[Cecal tuberculosis: the importance of a high diagnostic suspicion]. / Tuberculosis cecal: la importancia de una alta sospecha diagnóstica.

Intestinal tuberculosis is less common than pulmonary tuberculosis. Its clinical and endoscopic features are nonspe-cific, so diagnostic suspicion must be high in order to make an early diagnosis and prevent iatrogenia. Pharmacotherapy is often effective, with an excellent clinical and endoscopic evolution. Surgical treatment is reserved for complications. We present the case of cecal tuberculosis diagnosed endoscopically; this is the second case diagnosed in a few months in our center. In this case there were no risk factors, such as recent travel, risk of contacts or inmunosupression.

[Lymphoplasmacytic inflammatory pseudotumor of the liver]. / Pseudotumor inflamatorio hepático linfoplasmocítico.

We present the case of a middle-aged woman with antecedents of cholecystectomy and several episodes of resi-dual coledocolitiasis resolved endoscopically. She attended Emergency Services due to a new clinical picture of abdo-minal pain and alteration of hepatic enzymes. Image tests showed lesions that suggested hepatic abscesses without ruling out a malign origin. Given this doubt it was decided to carry out a thick needle biopsy obtaining a diagnosis of an inflammatory pseudotumour of the liver related to IgG4-related disease. This is an infrequent entity but must be taken into consideration because - unlike malign pathology, which is the main differential diagnosis - its behaviour is benign, with a good evolution with medical treatment. That is why a suitable diagnosis is vital to avoid aggressive, diagnostic-therapeutic procedures.

Pseudotumor inflamatorio hepático linfoplasmocítico / Lymphoplasmacytic inflammatory pseudotumor of the liver

Presentamos el caso de una mujer de mediana edad con antecedentes de colecistectomía y varios episodios de coledocolitiasis residual resueltos endoscópicamente. Acude al servicio de Urgencias por un nuevo cuadro de dolor abdominal y alteración de enzimas hepáticas, apreciándose en las pruebas de imagen lesiones sugestivas de abscesos hepáticos sin poder descartarse un origen maligno. Dada esta duda se decide realizar una biopsia con aguja gruesa llegando al diagnóstico de pseudotumor inflamatorio hepático relacionada con la enfermedad por IgG4. Ésta es una entidad infrecuente pero que debe ser tenida en cuenta debido a que, a diferencia de la patología maligna, que es el principal diagnóstico diferencial, su comportamiento es benigno, con buena evolución con tratamiento médico. Por ello es vital un adecuado diagnóstico para evitar procedimientos diagnóstico-terapéuticos agresivos (AU)

We present the case of a middle-aged woman with antecedents of cholecystectomy and several episodes of residual coledocolitiasis resolved endoscopically. She attended Emergency Services due to a new clinical picture of abdominal pain and alteration of hepatic enzymes. Image tests showed lesions that suggested hepatic abscesses without ruling out a malign origin. Given this doubt it was decided to carry out a thick needle biopsy obtaining a diagnosis of an inflammatory pseudotumour of the liver related to IgG4-related disease. This is an infrequent entity but must be taken into consideration because - unlike malign pathology, which is the main differential diagnosis - its behaviour is benign, with a good evolution with medical treatment. That is why a suitable diagnosis is vital to avoid aggressive, diagnostic-therapeutic procedures (AU)

Ultrasonography is an accurate technique for the diagnosis of gastrointestinal tumors in patients without localizing symptoms.

