LEARNING CURVE IN ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION BY WESTERN ENDOSCOSPISTS TRAINED IN JAPAN: EXPERIENCE IN LATIN AMERICA.

•This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Retrospective observational study, enrolling patients that underwent EESD from 2009 to 2021, divided in 2 groups. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). The learning curve in esophageal ESD could be overcomed effectively and safely by an adequately trained Western endoscopist. Background - Esophageal endoscopic submucosal dissection (EESD) is a complex and time-consuming procedure at which training are mainly available in Japan. There is a paucity of data concerning the learning curve to master EESD by Western endoscopists. Objective - This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Methods - This is a retrospective observational study. Enrolling patients that underwent EESD from 2009 to 2021. The analysis was divided into two periods; T1: case 1 to 49 and T2: case 50 to 98. The following features were analyzed for each group: patients and tumors characteristics, en-bloc, complete and curative resection rates, procedure duration and adverse events rate. Results - Ninety-eight EESD procedures were performed. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). En bloc resection rate was 93.8% and 97.9% for T1 and T2, respectively (P=0.307). Complete resection rate was 79.5% and 85.7% for T1 and T2, respectively (P=0.424). Curative resection rate was 65.3% and 71.4% for T1 and T2, respectively (P=0.258). Four patients had complications; three during T1 period and one during T2 period. Overall mortality rate: 0%. Conclusion - The esophageal endoscopic submucosal dissection could be performed effectively and safely by an adequately trained Western endoscopist.

Curva de aprendizagem de dissecção endoscópica de submucosa por endoscopistas ocidentais treinados no Japão: Experiência na América Latina / Learning curve in esophageal endoscopic submucosal dissection by western endoscospists trained in japan: experience in latin america

ABSTRACT Background: Esophageal endoscopic submucosal dissection (EESD) is a complex and time-consuming procedure at which training are mainly available in Japan. There is a paucity of data concerning the learning curve to master EESD by Western endoscopists. Objective: This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Methods: This is a retrospective observational study. Enrolling patients that underwent EESD from 2009 to 2021. The analysis was divided into two periods; T1: case 1 to 49 and T2: case 50 to 98. The following features were analyzed for each group: patients and tumors characteristics, en-bloc, complete and curative resection rates, procedure duration and adverse events rate. Results: Ninety-eight EESD procedures were performed. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). En bloc resection rate was 93.8% and 97.9% for T1 and T2, respectively (P=0.307). Complete resection rate was 79.5% and 85.7% for T1 and T2, respectively (P=0.424). Curative resection rate was 65.3% and 71.4% for T1 and T2, respectively (P=0.258). Four patients had complications; three during T1 period and one during T2 period. Overall mortality rate: 0%. Conclusion: The esophageal endoscopic submucosal dissection could be performed effectively and safely by an adequately trained Western endoscopist.

RESUMO Contexto: A dissecção endoscópica da submucosa do esôfago (DSEE) é um procedimento complexo, cujo treinamento está disponível principalmente no Japão. Há uma escassez de dados sobre a curva de aprendizado para se capacitar na realização da DSEE por endoscopistas ocidentais. Objetivo: Este estudo teve como objetivo avaliar o efeito da curva de aprendizado no resultado clínico dos pacientes submetidos a DSEE. Métodos: Trata-se de um estudo observacional retrospectivo. Foram incluídos pacientes submetidos a DSEE no período de 2009 a 2021. A análise foi dividida em dois períodos; T1: caso 1 a 49 e T2: caso 50 a 98. Os seguintes parâmetros foram analisados para cada grupo: características clínicas dos pacientes e dos tumores de esôfago, taxas de ressecção em bloco, completa e curativa, duração do procedimento e taxa de eventos adversos. Resultados: Noventa e oito procedimentos de DSEE foram realizados. O tempo médio do procedimento foi de 111,8 min e 103,6 min nos períodos T1 e T2, respectivamente (P=0,004). A taxa de ressecção em bloco foi de 93,8% e 97,9% nos períodos T1 e T2, respectivamente (P=0,307). A taxa de ressecção completa foi de 79,5% e 85,7% nos períodos T1 e T2, respectivamente (P=0,424). A taxa de ressecção curativa foi de 65,3% e 71,4% para T1 e T2, respectivamente (P=0,258). Quatro pacientes tiveram complicações; três durante o período T1 e um durante o período T2. Taxa de mortalidade geral: 0%. Conclusão: A DSEE pode ser realizada de forma eficaz e segura por um endoscopista ocidental adequadamente treinado.

