Early and/or immediately full caloric diet versus standard refeeding in mild acute pancreatitis: a randomized open-label trial.

UNLABELLED: Refeeding after acute pancreatitis (AP) is traditionally started in a successively increasing manner when abdominal pain is absent and pancreatic enzymes are decreasing. We aimed to evaluate length of hospital stay (LOHS) and refeeding tolerance for early refeeding and/or immediately full caloric intake in patients recovering from AP. METHODS: In this randomized, open-label trial, patients with AP were randomized into four different refeeding protocols. Group 1 and 2 received a stepwise increasing diet during three days while 3 and 4 received an immediately full caloric, low fat diet. Group 2 and 4 started refeeding early (once bowel sounds returned) and 1 and 3 started at standard time (bowel sounds present, no abdominal pain, no fever, leucocytes and pancreatic enzymes decreasing). Main outcomes measurements were LOHS and tolerance (ability to ingest >50% of meals without severe pain, nausea or AP relapse). RESULTS: Eighty patients were evaluated and 72 randomized (median age 60 years, range 24-85, 33 male). LOHS was significantly reduced after early refeeding (median 5 versus 7 days (p = 0.001)) but not in patients receiving immediately full caloric diet, compared to standard management (6 versus 6 days (p = 0.12)). There was no difference in refeeding tolerance comparing immediately full caloric diet versus stepwise increasing diet (31/35 (89%) versus 33/37 (89%) patients tolerating the treatment, p = 1.00) or early versus standard time for refeeding (33/37 (89%) versus 31/35 (89%), (p = 1.00)). CONCLUSIONS: Refeeding after AP when bowel sounds are present with immediately full caloric diet is safe and well tolerated. Early refeeding shortens LOHS.

Pancreatitis and systemic lupus erythematosus.

Gastrointestinal symptoms in patients with SLE are common, specifically abdominal pain. However, the rate of pancreatic diseases is much lower and does not reach 5% according to published series in Europe and the USA. This association between SLE and pancreatic disease is basically at the expense of episodes of acute pancreatitis. An association with chronic pancreatitis is much more uncommon, and only four articles have been published showing this relationship. Three cases of SLE-associated pancreatitis are described, and disease onset, etiological factors, and clinical progression are analyzed. A review of the literature and a brief discussion about pathophysiological mechanisms and the role of corticosteroids are also included.

Valganciclovir-induced leukopenia in liver transplant recipients: influence of concomitant use of mycophenolate mofetil.

INTRODUCTION: An increased incidence and magnitude of leukopenia during concomitant treatment with valganciclovir (VGC) and mycophenolate mofetil (MMF) has been reported. OBJECTIVE: To evalute the incidence and severity of leukopenia and neutropenia among liver recipients treated with VGC and related factors. PATIENTS AND METHODS: Retrospective analysis of clinical and analytical data related to leukopenia (<3000 leukocytes/mm(3)) and neutropenia (<900 neutrophils/mm(3)) in liver transplant patients who were treated with VGC from 2003 to 2007. We examined the influence of concomitant administration of MMF and development of subsequent infections. RESULTS: Among 209 liver transplants, 40 treatments with VGC were prescribed in 37 patients (17.7%), 12 of which (30%) were associated with MMF. The patients has an average age of 49.7 +/- 12.7, body mass index (BMI) of 27.28 +/- 5.17, and Model for End-stage Liver Disease Score (MELD) 12.45 +/- 7.5. The daily average dose of VGC was 1440 +/- 446.5 mg and MMF, 1454.5 +/- 350.3 mg. We observed a decrease of 30% in initial leukocyte count (5353.7 +/- 2706.6) and 40% in neutrophil count (3600 +/- 2182.1). With no relationship to total dose or BMI-adjusted dose of VGC nor concomitant administration of MMF. The initial leukocyte count was significantly lower (4411 +/- 1930 vs 6206 +/- 3053; P = .03) and underwent a main drop (2344.7 +/- 1974.3 vs 898.1 +/- 2435.6; P = .04) when leukopenia developed. In the induced neutropenia group, previous leukocyte count (3797.1 +/- 1223.9 vs 5683.9 +/- 2829.3; P = .01), MELD (18.7 +/- 8.8 vs 11.1 +/- 6.6; P = .01), and the creatinine pretreatment (1.44 +/- 0.4 vs 1.09 +/- 0.3; P = .01) were significantly different. Subsequent infections induced by the leukopenia were not observed. CONCLUSIONS: In our series, the concomitant use of VGC and MMF was not associated with a greater incidence of leukopenia and/or neutropenia than VGC administration alone. Previous leukocyte count was associated with them. MELD and renal dysfunction are factors related to severe neutropenia. Leukopenia was not associated with a greater incidence of infections.

