recanalización portal. El objetivo de este artículo es dar a conocer el éxito en la implantación de TIPS usando las diferentes técnicas descritas combinadas, lo que representa una buena alternativa terapéutica para esos pacientes difíciles de manejar debido a su deficiente condición clínica. Por tanto, la TVP/cavernomatosis no debe considerarse como una contraindicación para TIPS

Portal vein thrombosis is a common complication in patients with cirrhosis. Anticoagulation involves a high risk of bleeding secondary to portal hypertension, so placing transjugular intrahepatic portosystemic shunts (TIPS) has become an alternative treatment for portal vein thrombosis. Three strategies for TIPS placement have been reported: 1) portal recanalization and conventional implantation of the TIPS through the jugular vein; 2) portal recanalization through percutaneous transhepatic/transsplenic) access; and (3) insertion of the TIPS between the suprahepatic vein and a periportal collateral vessel without portal recanalization. We describe different materials that can be used as fluoroscopic targets for the TIPS needle and for portal recanalization. This article aims to show the success of TIPS implantation using different combinations of the techniques listed above, which is a good treatment alternative in these patients whose clinical condition makes them difficult to manage, and to show that portal vein thrombosis/cavernous transformation should not be considered a contraindication for TIPS

The keys to successful TIPS in patients with portal vein thrombosis and cavernous transformation. / Trombosis y cavernomatosis portal: las claves para el éxito de un TIPS.

Portal vein thrombosis is a common complication in patients with cirrhosis. Anticoagulation involves a high risk of bleeding secondary to portal hypertension, so placing transjugular intrahepatic portosystemic shunts (TIPS) has become an alternative treatment for portal vein thrombosis. Three strategies for TIPS placement have been reported: 1) portal recanalization and conventional implantation of the TIPS through the jugular vein; 2) portal recanalization through percutaneous transhepatic/transsplenic) access; and (3) insertion of the TIPS between the suprahepatic vein and a periportal collateral vessel without portal recanalization. We describe different materials that can be used as fluoroscopic targets for the TIPS needle and for portal recanalization. This article aims to show the success of TIPS implantation using different combinations of the techniques listed above, which is a good treatment alternative in these patients whose clinical condition makes them difficult to manage, and to show that portal vein thrombosis/cavernous transformation should not be considered a contraindication for TIPS.

Guía práctica para el manejo de la hemorragia digestiva alta no varicosa / Clinical practice guidelines for managing nonvariceal upper gastrointestinal bleeding

La hemorragia digestiva alta no varicosa (HDANV) es una emergencia médica frecuente que se asocia a una considerable morbilidad y mortalidad. En los últimos años se han producido importantes avances en el manejo de la HDANV, que han permitido disminuirla recidiva hemorrágica y la mortalidad en estos pacientes. El objetivo del presente documento es ofrecer una guía de manejo de la HDANV eminentemente práctica basada en la evidencia científica y en las recomendaciones de los recientes consensos. Lostres puntos clave del manejo de la HDANV son: a) la reanimación hemodinámica precozy la prevención de las complicaciones de la patología cardiovascular de base, quees frecuente en pacientes con HDANV; b) el tratamiento endoscópico de las lesiones con alto riesgo de recidiva; y c) el uso de inhibidores de la bomba de protones a dosis altas pre y postendoscopia. La combinación de estas medidas permite reducir la recidiva y la mortalidad de la HDANV (AU)

Nonvariceal upper gastrointestinal (GI) bleeding is a common medical emergency associated with appreciable morbidity and mortality. The significant advances made in managing this condition in recent years have reduced the rates of rebleeding and mortality. These clinical guidelines for managing this emergency are intended to be highly practical, evidence-based, and take recent consensus statements into account. The 3 keys to managing nonvariceal upper GIbleeding are a) early restoration of fluids and blood pressure and the prevention of underlying cardiovascular disease, which is common in these patients; b) endoscopy to treat lesions at high risk of rebleeding; and c) medical therapy with high doses of proton pump inhibitors before and after endoscopy. These 3 measures, used in combination, reduce upperGI rebleeding and mortality rates (AU)

Haemobilia due to iatrogenic portobiliary fistula after cholecystectomy.

