Choledocholithiasis in a patient carrying an intragastric balloon. Removal or direct ERCP?

Endoscopic retrograde cholangio-pancreatography (ERCP) is a diagnostic, therapeutic technique for the management of pancreato-biliary conditions. Technical contraindications include the presence of intraluminal foreign bodies precluding endoscope passage. Intragastric balloon (IGB) is a bariatric procedure that provides sensations of early fullness and satiety from intragastric occupation, thus leading to weight loss. While, according to guidelines, choledocholithiasis and cholangitis do not represent an indication for IGB removal in contrast to moderate-severe pancreatitis, where need for an ERCP and the procedure's technical difficulty most commonly require it. We report the case of a female patient with an IGB where ERCP was indicated. CASE REPORT: A 47-year-old woman visited the emergency room for epigastric abdominal pain radiating to her back. She had jaundice without pyrexic symptoms. At the ER an ultrasonogram revealed cholelithiasis and a dilated common bile duct (11 mm in diameter), no cause being then identified. Lab tests rule out pancreatic involvement and associated infection. The patient had an IGB (Photo 1a) implanted 5 months before the present episode. She was admitted to the gastroenterology ward with choledocholithiasis as suspected diagnosis. The study was completed by endoscopic ultrasound (EUS), which confirmed a dilated hepatocholedochal duct at 15.3 mm in diameter (Photo 1b), secondary to multiple choledochal stones. A direct ERCP procedure was initiated where the IGB precluded rectification and proper placement, which forced the use of a double-guidewire technique for cannulation (Photo 1c)5. Sphincterotomy and sphincteroplasty to 10 mm ensued, and 8 stones were removed using a balloon and then a basket catheter (Photo 1d). The patient was discharged at 24 hours after the procedure with no complications. DISCUSSION: No prior studies are available that describe the possibility of therapeutic ERCP for choledocholithiasis in IGB-carrying patients; in most cases IGB removal is taken for granted because of the procedure's technical difficulty. Our case report may well show a safe alternative to IGB removal by using less conventional cannulation techniques without higher complication rates. However, further cases are needed in order to draw significant conclusions regarding their widespread use.

Cuando la obstrucción intestinalno es quirúrgica / When intestinal obstruction is not a surgical condition

We report the case of a middle-aged man who had undergone two diagnostic laparoscopies with no significant findings after he was attended at the emergency department with cramping pain, abdominal distention and vomiting, with radiological images simulating a small bowel obstruction. After multiple hospitalisations and an extensive set of tests, including a genetic study, he was diagnosed with chronic pseudo-obstruction, an uncommon, unrecognides syndrome with high morbidity. Being aware of this pathology can make it easier to diagnose, and thereby, we can avoid unnecessary surgical interventions, because its management and treatment are mainly based on pharmacological therapy. After a proper diagnosis our patient's progression was satisfactory due to the treatment introduced, with no further hospitalisations.(AU)

Retirform purpura, a rare chemoembolization adverse outcome.

Transcatheter arterial chemoembolization (TACE) is currently one of the standards of treatment for unresectable hepatocellular carcinoma in the intermediate stage. It is a minimally invasive procedure whose adverse outcomes are well documented. Among those considered uncommon, we find skin outcomes. We report a 73-year-old man who, after undergoing TACE, develops a necrotic retiform purpura due to occlusion of the microcirculation of the cutaneous and subcutaneous tissue caused by migration of doxorubicin spheres. This is an infrequent complication, which presents with pain in the affected area. Its management is based on prevention, which is the reason why awareness of this condition is so important.

Benign intestinal pneumatosis associated with congenital Morgagni-Larrey diaphragmatic hernia.

Intestinal pneumatosis (IN) is an uncommon radiological finding defined as the accumulation of air in the gastrointestinal tract wall. Its clinical signs are nonspecific and include symptoms such as diarrhea or abdominal pain. It includes benign entities (with subtle symptoms and the accumulation of air in the form of cysts that appear as clustered nodular lesions on the endoscopy, collapsible and soft); or severe cases (symptoms indicative of general health compromise and linear accumulation of air or free fluid suggestive of hollow viscus perforation); which require different management. We present the case of a patient diagnosed with benign intestinal pneumatosis (BIN), associated with anatomical changes due to a diaphragmatic hernia. CASE REPORT We report the case of an 86-year-old woman with a Morgani-Larrey congenital diaphragmatic hernia (HML) (2) admitted due to exacerbation of chronic baseline diarrhea. A colonoscopy with biopsies was performed, but the study was incomplete due to colonic torsion at the hepatic angle deriving from HML, with uncomplicated colonic mucosa and absence of cystic nodulations. Figure 1a. Biopsies ruled out organicity. The abdominal computed tomography (CT) scan performed revealed the accumulation of pneumoperitoneum bubbles in the distal ileum and suprahepatic wall without identification of continuity changes, or signs of visceral perforation. Figure 1b-c. The patient was diagnosed with BIN associated with an anatomical change (HML). Medical treatment was initiated with metronidazole at a dose of 1500 mg/day for 1 week, along with the patient's usual probiotics, and commercial compounds containing xyloglucan (pea protein) to restore the intestinal barrier function. (3). The patient was discharged with complete resolution of the diarrhea. No surgical intervention for her HML was required. DISCUSSION The clinical and radiological data in the presence of IN help us differentiate between severe cases and BIN, the latter being managed conservatively without the need for medical or surgical treatment. The intestinal barrier restoration measures implemented in our patient may have contributed to this resolution, although there is not enough scientific evidence to support this. The endoscopic image of nodular cysts is not always present in these cases, and the diagnosis of choice for this condition is radiological and based on exclusion. (4).