Histopathologic Diagnosis Discrepancies Between Preoperative Endoscopic Forceps Biopsies and Specimens Resected by Endoscopic Submucosal Dissection in Superficial Gastric Neoplasms.

BACKGROUND: The standard of practice when a superficial lesion was identified during upper GI endoscopy is to take an endoscopic forceps biopsy (EFB) of the lesion. The histopathologic findings then will determine the management plan. Endoscopic submucosal dissection (ESD) enables en-bloc resection for early neoplasms of the gastrointestinal tract and provides an adequate specimen that permits a more reliable histopathologic assessment. The objective of this study was to determine the rate of histopathologic discrepancy between EFB and specimens resected by ESD, and to identify the predisposing risk factors for this discordance. MATERIALS AND METHODS: This is a retrospective study, enrolling patients with superficial gastric neoplasms that underwent EFB followed by ESD. We divided cases to concordant or discordant group according to the histopathologic diagnosis of EFB and ESD specimens. We also analyzed the features that may have influenced the occurrence of histopathologic discordance and the association between discordant samples of adenocarcinoma and neoplastic invasion to deeper layers. RESULTS: A total of 115 gastric ESD procedures were performed with 84 patients meeting the inclusion criteria. Histopathologic discordance between EFB and ESD specimens were observed in 35.8% of cases (30/84 lesions). The univariant-bivariant analysis and multivariate logistic regression analysis showed that histologic discordance was closely related to the size of the lesions ( P =0.028). CONCLUSION: Histopathologic discrepancy between EFB and ESD specimens may occur in approximately one-third of cases, particularly for lesions over 20 mm, which may lead to crucial delays in gastric cancer precise diagnosis and treatment.

Efficacy-safety profile of the video capsule endoscopy in the study of the small bowel: experience over 100 consecutive procedures.

Video capsule endoscopy (VCE) is currently considered the first-line study in the evaluation of the small bowel (SB). Retrospective study including consecutive patients from 2010 to 2021 in two referral endoscopic centers in Peru, who underwent VCE. Inclusion criteria were patients with middle gastrointestinal bleeding, chronic diarrhea and unexplained chronic abdominal pain (endoscopic studies prior to VCE: normal). We mainly used Pillcam SB VCE (Given Imaging, Israel) SB2 and SB3 generations.

Off-label use of 0.4 % sodium hyaluronate teardrops for endoscopic resection of a rectal carcinoid.

Different substances are used for submucosal injection in order to perform a safe endoscopic mucosal resection. Viscous solutions such as sodium hyaluronate are currently considered as the first line substances for submucosal injection. This product produces a durable lifting of the mucosa. However, this solution is expensive and only available in Japan. We report on the use of off-label 0.4 % sodium hyaluronate teardrops as a substance for submucosal injection.

Erratum: Off-label use of 0.4 % sodium hyaluronate teardrops: a safe and effective solution for submucosal injection in gastric endoscopic submucosal dissection.

[This corrects the article DOI: 10.1055/a-1265-6598.].

Off-label use of 0.4 % sodium hyaluronate teardrops: a safe and effective solution for submucosal injection in gastric endoscopic submucosal dissection.