Amiloidosis secundaria en la enfermedad inflamatoria intestinal / No disponible

La amiloidosis es una entidad clínica que se produce a consecuenciadel depósito a nivel extracelular de un material proteicoamorfo, causando una desorganización de la arquitectura normalde múltiples órganos y tejidos y, por tanto, una alteración funcionalde los mismos. La amiloidosis secundaria es una complicacióninfrecuente pero muy grave que aparece en el contexto de neoplasias,enfermedades infecciosas e inflamatorias de curso crónico,como es el caso de la enfermedad inflamatoria intestinal, principalmenteenfermedad de Crohn, ensombreciendo el pronósticode estos pacientes. A continuación presentamos dos casos clínicoscorrespondientes a dos pacientes con enfermedad de Crohnque desarrollaron amiloidosis secundaria

Amyloidosis is a clinical entity that results from the depositionof an extracellular protein material that causes disruption in thenormal architecture of multiple organs and tissues, and impairstheir function. Secondary amyloidosis is a rare but serious complicationthat may worsen the prognosis of patients with cancer, infectionor chronic inflammatory disease, including inflammatorybowel disease, particularly Crohn’s disease. We report two casesof Crohn’s disease associated with secondary amyloidosis

[Adult gastric duplication cyst: diagnosis by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA)]. / Quiste de duplicación gástrico: diagnóstico por punción-aspiración guiada por ecoendoscopia.

Duplication cysts are rare gastrointestinal congenital abnormalities. They can occur anywhere throughout the gastrointestinal tract, and gastric duplication cysts are most uncommon, representing only 4-8% of all gastrointestinal duplication cysts. Nowadays several theories try to explain the pathogenic mechanisms involved. These cysts are usually diagnosed during early childhood, and very rarely are detected in adults, mostly incidentally due to a lack of symptoms. Close to 50% of gastric cysts are associated with other abnormalities. It is extremely important that a meticulous differential diagnosis is performed regarding other diseases, mainly malignancies with a cystic component. Although extremely uncommon, a malignant transformation of these lesions has been reported, which highlights the importance of a correct diagnosis. Herein we report the case of a duplication cyst in an adult, which was detected by endoscopic ultrasound-guided fine-needle aspiration, recently proposed as the most accurate technique for the identification of these lesions.

Quiste de duplicación gástrico: diagnóstico por punción-aspiración guiada por ecoendoscopia / No disponible

Los quistes de duplicación son anomalías congénitas infrecuentesdel tracto gastrointestinal que pueden localizarse a cualquiernivel desde la boca hasta al ano. Los quistes de duplicación gástricosson los más excepcionales y constituyen tan sólo el 4-8% detodos ellos. Su patogénesis es controvertida y hoy en día aun existenmúltiples teorías que tratan de explicar su mecanismo etiopatogénico.En la mayoría de los casos el diagnóstico se realiza en laprimera infancia y tan sólo en una pequeña proporción se identificanen la edad adulta como un hallazgo incidental, ya que estasentidades suelen ser asintomáticas fuera de la infancia. Casi en lamitad de los casos se asocia a otras malformaciones congénitas yes de vital importancia realizar un minucioso diagnóstico diferencialcon otras entidades, en especial neoplasias con componentequístico. Aunque es extremadamente inusual, se ha publicado ladegeneración neoplásica de estas lesiones, lo que hace más importantesu preciso diagnóstico y estudio citohistológico. En esteartículo se presenta el caso de un quiste de duplicación gástricodiagnosticado en la edad adulta, mediante ultrasonografía endoscópicaasociado a punción-aspirativa, técnica que ha sido recientementepropuesta como la más eficaz para el diagnóstico

Duplication cysts are rare gastrointestinal congenital abnormalities.They can occur anywhere throughout the gastrointestinaltract, and gastric duplication cysts are most uncommon, representingonly 4-8% of all gastrointestinal duplication cysts. Nowadaysseveral theories try to explain the pathogenic mechanismsinvolved. These cysts are usually diagnosed during early childhood,and very rarely are detected in adults, mostly incidentallydue to a lack of symptoms. Close to 50% of gastric cysts are associatedwith other abnormalities. It is extremely important that ameticulous differential diagnosis is performed regarding other diseases,mainly malignancies with a cystic component. Although extremelyuncommon, a malignant transformation of these lesionshas been reported, which highlights the importance of a correctdiagnosis. Herein we report the case of a duplication cyst in anadult, which was detected by endoscopic ultrasound-guided fineneedleaspiration, recently proposed as the most accurate techniquefor the identification of these lesions

Endoscopic ultrasound for cholangiocarcinoma re-evaluation after Wallstent® placement

No disponible

[Secondary amyloidosis in Crohn's disease]. / Amiloidosis secundaria en la enfermedad inflamatoria intestinal.

