Recurrent hemobilia secondary to extrahepatic biliary tract cholangiocarcinoma. A diagnostic challenge.

The etiology of hemobilia has mainly iatrogenic (>50%), followed by traumatic causes. Others are biliopathy due to portal high pressure, or neoplastic or infective biliopathy. In the case of non-clear hemobilia, direct-vision-cholangioscopy can change the management in >34% of cases. Our patient had episodes of obstructive hemobilia with secondary cholangitis without objectifying underlying pathology. When she was referred to our center, SpyGlass®-cholangioscopy identified the suspicious lesion compatible with early-stage cholangiocarcinoma despite the diagnostic delay. In conclusion, it is important to keep in mind the neoformative etiology as a potential cause of hemobilia of unclear origin, in which case, cholangioscopy (SpyGlass®) can contribute to the recognition of the signs of malignancy of the lesion and, therefore, to the diagnosis.

Histiocytic sarcoma of the esophagus.

A 20-year-old male with no medical history of interest who goes to the emergency room because of retrosternal pain, odynophagia, dysphagia, and fever. On physical examination: 37.7ºC axillary temperature, bad general condition, and central chest pain on palpation. In the blood test: 16,200x10^6/L white blood cells, 12,800x10^6/L neutrophils, and 11.66mg/dL C reactive protein, with the rest of the complete blood count, coagulation, and biochemistry within normal values.

Aspectos endoscópicos del tratamiento de la enfermedad de Parkinson avanzada con levodopa/carbidopa intraduodenal / Endoscopic management of duodenal levodopa-carbidopa therapy of advanced Parkinson's disease

Introducción: el tratamiento con levodopa intraduodenal mediante gastrostomía endoscópica percutánea constituye una alternativa terapéutica en pacientes con enfermedad de Parkinson. Disponemos de pocos estudios que evalúen los aspectos endoscópicos en esta indicación. Objetivos: describir nuestra experiencia en esta técnica e identificar factores asociados a la aparición de complicaciones. Métodos: estudio observacional retrospectivo en centro terciario entre enero de 2007 y enero de 2019. Resultados: se incluyeron 37 pacientes (21 varones, edad 65,1 +/- 10,3 años, diez años [rango 25] de evolución de la enfermedad) seguidos durante una mediana de 16 meses (rango 143). El sistema se colocó con éxito en el 100% de los casos. La tasa de persistencia con el tratamiento al final del seguimiento fue del 62,2%. El sistema se retiró en 14 pacientes: siete por empeoramiento, cuatro por deseo del paciente y tres por complicaciones. Hubo 53 complicaciones en 23 pacientes (62,2%; 0,63 por paciente-año), cuatro mayores (8,1%, 0,05 por paciente-año). Complicaciones menores: 14 (37,8%) relacionados con el estoma, seis (16,2%) con la gastrostomía y 15 (40,5%) con la sonda duodenal. La mayoría se resolvieron endoscópicamente. Se realizaron 44 recambios de sonda en 20 pacientes (54,1%; 0,52 por paciente-año). El sexo masculino, la edad mayor de 70 años y un mayor índice de comorbilidad se asociaron a mayor probabilidad de persistencia del sistema. No se identificaron factores predictores de complicaciones asociadas a la gastrostomía. Conclusiones: la gastrostomía para infusión de levodopa intraduodenal presenta una alta tasa de éxito técnico. Las complicaciones son frecuentes, pero la mayoría se resuelven endoscópicamente

Background: treatment of intraduodenal levodopa using percutaneous endoscopic gastrostomy is an alternative therapy in patients with advanced Parkinson's disease. There are few studies that have evaluated the endoscopic aspects of this technique. Objectives: to describe our experience and adverse events regarding this technique in advanced Parkinson's disease. Method: a retrospective study was performed from January 2007 to January 2019 in a tertiary healthcare center. Results: thirty-seven patients aged 65.1 +/- 10.3 years were included in the study, 21 were male and the disease duration was ten years (1-26). The median follow-up was 16 months (1-144). The device was successfully placed in all cases. The persistence rate with the PEG-D at the end of follow-up was 62.2%. The system was removed in 14 patients, seven due to neurological impairment, four because of the decision of the patient and three due to related events. Fifty-nine adverse events occurred in 23 patients (62.2%, 0.63 per patient-year), four of which were severe (8.1%, 0.05 per patient-year). Minor adverse events included 14 (37.8%) related to the stoma, six (16.2%) to the gastric tube and 15 (40.5%) to the duodenal tube. Forty-four system replacements were performed in 20 patients (54.1%, 0.52 per patient-year). Male sex, age over 70 and a higher comorbidity index were associated with a greater likelihood of persistence of the system (OR: 0.14, 95% CI: 0.03-0.62; OR: 0.52, 95% CI: 0.32-0.86; OR: 0.16, 95% CI: 0.03-0.99, respectively). No predictors of adverse events associated with PEG-D were identified. Conclusions: percutaneous endoscopic gastrostomy for the continuous delivery of duodenal levodopa is a highly effective technique. Adverse events are common, although most are resolved by endoscopy