Haemobilia, defined as bleeding into the biliary tree is a rare condition. We describe a case report of a patient who presented it as a complication of iatrogenic portobiliary fistula, followed after an open cholecystectomy. The patient presented to the emergency department with late onset symptoms of haematemesis and melena a month after surgery. Findings were confirmed by Doppler ultrasound that showed the appearance of intragallbladder mass with high echogenicity representing a blood clot. Also, next to the portal vein and the biliary duct a lesion with mixed blood flow was detected confirming a portobiliary fistula. This case was successfully managed by angiography and selective embolisation.

[Musculoskeletal hydatidosis: an unusual location]. / Hidatidosis musculoesquelética: una localización atípica.

Hydatidosis is a zoonosis with a continuing high prevalence in our environment. The most commonly affected organs are the lungs and the liver, with the musculoskeletal location being considered an unusual one. We comment the case of a patient who presented a series of lesions in his left iliac crest and middle left buttock with spontaneous fistulization to the skin surface. In this case a combined treatment was given; prior to the surgical operation we administered a cycle of albendazol. Following removal of the lesion, the patient was given two further cycles of albendazol in order to minimize the risk of a recurrence of the illness. This patient is currently free of any symptoms relating to this illness.

[Spontaneous intramural dissection of the esophagus]. / Perforación intramural espontánea del esófago.

Spontaneous intramural dissection of the esophagus (SIDE) is an unusual clinical entity. It is a benign disease that, despite its alarming endoscopic appearance, usually responds well to conservative management and has an excellent prognosis. Nevertheless, some situations require emergency surgical treatment. These situations include esophageal perforation with mediastinitis, massive bleeding, and abscess, among others. Upper gastrointestinal endoscopy is a useful diagnostic test when radiological examinations (hydrosoluble contrast esophagogram, computed tomography, or magnetic resonance imaging) have excluded perforation. We present the case of a 42-year-old woman who was admitted to our hospital complaining of acute chest pain, dysphagia, and odynophagia. Because of the persistence of symptoms and diagnostic uncertainty (SIDE versus complicated esophageal duplication cyst) surgery was performed. The definitive diagnosis was SIDE.

Perforación intramural espontánea del esófago / Spontaneous intramural dissection of the esophagus

La perforación intramural espontánea del esófago (PIEE) es un trastorno esofágico raro. Es una enfermedad benigna, que a pesar del aspecto endoscópico tan alarmante, tiene una buena respuesta al tratamiento conservador y un pronóstico excelente. Sin embargo, algunas situaciones requieren un tratamiento quirúrgico urgente: perforación con mediastinitis, sangrado masivo o absceso entre otras. La gastroscopia es una prueba fundamental para el diagnóstico, una vez garantizada la indemnidad del esófago mediante pruebas radiológicas (esofagograma con contraste hidrosoluble, tomografía computarizada, resonancia magnética). Exponemos el caso de una mujer de 42 años de edad, con dolor torácico agudo, disfagia y odinofagia, que sometemos a estudio radiológico y endoscópico. Ante la persistencia de la clínica y la duda diagnóstica (perforación esofágica transmural frente a quiste de duplicación esofágico complicado), se decide intervenir quirúrgicamente. El diagnóstico final fue de PIEE

Spontaneous intramural dissection of the esophagus (SIDE) is an unusual clinical entity. It is a benign disease that, despite its alarming endoscopic appearance, usually responds well to conservative management and has an excellent prognosis. Nevertheless, some situations require emergency surgical treatment. These situations include esophageal perforation with mediastinitis, massive bleeding, and abscess, among others. Upper gastrointestinal endoscopy is a useful diagnostic test when radiological examinations (hydrosoluble contrast esophagogram, computed tomography, or magnetic resonance imaging) have excluded perforation. We present the case of a 42-year-old woman who was admitted to our hospital complaining of acute chest pain, dysphagia, and odynophagia. Because of the persistence of symptoms and diagnostic uncertainty (SIDE versus complicated esophageal duplication cyst) surgery was performed. The definitive diagnosis was SIDE

Hidatidosis musculoesquelética: una localización atípica / Musculoskeletal hydatidosis: an unusual location

La hidatidosis es una zoonosis con una elevada prevalencia aún en nuestro medio. Generalmente afecta a hígado y pulmón, debiendo considerarse la afectación músculo-esquelética una localización atípica de la enfermedad. Presentamos el caso de un paciente con lesiones en cresta iliaca y glúteo medio izquierdos, con fistulización espontánea a través de la piel. Se realizó tratamiento combinado con un ciclo de albendazol previo a la intervención y exéresis quirúrgica de la lesión. En el postoperatorio se completaron dos ciclos más de tratamiento con albendazol en un intento de disminuir el riesgo de recurrencia de la enfermedad. El paciente se encuentra asintomático y no ha presentado ninguna complicación hasta la fecha