INTRODUCTION AND OBJECTIVES: This study compared the accuracy of ultrasonography in the diagnosis of gastrointestinal tumors in patients with several degrees of clinical suspicion. MATERIAL AND METHODS: We recruited patients that were suspect for gastrointestinal neoplasia but with no evidence of localizing symptoms (group A), and patients that were suspect for colon cancer (group B) or for gastric cancer (group C). Accuracy in the diagnosis was compared for: gastric cancer in groups A and C, and for colon cancer in groups A and B. The comparison was made by using the contingency coefficient, which quantifies coincidence of endoscopic and ultrasonographic diagnoses. RESULTS: Seventy-nine patients were included in group A (48 males), wherein 12 colon and 5 gastric neoplasms were detected. Group B was comprised of 153 patients (78 males) and included 66 patients with colorectal cancer (CCR). Group C contained 58 patients (35 males), 31 of whom were diagnosed with gastric cancer. The accuracy of sonography for diagnosing colon cancer was 95.5% for group A and 87.5% for group B. The contingency coefficient for endoscopy vs. ultrasonography was greater for group A: 0.658 than for group B: 0.549. The diagnostic accuracy for gastric cancer was 97.4% for group A and 86.2% for group C. The contingency coefficient between endoscopic and ultrasonographic diagnoses was also greater in group A (0.618) than in group C (0.588). CONCLUSIONS: The accuracy of ultrasonography in diagnosing colon and gastric cancer is not lower in patients without localizing symptoms.

La ecografía es una técnica sensible en el diagnóstico de las neoplasias gastrointestinales en pacientes sin síntomas localizadores / Ultrasonography is an accurate technique for the diagnosis of gastrointestinal tumors in patients without localizing symptoms

Introducción y objetivos: en todos los estudios publicadoshasta la fecha se ha evaluado la precisión de la ecografía en eldiagnóstico del cáncer de colon y del cáncer gástrico en pacientesen los que esta era la sospecha diagnóstica o ya con un diagnósticoestablecido de esta patología. Nosotros, en este estudio, comparamosla sensibilidad de la ecografía en pacientes con diferentesgrados de sospecha clínica.Material y método: reclutamos pacientes con sospecha deneoplasia digestiva, sin evidencia de síntomas localizadores (grupoA), pacientes con sospecha de cáncer de colon (grupo B) y pacientescon sospecha de cáncer gástrico (grupo C). Comparamosla precisión de la ecografía en el diagnóstico del cáncer gástricoen los grupos A y C, y la precisión en el diagnóstico del cáncer decolon en los grupos A y B. El parámetro usado en la comparaciónes el coeficiente de contigencia que cuantifica la coincidencia dediagnóstico endoscópico y ecográfico.Resultados: se han incluido 79 pacientes en el grupo A (48varones y 31 mujeres, con una edad media de 69,3 años), en losque se han diagnosticado 12 neoplasias colónicas y 5 gástricas. Elgrupo B se compone de 153 pacientes (78 varones y 75 mujeres,con una edad media de 66,5 años) e incluye 66 pacientes conCCR. Finalmente, el grupo C está formado por 58 pacientes (35varones y 23 mujeres, con una edad media de 67,4 años), siendodiagnosticados de cáncer gástrico 31 pacientes. La precisión de laecografía en el diagnóstico del cáncer de colon fue del 95,5% enel grupo A y del 87,5% en el grupo B. El coeficiente de contingenciaentre los diagnósticos endoscópico y ecográfico tambiénfue superior en el grupo A: 0,658 frente a 0,549. La precisión dela ecografía en el diagnóstico del cáncer gástrico fue del 97,4% enel grupo A y del 86,2% en el grupo C...(AU)