Background and study aims Submucosal (SM) injection is a critical step in endoscopic submucosal dissection (ESD). In Japan, use of viscous solutions such as sodium hyaluronate are recommended; the commercially product available is MucoUp (Seikagaku Co. and Boston Scientific Japan Co., Japan). Nevertheless, MucoUp is expensive and unavailable in many Western countries. For the past 8 years, we have been using low-cost sterile teardrops solution composed of 0.4 % sodium hyaluronate (Adaptis Fresh, Legrand Laboratory, Brazil). This solution is readily available in drugstores with a cost of approximately US$ 10.00 for each 10-cc bottle. The aim of this study was to present the clinical outcome with off-label sodium hyaluronate use for SM injection in gastric ESD. Patients and methods A single-center retrospective study of collected data investigating consecutive patients that underwent gastric ESD between 2012 and 2019. ESD was performed using 0.4 % sodium hyaluronate teardrop for SM injection and Flush Knife BT 2.5 (Fujifilm Co., Japan). The following data were analyzed: clinical-pathological features, en-bloc, R0 and curative resection rate, procedure duration, adverse events, and clinical outcome. Results ESD was performed with sodium hyaluronate for submucosal injection in 78 patients. The en-bloc resection rate and R0 resection rate were 96.1 % and 92.3 %, respectively. The curative resection rate for epithelial lesions was 83.8 %. Adverse events occurred in 5 cases (6.3 %): delayed bleeding (3.8 %, 3 cases) and perforation (2.5 %, 2 cases); all managed successfully by clipping and thermal coagulation. The mean volume of sodium hyaluronate solution used per patient was 10 cc (SD: ±â€Š8 cc). During follow-up (mean: 17 months; SD: ±â€Š14.5 months), two patients developed metachronous lesions (2.5 %). Conclusions Off-label use of teardrops with 0.4 % sodium hyaluronate for submucosal injection was demonstrated to be safe and able to provide an effective submucosal cushion that facilitates SM dissection in gastric ESD procedures.

[Comparison of the prevalence of Helicobacter pylori infection in dyspeptic patients between two institutional centers of different socio-economic strata during 2017-2018]. / Comparación de prevalencia de infección por Helicobacter pylori en pacientes con dispepsia entre dos instituciones de diferentes estratos socioeconómicos en el periodo 2017-2018.

Helicobacter pylori (Hp) infection is associated with multiple digestive problems from gastroduodenal ulcers to gastric adenocarcinoma and/or MALT lymphoma. Peru is considered a place of high prevalence of Hp. In the world, significant differences have been described in the prevalence of Hp infection associated with the socioeconomic characteristics of the population. OBJECTIVE: To compare the prevalence of Hp infection in dyspeptic patients between 2 institutional centers of different socio-economic strata during 2017-2018. MATERIALS AND METHODS: A sample of 633 patients with dyspepsia was collected retrospectively and randomly, without previous endoscopic study, or a history of Hp eradication therapy that came to the gastroenterology services of the Hospital Cayetano Heredia (HCH) in San Martin de Porres, and of the Anglo American Clinic (CAA) in San Isidro, during the period of June 2017 - July 2018 (CAA: 300 and HCH: 333). Proceeding then to review the clinical history, endoscopy report and pathological anatomy of each of them, for further statistical analysis using the SPSS program. RESULTS: A prevalence of Hp was found in the HCH of 54.1%, while in the CAA it was only 29.3% (p < 0.05), this relationship being maintained in the different age groups. Likewise, the prevalence of intestinal metaplasia (MI) in the total of patients with dyspepsia in the HCH was 33.9% (MI + in Hp + was 34.4%) and in the CAA the presence of MI without considering the Hp status was only 6.7% (MI + in HP + was 6.8%) (p < 0.05). Finally, the presence of gastric atrophy in the HCH was 26.7% and in the CAA it was 1.3% (p < 0.05). CONCLUSION: There is a clear relationship between the low socioeconomic stratum and the presence of Hp, gastric atrophy and intestinal metaplasia (the latter relationship remaining independent of Hp status).

[Barrett's esophagus with high grade dysplasia or intramucosal adenocarcinoma: EMR or ESD?] / Esófago de Barrett con displasia de alto grado o adenocarcinoma intramucoso: ¿EMR o ESD?

Barrett's esophagus (BE) is a relatively common clinical entity with an important impact on the quality of life of these patients. The incidence of this pathology has been increasing in recent years due to an increase in the occurrence of predisposing factors such as gastroesophageal reflux disease. BE carries an oncogenic potential with the development of dysplasia or esophageal adenocarcinoma. Thus, endoscopic surveillance is recommended to BE patients, aiming to detect neoplastic transformation in an early stage, enabling less invasive therapeutic options like endoscopic resection as the first line of therapy. One of the most controversial issues in the recent management of Barrett's esophagus complicated by a pre-neoplastic or early neoplastic lesion is the technique of endoscopic approach: endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). This question is extremely important because a complete endoscopic resection (R0) regardless of the technique utilized significantly reduces local recurrence rate, improving survival in the medium and long term. The objective of this article is to review the most important studies published about this topic, in order to better understand which endoscopic therapeutic procedure of the aforementioned (EMR or ESD) may lead to better clinical outcome for this type of lesions in patients with Barrett's esophagus.