Hydatidosis is a zoonosis with a continuing high prevalence in our environment. The most commonly affected organs are the lungs and the liver, with the musculoskeletal location being considered an unusual one. We comment the case of a patient who presented a series of lesions in his left iliac crest and middle left buttock with spontaneous fistulization to the skin surface. In this case a combined treatment was given; prior to the surgical operation we administered a cycle of albendazol. Following removal of the lesion, the patient was given two further cycles of albendazol in order to minimize the risk of a recurrence of the illness. This patient is currently free of any symptoms relating to this illness

Biliopancreatic tumors: patient survival and quality of life after palliative treatment.

OBJECTIVES: to analyse survival and quality of life of patients with malignant obstructive jaundice after palliative treatment, comparing endoscopic stent insertion and palliative surgical (palliative resection and bypass surgical). PATIENTS AND METHOD: eighty and seven patients were included in a trial. They were distributed to endoscopic stent (50) and palliative surgical (37). It analysed survival, quality of life and comfort index of jaundiced patients. The good quality of life was defined by absence of jaundice, pruritus and cholangitis after the initial treatment. RESULTS: the median survival of the patients treated to endoscopic stent was 9,6 months whereas the patients to surgical treatment survived a median of 17 months. The time free of disease was 4 months in stented patients and 10,5 months in surgical patients. There was no significant difference in comfort index between the two groups (stented 34%, surgical 42,5%) Neither was there significant difference in survival and quality of life between palliative resection and bypass surgery. CONCLUSIONS: despite the survival and time free of disease being better in surgical patients, there was no significant difference in overall quality of life between the two groups. The survival and quality of life are the same after palliative resection as after bypass surgery, for this should not be performed routinely or to justify resection as a debulking procedure.

Failure of endoscopic therapy in upper gastrointestinal hemorrhage due to duodenal ulcers.

OBJECTIVES: to evaluate the efficacy of endoscopic treatment in patients with upper gastrointestinal (UGIH) due to duodenal ulcer with high risk of persistent or recurrent bleeding and to determine the associated failure factors of this procedure. PATIENTS AND METHOD: three hundred and thirty-six patients with UGIH due to duodenal ulcer requiring endoscopic treatment were analyzed between January 1992 and December 2001. The patients were classified according to the endoscopic findings: a) patients with limited bleeding; and b) patients with persistent and/or recurrent bleeding due to therapeutic failure. The clinical guidelines followed in patients with endoscopic treatment failure were previously established in the internal protocol. The variables that obtained statistical significance in the univariate analysis were included in the logistic regression model to identify those with an independent predictive value for failure of the endoscopic treatment. RESULTS: mean age of the patients was 60 +/- 17 years, 271 (81%) were male. Bleeding with severe hemodynamic affectation was detected in 82 patients (24%). The most common location of the duodenal ulcer was on the anterosuperior part of the duodenal bulb (227 patients, 68%). In 43 patients (13%) the ulcer was larger than 2 cm. The bleeding stigmata were classified as: Forrest I in 125 (38%) and Forrest II in 211 (62%). It was initially reached in 297 patients (88%). Twenty-two patients required emergency surgery (6,5%) and the global mortality rate was 3%. Severe hemodynamic affectation at admission (OR 11.8, p>0.001), ulcers exceeding 2 cm (OR 6.95, p = 0.019) and the presence of active bleeding during endoscopy (Forrest I) (OR 3.55, p = 0.08) were the variables included in the multivariate analysis independently associated to endoscopic therapy failure. CONCLUSION: endoscopic therapy is an efficient treatment of upper gastrointestinal bleeding due to duodenal ulcer. By means of a clinical variable, the hemodynamic status and two endoscopies, bleeding stigmata and the size of the ulcer, a group of patients with high risk of endoscopic treatment failure can be selected.