Introduction and objectives: this study compared the accuracyof ultrasonography in the diagnosis of gastrointestinal tumorsin patients with several degrees of clinical suspicion.Material and methods: we recruited patients that were suspectfor gastrointestinal neoplasia but with no evidence of localizingsymptoms (group A), and patients that were suspect for coloncancer (group B) or for gastric cancer (group C). Accuracy in thediagnosis was compared for: gastric cancer in groups A and C,and for colon cancer in groups A and B. The comparison wasmade by using the contingency coefficient, which quantifies coincidenceof endoscopic and ultrasonographic diagnoses.Results: seventy-nine patients were included in group A (48males), wherein 12 colon and 5 gastric neoplasms were detected.Group B was comprised of 153 patients (78 males) and included66 patients with colorectal cancer (CCR). Group C contained 58patients (35 males), 31 of whom were diagnosed with gastric cancer.The accuracy of sonography for diagnosing colon cancer was95.5% for group A and 87.5% for group B. The contingency coefficientfor endoscopy vs. ultrasonography was greater for groupA: 0.658 than for group B: 0.549. The diagnostic accuracy forgastric cancer was 97.4% for group A and 86.2% for group C.The contingency coefficient between endoscopic and ultrasonographicdiagnoses was also greater in group A (0.618) than ingroup C (0.588).Conclusions: the accuracy of ultrasonography in diagnosingcolon and gastric cancer is not lower in patients without localizingsymptoms(AU)

[Usefulness of ultrasonography in diagnosing patients suspect for digestive tract neoplasms]. / Utilidad de la ecografía en el diagnóstico de los pacientes con sospecha de neoplasias del tubo digestivo.

BACKGROUND: The Positive Predictive Value (PPV) of signs and symptoms for the diagnosis of colon and gastric cancer is low. Furthermore, many patients are referred to us to discard a digestive tract neoplasm with no symptoms suggestive of its whereabouts, in whom clinical PPV is even lower. This study evaluates the usefulness of ultrasonography as a first approach to diagnosis. MATERIAL AND METHODS: Seventy-nine patients were recruited into the study (48 males with an average age of 69.3 years). Ultrasonography was performed on all patients prior to endoscopy. Parameters studied included diagnostic accuracy for colon and gastric cancer, ultrasonographic diagnoses, and number of endoscopies that can be avoided. Predictive factors for neoplasm location were also studied. RESULTS: Five gastric cancers (6.3%), 12 colon cancers (15,1%), 3 pancreatic cancers (3.8%), 2 uterine neoplasms (2.5%), and 2 hypernephromas (2.5%) were diagnosed. The figures for sensitivity, specificity, PPV, Negative Predictive Value (NPV) and global accuracy of ultrasonography were 80%, 98.6%, 80%, 98.6%, and 97.4%, respectively, for gastric cancer, while these figures were 100%, 94.5%, 80%, 100%, and 95.5%, respectively, for colon cancer. Ultrasonography enabled to avoid 10% of endoscopic explorations. The only parameter that helps locate a neoplasm is the presence of anemia, which is more frequently associated with a diagnosis of colon cancer: 30.4 versus 4.3% (p = 0.033). CONCLUSIONS: In patients without specific symptoms who were sent to us for discarding digestive tract neoplasm, "extra-digestive" neoplasms were frequently diagnosed. If we further take into account the high diagnostic accuracy of ultrasonography, then this procedure could be a very good first approach towards such diagnosis.

Utilidad de la ecografía en el diagnóstico de los pacientes con sospecha de neoplasias del tubo digestivo / No disponible