Clinical and endoscopic findings of patients with cutaneous Kaposi sarcomaand gastrointestinal involvement. Experience in a single center of Lima-Peruin the last 3 years.

INTRODUCTION: Kaposi sarcoma is a low-grade angioproliferative neoplasm strongly associated with infection by herpes virus type 8 (HHV-8). Gastrointestinal (GI) involvement is an infrequent finding, whose clinical and endoscopic characteristics are poorly defined in the literature. OBJECTIVE: The aim of our study was to describe the clinical and endoscopic findings of patients with gastrointestinal Kaposi Sarcoma. MATERIALS AND METHODS: We reviewed all clinical histories, endoscopic and anatomopathologic reports of all patients with cutaneous Kaposi sarcoma (CKS) who came to Cayetano Heredia Gastroenterology Service during the period between August 2015 to October 2018. We included all patients with CKS that had gastrointestinal involvement confirmed with biopsy. RESULTS: We found 50 patients with cutaneous Kaposi sarcoma. Thirteen patients had gastrointestinal Kaposi sarcoma (26%). 53.8% (7/13 cases) were asymptomatic. 92.3% (12/13 cases) had HIV infection. Nine of the twelve HIV+ patients had CD4 count below 200 cells/µl. When Kaposi affects GI tract, the mayority have multiple GI organs affected. Stomach and colon are the most common sites affected. CONCLUSION: Gastrointestinal involvement was presented in 26% of our patients with cutaneos Kaposi sarcoma, a half of them had no GI symptoms. The majority of cases were young male and had HIV in AIDS stage. The mortality in our series was 15.3% at 6 months of follow-up.

Esófago de Barrett con displasia de alto grado o adenocarcinoma intramucoso: ¿EMR o ESD?

El esófago de Barrett (EB) es una entidad clínica relativamente frecuente con un importante impacto en la calidad de vida de estos pacientes. La incidencia de esta patología se ha incrementado en los últimos años debido al aumento de los diversos factores de riesgo que la condicionan, entre ellos principalmente la enfermedad por reflujo gastroesofágico. Se sabe del potencial oncogénico a la cual predispone esta condición clínica (displasia/adenocarcinoma) existiendo por tal motivo una recomendación de vigilancia endoscópica con la finalidad de detectar lesiones neoplásicas tempranas y ofrecer opciones terapéuticas menos invasivas siendo la resección endoscópica la de primera línea para estos casos. Sin embargo, uno de los puntos más controversiales en el manejo del esófago de Barrett complicado con alguna lesión pre-neoplásica o neoplásica temprana es el tipo de abordaje endoscópico resectivo: resección endoscópica de mucosa (EMR) o disección endoscópica de submucosa (ESD). Siendo esto sumamente importante debido a que una resección endoscópica completa (R0) independientemente de la técnica utilizada reduce significativamente la tasa de recurrencia local mejorando la sobrevida a mediano y largo plazo. El objetivo del presente artículo es revisar los principales estudios que nos ayuden a tener una visión más clara y a elegir el procedimiento endoscópico terapéutico resectivo de los mencionados (EMR/ESD) con mejor evidencia científica para este tipo de lesiones en pacientes con esófago de Barrett.

Barrett's esophagus (BE) is a relatively common clinical entity with an important impact on the quality of life of these patients. The incidence of this pathology has been increasing in recent years due to an increase in the occurrence of predisposing factors such as gastroesophageal reflux disease. BE carries an oncogenic potential with the development of dysplasia or esophageal adenocarcinoma. Thus, endoscopic surveillance is recommended to BE patients, aiming to detect neoplastic transformation in an early stage, enabling less invasive therapeutic options like endoscopic resection as the first line of therapy. One of the most controversial issues in the recent management of Barrett's esophagus complicated by a pre-neoplastic or early neoplastic lesion is the technique of endoscopic approach: endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). This question is extremely important because a complete endoscopic resection (R0) regardless of the technique utilized significantly reduces local recurrence rate, improving survival in the medium and long term. The objective of this article is to review the most important studies published about this topic, in order to better understand which endoscopic therapeutic procedure of the aforementioned (EMR or ESD) may lead to better clinical outcome for this type of lesions in patients with Barrett's esophagus.