Amyloidosis is a clinical entity that results from the deposition of an extracellular protein material that causes disruption in the normal architecture of multiple organs and tissues, and impairs their function. Secondary amyloidosis is a rare but serious complication that may worsen the prognosis of patients with cancer, infection or chronic inflammatory disease, including inflammatory bowel disease, particularly Crohn's disease. We report two cases of Crohn's disease associated with secondary amyloidosis.

[Life-threatening acute lower gastrointestinal bleeding in patients with Crohn's disease]. / Hemorragia digestiva baja masiva en pacientes con enfemedad de Crohn.

OBJECTIVE: We aimed at evaluating the frequency of acute severe bleeding in CD and its potential association to some risk factors, including clinical features of CD, environmental factors, and genetic alterations. MATERIAL AND METHODS: 174 consecutive patients with CD (103 female (59%) and 71 men (41%), with a mean age of 37 years) were included. We analyzed all major acute lower gastrointestinal (GI) hemorrhage related to CD. Potential risk factors like smoking, site of disease, and presence of gene mutations in CARD15, TLR-4, and CD14 were also analyzed. RESULTS: Three patients (1.7%) suffered from severe acute lower GI bleeding. All patients required surgery to resolve their hemorrhage, and this indication represented 3.4% of all surgical procedures related to CD. All three patients were young ( < 25 years) and suffered ileal CD with inflammatory pattern (L1-B1 in the Vienna Classification). No relationship was found between acute bleeding and any of the potential risk factors evaluated. CONCLUSIONS: Acute severe GI bleeding is a rare, but severe complication in CD patients, and presents mainly in patients with inflammatory ileal disease. An association of endoscopy and arteriography is necessary for diagnosis. Urgent surgery is usually required in these patients.

Hemorragia digestiva baja masiva en pacientes con enfemedad de Crohn / Major acute bleeding in patients with Crohn's disease

Objetivo: analizar la frecuencia de las hemorragias masivasen la EC e intentar determinar sus potenciales factores de riesgo(ambientales, propios de la enfermedad y genéticos).Material y métodos: se estudió de manera retrospectiva unacohorte de 174 pacientes –103 mujeres (59%) y 71 hombres(41%), edad media de 37 años– con EC, analizándose las hemorragiasdigestivas masivas que se habían producido en relacióncon su enfermedad. Se revisaron asimismo potenciales factoresde riesgo como hábito tabáquico, localización de la enfermedad ypresencia de mutaciones genéticas en CARD15, RTL-4 y CD14,entre otros.Resultados: tres pacientes (1,7%) presentaron una hemorragiadigestiva masiva que precisó intervención quirúrgica para suresolución. Esta indicación de cirugía supone el 3,4% de las cirugíasen relación con la EC. Todos los pacientes eran jóvenes y suenfermedad seguía un patrón inflamatorio y estaba localizada enel íleon. No se ha evidenciado asociación estadísticamente significativaentre las hemorragias digestivas masivas y los potencialesfactores de riesgo analizados.Conclusiones: la hemorragia digestiva baja masiva es unacomplicación poco común, aunque grave de la EC. Se trata habitualmentede pacientes con patrón inflamatorio de la enfermedady afectación ileal. Para su diagnóstico resulta clave la asociaciónde endoscopia y arteriografía, y su resolución suele ser quirúrgica

Objective: we aimed at evaluating the frequency of acute severebleeding in CD and its potential association to some risk factors,including clinical features of CD, environmental factors, andgenetic alterations.Material and methods: 174 consecutive patients with CD(103 female (59%) and 71 men (41%), with a mean age of 37years) were included. We analyzed all major acute lower gastrointestinal(GI) hemorrhage related to CD. Potential risk factors likesmoking, site of disease, and presence of gene mutations inCARD15, TLR-4, and CD14 were also analyzed.Results: three patients (1.7%) suffered from severe acute lowerGI bleeding. All patients required surgery to resolve their hemorrhage,and this indication represented 3.4% of all surgical proceduresrelated to CD. All three patients were young (< 25 years)and suffered ileal CD with inflammatory pattern (L1-B1 in the ViennaClassification). No relationship was found between acutebleeding and any of the potential risk factors evaluated.Conclusions: acute severe GI bleeding is a rare, but severecomplication in CD patients, and presents mainly in patients withinflammatory ileal disease. An association of endoscopy and arteriographyis necessary for diagnosis. Urgent surgery is usually requiredin these patients