Endoscopic management of duodenal levodopa-carbidopa therapy of advanced Parkinson's disease.

BACKGROUND: treatment of intraduodenal levodopa using percutaneous endoscopic gastrostomy is an alternative therapy in patients with advanced Parkinson's disease. There are few studies that have evaluated the endoscopic aspects of this technique. OBJECTIVES: to describe our experience and adverse events regarding this technique in advanced Parkinson's disease. METHOD: a retrospective study was performed from January 2007 to January 2019 in a tertiary healthcare center. RESULTS: thirty-seven patients aged 65.1 ± 10.3 years were included in the study, 21 were male and the disease duration was ten years (1-26). The median follow-up was 16 months (1-144). The device was successfully placed in all cases. The persistence rate with the PEG-D at the end of follow-up was 62.2%. The system was removed in 14 patients, seven due to neurological impairment, four because of the decision of the patient and three due to related events. Fifty-nine adverse events occurred in 23 patients (62.2%, 0.63 per patient-year), four of which were severe (8.1%, 0.05 per patient-year). Minor adverse events included 14 (37.8%) related to the stoma, six (16.2%) to the gastric tube and 15 (40.5%) to the duodenal tube. Forty-four system replacements were performed in 20 patients (54.1%, 0.52 per patient-year). Male sex, age over 70 and a higher comorbidity index were associated with a greater likelihood of persistence of the system (OR: 0.14, 95% CI: 0.03-0.62; OR: 0.52, 95% CI: 0.32-0.86; OR: 0.16, 95% CI: 0.03-0.99, respectively). No predictors of adverse events associated with PEG-D were identified. CONCLUSIONS: percutaneous endoscopic gastrostomy for the continuous delivery of duodenal levodopa is a highly effective technique. Adverse events are common, although most are resolved by endoscopy.

[Anti-fungal drugs. Current status and guidelines for their administration]. / Fármacos antifúngicos. Situación actual y pautas para su administración.

Current medicine, in its zeal to cure diseases that, to-date, have been incurable, has overcome many barriers. High-dose chemotherapy, bone marrow and solid organ transplant, haemodialysis, parenteral and enteral nutrition, and other techniques have produced longer survival and cures for seriously ill patients. Over the past few years, fungal infections have become an important factor in morbidity and mortality in patients who are not only immunocompromised but also suffering severe pathologies. Anti-fungal treatment has been enriched, recently, with new compounds that are widening the therapeutic options for many of these patients.

Fármacos antifúngicos. Situación actual y pautas para su administración / Anti-fungal drugs. Current status and guidelines for their administration

La medicina actual, en su afán por curar enfermedades que hasta ahora eran incurables, ha rebasado muchas fronteras; en efecto, la quimioterapia a dosis elevadas, el trasplante de médula ósea y de órganos sólidos, la hemodiálisis, la nutrición parenteral y otras técnicas han permitido largas sobrevivencias y curaciones de pacientes muy graves; ello ha hecho que, en los últimos años, las infecciones fúngicas invasoras se hayan convertido en causa importante de morbilidad y mortalidad en pacientes tanto inmunocomprometidos como con patologías de base graves. El tratamiento antifúngico se ha enriquecido, recientemente, con nuevos preparados que están mejorando las opciones terapéuticas de muchos de estos pacientes

Current medicine, in its zeal to cure diseases that, to-date, have been incurable, has overcome many barriers. High-dose chemotherapy, bone marrow and solid organ transplant, haemodialysis, parenteral and enteral nutrition, and other techniques have produced longer survival and cures for seriously ill patients. Over the past few years, fungal infections have become an important factor in morbidity and mortality in patients who are not only immunocompromised but also suffering severe pathologies. Anti-fungal treatment has been enriched, recently, with new compounds that are widening the therapeutic options for many of these patients