[Jejunal phlebectasia as a cause of massive gastrointestinal haemorrhage]. / Flebectasia yeyunal como causa de hemorragia digestiva media masiva.

Vascular abnormalities of the gastrointestinal tract are a common cause of gastrointestinal bleeding. Most of them are located within the reach of the upper endoscopy or colonoscopy, although once discarded, it forces to consider small bowel as the source of bleeding. The successful management of a gastrointestinal bleeding depends mainly on the timely location of the source of bleeding. Nevertheless this task can be difficult when the cause is not within the reach of conventional methods. We present a case of a 21 year-old men in which the diagnosis of bleeding yeyunal phlebectasia was made by the findings of the capsule endoscopy and laparoscopy.

Clinical and endoscopic findings of patients with cutaneous Kaposi sarcoma and gastrointestinal involvement: Experience in a single center of Lima-Peru in the last 3 years / Hallazgos clínicos y endoscópicos en pacientes con sarcoma de Kaposi cutáneo y compromiso gastrointestinal: Experiencia de un centro de Lima - Perú en los últimos 3 años

Introduction: Kaposi sarcoma is a low-grade angioproliferative neoplasm strongly associated with infection by herpes virus type 8 (HHV-8). Gastrointestinal (GI) involvement is an infrequent finding, whose clinical and endoscopic characteristics are poorly defined in the literature. Objective: The aim of our study was to describe the clinical and endoscopic findings of patients with gastrointestinal Kaposi Sarcoma. Materials and methods: We reviewed all clinical histories, endoscopic and anatomopathologic reports of all patients with cutaneous Kaposi sarcoma (CKS) who came to Cayetano Heredia Gastroenterology Service during the period between August 2015 to October 2018. We included all patients with CKS that had gastrointestinal involvement confirmed with biopsy. Results: We found 50 patients with cutaneous Kaposi sarcoma. Thirteen patients had gastrointestinal Kaposi sarcoma (26%). 53.8% (7/13 cases) were asymptomatic. 92.3% (12/13 cases) had HIV infection. Nine of the twelve HIV+ patients had CD4 count below 200 cells/μl. When Kaposi affects GI tract, the mayority have multiple GI organs affected. Stomach and colon are the most common sites affected. Conclusion: Gastrointestinal involvement was presented in 26% of our patients with cutaneos Kaposi sarcoma, a half of them had no GI symptoms. The majority of cases were young male and had HIV in AIDS stage. The mortality in our series was 15.3% at 6 months of follow-up.

Introducción: El Sarcoma de Kaposi es una neoplasia angioproliferativa de bajo grado altamente asociada con la presencia del herpes virus tipo 8 (HHV-8). El compromiso gastrointestinal es un hallazgo infrecuente, cuyas características clínicas y endoscópicas son pobremente descritas en la literatura. Objetivos: El objetivo del estudio fue describir las características clínicas y endoscópicas de pacientes con Sarcoma de Kaposi gastrointestinal. Materiales y métodos: Nosotros revisamos todas las historias clínicas, reportes endoscópicos y anatomo patológicos de todos los pacientes con Sarcoma de Kaposi cutáneo que fueron al Servicio de Gastroenterología del Hospital Cayetano Heredia durante el periodo de Agosto del 2015 a Octubre del 2018. Se incluyeron todos los pacientes con SKC que tuvieron compromiso gastrointestinal confirmado en la biopsia. Resultados: Nosotros encontramos 50 pacientes con Sarcoma de Kaposi cutáneo. 13 pacientes tuvieron compromiso gastrointestinal (26%). 53.8% (7/13) fueron asintomáticos. 92.3% (12/13 casos) tuvieron infección con virus de VIH. Nueve de trece pacientes con VIH+ tuvieron conteos de CD4 menores de 200 cel/μl. Cuando el Kaposi afectaba el aparato digestivo, la mayoría tenía compromiso de múltiples segmentos. El estómago y el colon eran los lugares más comprometidos. Conclusión: El compromiso gastrointestinal se presentó en 26% de los pacientes con Sarcoma de Kaposi cutáneo, la mitad de ellos no tenían síntomas digestivos. La mayoría de los casos fueron varones jóvenes y tenían infección por VIH estadío SIDA. La mortalidad en nuestra serie fue 15.3% a los 6 meses de seguimiento.