Introducción: el valor predictivo positivo de síntomas y signosen el diagnóstico del cáncer de colon y gástrico es bajo. Además,muchos pacientes son remitidos para descartar una neoplasiadigestiva, sin síntomas que sugieran su localización, siendo elVPP de la clínica aún menor. En este trabajo evaluamos la utilidadde la ecografía como primera aproximación diagnóstica.Material y método: se han reclutado 79 pacientes (48 varones,edad media 69,3 años). En todos ellos se realiza una ecografíaantes de la endoscopia. Se evalúa la precisión en el diagnósticodel cáncer de colon y gástrico, los diagnósticos ecográficos y elnúmero de endoscopias que se evitarían. También se buscan factorespredictivos de la localización de la neoplasia.Resultados: se han diagnosticado 5 neoplasias gástricas(6,3%) y 12 de colon (19%), 3 cáncer de páncreas (3,8%), 2 neoplasiasuterinas (2,5%) y 2 hipernefromas (2,5%). Las cifras desensibilidad, especificidad, VPP, VPN y precisión de la ecografíafueron 80%, 98,6%; 80%; 98,6%; y 97,4% respectivamente enel diagnóstico del cáncer gástrico, y del 100%, 94,5%; 80%;100% y 95,5% respectivamente en el diagnóstico del cáncer decolon. La ecografía permitió evitar el 10% de las endoscopias. Elúnico dato que orienta la localización de la neoplasia es la presenciade anemia, que se asocia con mayor frecuencia al diagnósticode cáncer de colon: 30,4 versus 4,3% (p = 0,033).Conclusiones: en los pacientes remitidos para descartar unaneoplasia digestiva, con síntomas inespecíficos, se diagnostica confrecuencia de patología neoplásica ajena al tubo digestivo. Si consideramos,además, la elevada precisión diagnóstica de la ecografía,esta podría ser una muy buena primera aproximación diagnóstica

Background: the Positive Predictive Value (PPV) of signs andsymptoms for the diagnosis of colon and gastric cancer is low. Furthermore,many patients are referred to us to discard a digestive tractneoplasm with no symptoms suggestive of its whereabouts, in whomclinical PPV is even lower. This study evaluates the usefulness of ultrasonographyas a first approach to diagnosis.Material and methods: seventy-nine patients were recruitedinto the study (48 males with an average age of 69.3 years). Ultrasonographywas performed on all patients prior to endoscopy. Parametersstudied included diagnostic accuracy for colon and gastriccancer, ultrasonographic diagnoses, and number of endoscopies thatcan be avoided. Predictive factors for neoplasm location were alsostudied.Results: five gastric cancers (6.3%), 12 colon cancers (15,1%), 3pancreatic cancers (3.8%), 2 uterine neoplasms (2.5%), and 2 hypernephromas(2.5%) were diagnosed. The figures for sensitivity, specificity,PPV, Negative Predictive Value (NPV) and global accuracy ofultrasonography were 80%, 98.6%, 80%, 98.6%, and 97.4%, respectively,for gastric cancer, while these figures were 100%,94.5%, 80%, 100%, and 95.5%, respectively, for colon cancer. Ultrasonographyenabled to avoid 10% of endoscopic explorations.The only parameter that helps locate a neoplasm is the presence ofanemia, which is more frequently associated with a diagnosis ofcolon cancer: 30.4 versus 4.3% (p = 0.033).Conclusions: in patients without specific symptoms who weresent to us for discarding digestive tract neoplasm, “extra-digestive”neoplasms were frequently diagnosed. If we further take into accountthe high diagnostic accuracy of ultrasonography, then this procedurecould be a very good first approach towards such diagnosis

[Perforation risk in esophageal endoscopic mucosal resection with ligation: an experimental study with two ligator models]. / Riesgo de perforación en la mucosectomía esofágica con banda: estudio experimental con dos modelos de ligadores.

OBJECTIVE: endoscopic mucosal resection with ligation (EMRL) is considered an efficient, safe method for the treatment of some esophageal, gastric and colorectal tumors. We conducted this study using a porcine model in order to compare the safety of esophageal EMRL with two multiband ligation systems, since many centers only use these ligator models in EMRL (commercialized for varix ligation). METHODS: eight pigs were used, which were submitted to 23 esophageal resections without previous injection. Ten resections were conducted using the Six Shooter Saeed model, and 13 resections used the Speedband Superview Super 7 model. The technique was also compared by making random cuts either above or below the band. RESULTS: five perforations occurred, all of them using the Speedband model. This represents 38.5% of total in the Speedband model group. No perforation occurred when using the Six Shooter model (p = 0.046). On the contrary, no significant differences were found regarding frequency of perforation when cutting above or below the band. CONCLUSIONS: esophageal EMRL using the Speedband model without previous injection leads to perforation in a high percentage of cases in an experimental animal model. Further studies are required to find out whether a previous injection may increase the safety of this technique with this ligator model.