Fracaso de la terapéutica endoscópica en enfermos con hemorragia digestiva por úlcera duodenal / No disponible

Objetivos: analizar la eficacia de la terapéutica endoscópica en enfermos con alto riesgo de persistencia y/o recidiva del sangrado específicamente en hemorragia digestiva alta (HDA) por úlcera duodenal y determinar los factores asociados al fracaso de esta técnica. Pacientes y método: se analizaron 336 enfermos con HDA por úlcera duodenal que requirieron terapéutica endoscópica, entre enero 1992 y diciembre 2001. Se clasificaron los enfermos en función de la respuesta al tratamiento endoscópico: a) pacientes con hemorragia limitada; y b) pacientes con persistencia y/o recidiva del sangrado por fracaso terapéutico. La pauta de actuación en los enfermos con fallo del tratamiento endoscópico se hizo en función de un protocolo previamente establecido. Las variables que alcanzaron significación estadística en el análisis univariante se incluyeron en un modelo de regresión logística para identificar aquellas con un valor predictivo independiente para el fracaso de la terapéutica endoscópica. Resultados: la edad media fue de 60 ± 17 años, 271 (81%) eran hombres. La hemorragia se presentó con afectación hemodinámica grave en 82 pacientes (24%). La localización más frecuente de la úlcera duodenal fue en cara anterosuperior de bulbo duodenal en 227 pacientes (68%). En 43 enfermos (13%) la úlcera era mayor de 2 cm. Los estigmas de sangrado encontrados en la endoscopia fueron: Forrest I, en 125 (38%) y Forrest II, 211 (62%). La hemostasia inicial se logró en 297 pacientes (88%). Requirieron cirugía urgente 22 enfermos (6,5%) y la mortalidad global de nuestra serie fue del 3%. En el análisis multivariante, las variables que se asociaron independientemente al fracaso de la terapéutica endoscópica fueron la afectación hemodinámica grave al ingreso (OR 11,8, p<0,001), el tamaño de la úlcera mayor a 2 cm (OR 6,95, p= 0,019) y la presencia de sangrado activo en la endoscopia (Forrest I) (OR 3,55, p=0,08). Conclusión: la terapéutica endoscópica es eficaz en la hemorragia digestiva alta por úlcera duodenal. Mediante una variable clínica, el estado hemodinámico y dos endoscópicas, los estigmas de sangrado y el tamaño de la úlcera, podemos seleccionar un grupo de enfermos con mayor riesgo de fracaso del tratamiento endoscópico (AU)

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[Factors associated with failure of endoscopic therapy in gastric ulcer bleeding]. / Factores asociados al fracaso de la terapéutica endoscópica en la hemorragia digestiva por úlcera gástrica.

INTRODUCTION: Endoscopic therapy is an effective technique in the control of bleeding due to peptic ulcer. However, bleeding persists or recurs in as many as 10-30% of patients. Gastric and duodenal ulcers present different clinical and endoscopic features and consequently the efficacy of endoscopic therapy and the factors associated with its failure should be studied separately. OBJECTIVES: To analyze the efficacy of endoscopic therapy in patients at high risk of persistent or recurrent bleeding due to gastric ulcer and to identify the factors associated with the failure of this technique. PATIENTS AND METHODS: We performed a retrospective study based on a clinical intervention protocol. Two hundred eight patients admitted for bleeding secondary to gastric ulcer with active bleeding or stigmas of recent bleeding who received endoscopic therapy between January 1992 and December 2001 were analyzed. Clinical, laboratory and endoscopic variables on admission, as well as the medical treatment and endoscopic procedure applied, were registered. Endoscopy was performed within 12 hours of admission. Patients were classified according to their response to endoscopic therapy: a) patients with limited bleeding, and b) patients with persistent or recurrent bleeding due to therapeutic failure. Intervention in patients with therapeutic failure was performed according to a previously established protocol. Variables that were statistically significant in the univariate analysis were included in a logistic regression model to identify those with an independent predictive value for failure of endoscopic therapy. RESULTS: Definitive hemostasis was achieved after initial therapy in 181 patients (87%). The efficacy of a second procedure increased the percentage of hemostasis to 91% of the patients. In the logistic regression model, the only variables that were independently associated with initial therapeutic failure were: hemodynamic status on admission (p = 0.016; OR = 3.99), the need for transfusion of blood products prior to endoscopy (p = 0.025; OR = 3.48), upper localization of the gastric ulcer (p = 0.050; OR = 3.08) and unsatisfactory endoscopic therapy (p = 0.009; OR = 17.39). CONCLUSION: These variables could contribute to the early identification of a subgroup of patients, which would enable us to increase medical-surgical surveillance and offer them other therapeutic alternatives.

Ligadura de varices en pacientes pediátricos / Variceal ligation in pedidatric patients

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[Early-onset acute toxic hepatitis induced by intravenous amiodarone administration]. / Hepatitis tóxica aguda de instauración precoz por amiodarona intravenosa.