Flebectasia yeyunal como causa de hemorragia digestiva media masiva / Jejunal phlebectasia as a cause of massive gastrointestinal hemorrhage

Las anormalidades vasculares del tracto gastrointestinal son una causa común de sangrado digestivo. La mayoría se localizan al alcance de la endoscopía digestiva alta y/o colonoscopía, una vez descartado ello, obliga a considerar al intestino delgado como causa de la hemorragia. El manejo exitoso de una hemorragia digestiva depende principalmente de la localización oportuna de la fuente del sangrado, sin embargo esta tarea puede ser difícil, cuando la causa no está al alcance de los métodos convencionales. Presentamos el caso de un paciente varón de 21 años cuyo diagnóstico fue una flebectasia yeyunal sangrante, luego de una cuidadosa evaluación de los hallazgos de la cápsula endoscópica y laparoscopía.

Vascular abnormalities of the gastrointestinal tract are a common cause of gastrointestinal bleeding. Most of them are located within the reach of the upper endoscopy or colonoscopy, although once discarded, it forces to consider small bowel as the source of bleeding. The successful management of a gastrointestinal bleeding depends mainly on the timely location of the source of bleeding. Nevertheless this task can be difficult when the cause is not within the reach of conventional methods. We present a case of a 21 year-old men in which the diagnosis of bleeding yeyunal phlebectasia was made by the findings of the capsule endoscopy and laparoscopy.

[Fulminating ischemic hepatitis induced by severe cardiac dysfunction: case report]. / Hepatitis isquémica fulminante inducida por disfunción cardiaca severa: reporte de caso.

Ischemic Hepatitis is an uncommon entity in daily clinical practice with a prevalence of 0.16 to 0.5% among patients admitted to a critical care unit, associated with an approximate 60% mortality rate. This liver disease is characterized by a rapid and marked increase (more than 20 times the normal value) of the level of transaminases secondary to a severe and persistent hepatic hypoperfusion caused by multiple etiologies, which may be transient when the triggering cause is timely identified and appropiately treated. The case of an elderly adult patient with a clinical, epidemiological and biochemical profile compatible with ischemic hepatitis secondary to severe cardiac dysfunction is presented below.

Anemia ferropénica severa asintomática como presentación inusual de divertículo de Meckel / Severe asymptomatic iron deficiency anemia as an unusual presentation of a Meckel diverticulum

El divertículo de Meckel es un diagnóstico poco frecuente dentro de la práctica clínica diaria. Sin embargo, debe ser considerado dentro del diagnóstico diferencial de todo paciente que acude por hemorragia digestiva oscura, tanto manifiesta como oculta. Anteriormente, el intestino delgado era inexplorable; en la actualidad, su evaluación es posible gracias a nuevos métodos diagnósticos: cápsula endoscópica, enteroscopía, enterotomografía y enteroresonancia. La cápsula endoscópica no permite tomar biopsias, es un examen sin insuflación, no controlado y depende mucho de la interpretación del evaluador. Sin embargo, dentro del algoritmo diagnóstico de todo paciente con hemorragia digestiva oscura, la cápsula endoscópica suele ser el estudio inicial, por ser mínimamente invasiva y por permitirnos definir la mejor ruta de abordaje para realizar procedimientos posteriores, como la enteroscopía asistida por balón (simple o doble) que nos permite profundizar la evaluación del intestino delgado, tomar biopsias y hacer medidas terapéuticas. Como veremos, la cápsula endoscópica y la enteroscopía asistida por balón son complementarios y no excluyentes en todo paciente con hemorragia oscura. En este reporte presentamos el caso de un paciente adulto joven, asintomático, deportista, que en un examen de rutina evidenció anemia severa por deficiencia de hierro, sin historia de pérdidas gastrointestinales manifiestas. La evaluación del intestino delgado, mediante cápsula endoscópica y enteroscopía asistida por balón, nos permitió demostrar la presencia de un divertículo de Meckel ulcerado, y una laparoscopia orientada por los hallazgos nos permitió un tratamiento efectivo y una evolución favorable de esta presentación poco frecuente.