Obscure gastrointestinal bleeding: a complication of radiation enteritis diagnosed by wireless capsule endoscopy.

Obscure gastrointestinal bleeding is a common disorder and may account for as many as 5% of all gastrointestinal hemorrhages. It is often caused by lesions in the small intestine, which were very complicated to examine prior to the advent of wireless capsule endoscopy. Here we present the case of a 31-year-old woman with obscure gastrointestinal bleeding as a complication of radiation enteritis, which was diagnosed only after she underwent an examination with wireless capsule endoscopy. This technique has proven to be far superior to other radiographic and endoscopic methods in diagnosing obscure gastrointestinal bleeding and pathologies of the small intestine in general.

Recurrent Dieulafoy's disease with surgical management: diagnosis by endoscopic ultrasonography.

Dieulafoy's disease is an uncommon but potentially significant cause of gastrointestinal bleeding caused by a large-caliber arterial vessel in the submucosa, which causes erosion and debilitation of the surrounding mucosa and may lead to massive gastrointestinal bleeding. Since endoscopy may prove insufficient, echoendoscopy may help in the diagnosis of this condition. Echoendoscopy may also help improve endoscopic management using mechanical techniques (hemoclips or band ligation) or a combination of thermal techniques and injection sclerotherapy, since this allows an accurate localization of the submucosal vessel. We present a case illustrating this approach by endoscopic ultrasonography, and describe the morphological substrate of this condition.

Endoscopic ultrasound-assisted endoscopic resection of carcinoid tumors of the gastrointestinal tract.

INTRODUCTION: Usually found in the gastrointestinal tract, carcinoids are the most frequent neuroendocrine tumors. Most of these lesions are located in areas that are difficult to access using conventional endoscopy (small intestine and appendix); carcinoid tumors found in the gastroduodenal tract and in the large intestine can be studied endoscopically; in these cases, if localized disease is confirmed, local treatment by endoscopic resection may be the treatment of choice. Since endoscopic ultrasonography has been shown to be the technique of choice for the study of tumors exhibiting submucosal growth, the selection of patients who are candidates for a safe and effective local resection should be based on this technique. PATIENTS AND METHOD: We selected patients with gastrointestinal carcinoid tumors who were endoscopically treated between 1997 and 2002. Those patients with tumors measuring less than 10 mm, which had not penetrated the muscularis propria, and those with localized disease were considered candidates for endoscopic resection. The endpoints of this study were to assess the effectiveness (complete resection) and safety (complications) of the technique. Follow-up consisted of eschar biopsies performed one month and twelve months after the resection. RESULTS: During the aforementioned period, we resected endoscopically 24 tumors in 21 patients (mean age: 51.7 years; 71.5% males). Most lesions were incidental discoveries made during examinations indicated for other reasons. Resection was indicated in most cases as a result of the suspected presence of a carcinoid tumor after endoscopic ultrasonography. Endoscopic ultrasonography also enabled us to clearly identify the layer where the lesion had originated, as well as the size of the lesion. The carcinoid tumor was removed in 13 cases (54.2%) by using the conventional snare polypectomy technique, in 9 cases (37.5%) assisted by a submucosal injection of saline solution and/or adrenaline, and in 2 cases (8.3%) after ligating the lesion with elastic bands. In all cases the resection was complete, with no recurrence during the follow-up period, and no major complications, except for a single case in which a post-polypectomy hemorrhage occurred that was endoscopically solved. CONCLUSIONS: In properly selected patients, the endoscopic resection of carcinoid tumors is a safe and effective technique that permits a complete resection in all cases with few complications. Endoscopic ultrasonography is the technique of choice for selecting the patients who are candidates for endoscopic resection.

Endoscopic sphincterotomy for prevention of the recurrence of acute biliary pancreatitis in patients with gallbladder in situ: long-term follow-up of 88 patients.