Amiodarone is a widely used and effective long-term antiarrhythmic drug but with known adverse effects. Prolonged oral administration of this drug has been implicated in numerous hepatic lesions, ranging from isolated, asymptomatic transaminase elevation to fulminant, fatal liver failure. Few cases of acute hepatotoxicity due to intravenous administration have been reported. We present a 69-year-old woman with atrial fibrillation who developed acute hepatitis within 24 hours of amiodarone infusion at the recommended dosage. The drug was withdrawn and laboratory findings progressively returned to normal over the following days. We analyze a possible mechanism of action for hepatotoxicity and highlight the importance of monitoring liver function in patients receiving this drug.

[Role of early colonoscopy in severe acute lower gastrointestinal bleeding]. / Rendimiento de la colonoscopia precoz en la hemorragia digestiva baja aguda grave.

BACKGROUND: Severe acute lower gastrointestinal bleeding (SALGIB) accounts for 15% of cases of acute lower gastrointestinal bleeding (ALGIB). The incidence increases with age and comorbidity. Identification of the origin of bleeding may be difficult. Colonoscopy has been proposed as the primary investigative tool. AIM: To assess the role of early colonoscopy as the primary method of evaluation in patients with SALGIB. PATIENTS AND METHOD: Retrospective study based on a guideline for clinical practice approved in our institution. The study included 50 patients with SALGIB admitted to our gastrointestinal bleeding unit between January 1998 and April 2000. SALGIB was suspected when patients fulfilled two or more of the following criteria: 1) significant hemodynamic compromise, 2) decrease in hemoglobin 2 g/dl, and 3) transfusion requirement >= 2 blood units. Early colonoscopy was performed within 24 hours of onset of bleeding. An accurate endoscopic diagnosis was established if a lesion with active bleeding, visible non-hemorrhagic vessel or adherent red clot was identified. A presumptive diagnosis was made when hematochezia or fresh blood localized in a colonic segment, associated with a single, potentially hemorrhagic lesion, was observed and when the results of esophagogastroduodenoscopy were negative. Colonoscopy, esophagogastroduodenoscopy, barium studies, nuclear scan and angiography were performed. RESULTS: Two hundred twenty-two patients were admitted for ALGIB. Fifty patients(22%) fulfilled the SALGIB criteria. The male/female ratio was 1:1. Definitive diagnosis was accurate in 20 patients. The most frequent cause was angiodysplasia (6 patients) and rectal ulcer (6 patients). Eighteen patients had a presumptive diagnosis; of these 14 had diverticulosis. In 12 patients, no cause was identified. Colonoscopy was performed in 45 patients, of which 32 were performed early and 13 electively. Accurate endoscopic diagnosis was more frequently established with early colonoscopy than with elective colonoscopy (15 [47%] vs 2 [15%], p < 0.05). The results of urgent nuclear scans contributed to accurate diagnosis in 5 out of the 10 patients in whom this technique was performed. Angiography was performed in 2 patients. Endoscopic therapy was attempted in 4 patients, all during early colonoscopy. Ten patients (20%) underwent surgery and 3 patients (6%) died. CONCLUSIONS: In 22% of patients with ALGIB admitted to our hospital bleeding was severe. Colonoscopy is the diagnostic tool of choice. When performed within 24 hours of hospital admission, this technique provides more accurate diagnosis than when performed electively.

Diagnóstico etiopatogénico de la pancreatitis crónica y de la recurrente / Etiopathogenic diagnosis of chronic and relapsing pancreatitis

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[Clinical approach to portal hypertension]. / Aspectos clínicos del síndrome de hipertensión portal.

Portal Hypertension is one of the most common and severe complication arising from hepatic cirrhosis natural history. Its development conditions the patient prognosis, and its diagnosis and correct evaluation contribute to the correct management of the patient. New techniques for the measurement of portal pressure gradient allow the study and follow-up of patients with esophageal and gastric varices and with risk of hemorrhage, analyzing the efficacy of the treatment applied in a reliable and secure way. It has been probed its utility in the study of the patient with hepatocellular carcinoma, complications after liver transplantation, portal hypertension with no hepatopathy, etc. This review analyzes, from a clinical point of view, the repercussion of the development of portal hypertension in the patient with hepatic cirrhosis, its diagnosis and interpretation, and the importance that its adequate valuation has for the clinical practice.