Meckel's diverticulum is a rare clinical entity in clinical practice. However, it should be considered as an important differential diagnosis in patients with both obscure overt and occult gastrointestinal bleeding. Years ago, the evaluation of the small bowel was impossible without surgery, nowadays the development of new diagnostic methods has changed this horizon. Capsule endoscopy cannot take biopsies, has not bowel insufflation, and its final report depends a lot on the interpretation of the evaluator. However, capsule endoscopy is usually the first procedure in all patients with obscure gastrointestinal bleeding, because is minimally invasive, and it has a main role in predicting the better route to perform a balloon assisted enteroscopy (single or double) that allows us to explore the small bowel, take biopsies and do therapeutic procedures. Capsule endoscopy and balloon assisted enteroscopy are complementary procedures in every patient with obscure gastrointestinal bleeding. In this report, we present a case of young adult without history of gastrointestinal bleeding who had severe asymptomatic iron deficiency anemia, in which the evaluation of small bowel with capsule endoscopy and balloon-assisted enteroscopy allow us to diagnosis ulcerated Meckel diverticulum.

Hepatitis isquémica fulminante inducida por disfunción cardiaca severa: reporte de caso / Fulminating ischemic hepatitis induced by severe cardiac dysfunction: case report

La hepatitis isquémica es una entidad infrecuente en la práctica clínica diaria con una prevalencia de 0,16 a 0,5% entre los pacientes admitidos en unidad de cuidados críticos, asociado a una mortalidad aproximada en el 60% de los casos. Esta hepatopatía se caracteriza por un incremento rápido y marcado (más de 20 veces el valor normal) del nivel de transaminasas secundario a una hipoperfusión hepática severa y persistente ocasionada por múltiples etiologías, que puede ser transitoria de identificarse y tratar la causa desencadenante oportunamente. A continuación presentamos el caso de un paciente adulto mayor con un cuadro clínico, epidemiológico y bioquímico compatible con hepatitis isquémica secundario a disfunción cardiaca severa.

Ischemic Hepatitis is an uncommon entity in daily clinical practice with a prevalence of 0.16 to 0.5% among patients admitted to a critical care unit, associated with an approximate 60% mortality rate. This liver disease is characterized by a rapid and marked increase (more than 20 times the normal value) of the level of transaminases secondary to a severe and persistent hepatic hypoperfusion caused by multiple etiologies, which may be transient when the triggering cause is timely identified and appropiately treated. The case of an elderly adult patient with a clinical, epidemiological and biochemical profile compatible with ischemic hepatitis secondary to severe cardiac dysfunction is presented below.

[Severe asymptomatic iron deficiency anemia as an unusual presentation of a Meckel diverticulum]. / Anemia ferropénica severa asintomática como presentación inusual de divertículo de Meckel.

Meckel's diverticulum is a rare clinical entity in clinical practice. However, it should be considered as an important differential diagnosis in patients with both obscure overt and occult gastrointestinal bleeding. Years ago, the evaluation of the small bowel was impossible without surgery, nowadays the development of new diagnostic methods has changed this horizon. Capsule endoscopy cannot take biopsies, has not bowel insufflation, and its final report depends a lot on the interpretation of the evaluator. However, capsule endoscopy is usually the first procedure in all patients with obscure gastrointestinal bleeding, because is minimally invasive, and it has a main role in predicting the better route to perform a balloon assisted enteroscopy single or double) that allows us to explore the small bowel, take biopsies and do therapeutic procedures. Capsule endoscopy and balloon assisted enteroscopy are complementary procedures in every patient with obscure gastrointestinal bleeding. In this report, we present a case of young adult without history of gastrointestinal bleeding who had severe asymptomatic iron deficiency anemia, in which the evaluation of small bowel with capsule endoscopy and balloon-assisted enteroscopy allow us to diagnosis ulcerated Meckel diverticulum.