BACKGROUND: Endoscopic sphincterotomy without cholecystectomy is a therapeutic option in selected patients after acute biliary pancreatitis. We conducted a prospective evaluation of the long-term effects of sphincterotomy in terms of the need for of subsequent cholecystectomy and the recurrence of gallstone pancreatitis. METHODS: We studied 88 patients with acute biliary pancreatitis and an intact gallbladder who, underwent endoscopic sphincterotomy either because they were high-risk candidates for surgery or because they had refused of cholecystectomy. The median follow-up was 51 months (range, 5-86). RESULTS: Only two patients (2.2%) experienced recurrent pancreatitis. Subsequent cholecystectomy was performed in 10 patients because of acute cholecystitis in eight cases and biliary colic in two cases. Sixty-six patients (75%) remained asymptomatic. CONCLUSIONS: Endoscopic sphincterotomy is a safe and acceptable alternative to cholecystectomy for the prevention of recurring attacks of gallstone pancreatitis. As a result of this procedure, 75% of patients remained free of symptoms in the long term.

Indication and results of endoscopic management of sigmoid volvulus.

INTRODUCTIONS: sigmoid volvulus is a relatively common cause of intestinal obstruction, particularly in the elderly and in patients with debilitating conditions. As the risks associated with surgical treatment of the sigmoid volvulus are in many cases too high, conservative (endoscopic) management is an option to be considered. MATERIAL AND METHODS: all emergency lower gastrointestinal endoscopies performed between January 1, 1996 and December 31, 2001 were review and, among these, the cases of diagnosis of sigmoid volvulus were selected. The results of the endoscopic management, percentage of recurrence, mortality rate, complications, surgical procedures etc were evaluated in the select cases. RESULTS: lower gastrointestinal endoscopy was diagnostic in all cases. Endoscopic management showed and overall efficacy of 87.5%. recurrence appeared in approximately 57% of the cases. Successful treatment was accomplished for the first episode in 25% of the cases. In case of recurrence, endoscopic management could be performed again with similar efficacy and safety. CONCLUSIONS: endoscopic reduction is a safe and successful technique for the management of emergency sigmoid volvulus, provided vascular compromise in the intestinal wall is ruled out. As recurrence is frequent, elective definitive surgery could be a treatment to consider. Endoscopic management could be the only choice treatment in the case of patients not it for surgery due to the very important risks associated with it their cases.

Treatment of achalasia with the Witzel dilator: a prospective randomized study of two methods.

BACKGROUND AND STUDY AIMS: Several studies have shown that the use of the Witzel dilator is an effective and safe treatment for achalasia. However, the optimal values for pressure, number of dilations, and duration of application have not yet been established. The aim of this study was to determine these three parameters. PATIENTS AND METHODS: 43 patients with a diagnosis of achalasia (based on clinical, radiological, manometric and endoscopic evaluation) were randomly allocated to one of two treatment groups. Patients in group A (n=21) underwent three consecutive 1-minute dilations per session at 1-minute intervals, at 200 mmHg for the first dilation and 300 mmHg for the second and third. In group B patients (n=22) only one dilation was done, at 200 mmHg for 2 minutes. Before and after treatment, the clinical score, the maximum esophageal diameter (obtained using barium contrast studies) and the basal pressure of the lower esophageal sphincter were evaluated in each patient. The need for further treatment and the presence of complications were also determined. RESULTS: Both methods led to clinical, radiological, and manometric benefits. No differences were observed between the methods (satisfactory results in 86%; one perforation in each group). Six patients underwent operation; five for an incomplete response and one for a perforation. CONCLUSIONS: There were no differences between the two groups investigated, suggesting that only one 2-minute dilation at 200 mmHg is sufficient.

Test de IBP y endoscopia en la ERGE / PPI test and endoscopy in GERD

No disponible