Hematoma post-endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures in the treatment of biliary-pancreatic diseases. Hematoma after ERCP is an infrequent and highly serious complication. We present three cases with hepatic hematoma after a CPRE.

Autoimmune hepatitis after SARS-C¬¬oV-2 vaccination.

Vaccination against SARS-CoV-2 have been reported like a potential trigger of some autoimmune diseases, like autoimmune hepatitis (HAI). We present three cases of AIH developed after the administration of the SARS-Cov-2 vaccine.

When intestinal obstruction is not a surgical condition.

We report the case of a middle-aged man who had undergone two diagnostic laparoscopies with no significant findings after he was attended at the emergency department with cramping pain, abdominal distention and vomiting, with radiological images simulating a small bowel obstruction. After multiple hospitalisations and an extensive set of tests, including a genetic study, he was diagnosed with chronic pseudo-obstruction, an uncommon, unrecognides syndrome with high morbidity. Being aware of this pathology can make it easier to diagnose, and thereby, we can avoid unnecessary surgical interventions, because its management and treatment are mainly based on pharmacological therapy. After a proper diagnosis our patient's progression was satisfactory due to the treatment introduced, with no further hospitalisations.

Relación de los factores demográficos e higiénico-dietéticos con la patología hallada en las colonoscopias ambulatorias realizadas en un centro del Servicio Castellano y Leonés de Salud / Relationship of demographic and dietary hygiene factors with the pathology found in outpatient colonoscopies performed in a Castilla y León Health Service center

Introducción: el cáncer colorrectal (CCR) es un tumor muy frecuente en términos de incidencia y mortalidad. Su patogenia se ha relacionado con diversos factores ambientales y hereditarios. Objetivos: analizar la asociación de edad, sexo y factores dietéticos con el diagnóstico de adenomas y CCR. Métodos: se realizó un estudio descriptivo prospectivo con los pacientes del Área Sanitaria de León que se sometieron a una colonoscopia ambulatoria entre 09/09/2012 y 30/06/2013. Mediante un formulario autoadministrado se recogieron datos sociodemográficos, tóxicos y dietéticos usando un cuestionario alimentario de frecuencia semicuantitativo. Se analizaron las diferencias en el diagnóstico según los datos sociodemográficos e higiénico-dietéticos, con análisis multivariante mediante regresión logística por pasos hacia delante. Resultados: se recogieron datos de 1390 pacientes cuya edad media fue de 57 (15) años; de ellos, el 47,8 % eran varones. Se diagnosticaron CCR en el 5 % de los pacientes y pólipos en el 20,4 % (9,4 % de adenomas de alto riesgo (AAR)). El hallazgo de pólipos y AAR fue más frecuente en los varones (26,9 % vs. 14,5 % y 12,6 % vs. 6,3 %, respectivamente (p < 0,001)). La edad media fue significativamente superior en los pacientes que presentaban pólipos (56.51 (15.45) vs. 63.22 (12.69) años; p < 0,001). En la población que refirió un consumo diario de carnes procesadas se duplicaba la proporción de pólipos detectados (2,9 % vs. 6,7 %; p = 0,02). Aquellos pacientes que consumían alcohol diariamente tenían mayor incidencia de pólipos frente al consumo ocasional y los abstemios (32 % vs. 20 % vs. 18,6 %; p = 0,002). Conclusiones: la edad se relacionaba con un mayor riesgo de pólipos, AAR y CCR. Los varones también tenían más riesgo de pólipos y AAR. El consumo de alcohol, carnes rojas y procesadas incrementaba el riesgo de pólipos. (AU)

Background: colorectal cancer (CRC) is one of the most frequent tumors in terms of incidence and mortality. Several elements, both inherited and environmental, have been related with its pathogenesis. Aims: to analyze the influence of age, gender and nutritional factors on the diagnosis of colonic polyps and CRC. Methods: a prospective, descriptive study over outpatients from the Health Area of León who took a colonoscopy between 09/09/2012 and 06/30/2013. Patients were asked to fill a semiquantitative food frecuency questionnaire with data such a sociodemographic, toxic and dietetic facts. Differences in diagnosis according to sociodemographic and hygiene-dietetic data were analyzed with a multivariate analysis by forward stepwise logistic regression. Results: data were collected from 1390 patients. Mean age was 57.88 (15.17) years and 47.8 % were male. CRC was diagnosed in 5 % of colonoscopies, and polyps in 20.4 %, with 9.4 % of them being HRA. Risk of polyps and HRA was higher in males (26.9 % vs 14.5 %) and (12.6 % vs 6.3 %), respectively (p < 0.001). Mean age was significantly higher in patients who presented polyps (56.51 (15.45) vs 63.22 (12.69) years; p < 0.001). Among the group who reported intake of smoked and salted food, the risk of polyps doubled (2.9 % vs 6.7 %, p = 0.002). In relation to alcohol intake we found that subjects with daily alcohol consumption showed a higher incidence of polyps whe compared to occasional drinkers and teetotallers (32 % vs 20 % vs 18.6 %, p = 0.002) Conclusions: age correlated with higher risk of polyps, HRA and CRC. Moreover, male gender also was associated with a high risk of polyps and HRA. Alcohol and red and processed meat intake increased polyp risk. (AU)

[Relationship of demographic and dietary hygiene factors with the pathology found in outpatient colonoscopies performed in a Castilla y León Health Service center]. / Relación de los factores demográficos e higiénico-dietéticos con la patología hallada en las colonoscopias ambulatorias realizadas en un centro del Servicio Castellano y Leonés de Salud.

Introduction: Background: colorectal cancer (CRC) is one of the most frequent tumors in terms of incidence and mortality. Several elements, both inherited and environmental, have been related with its pathogenesis. Aims: to analyze the influence of age, gender and nutritional factors on the diagnosis of colonic polyps and CRC. Methods: a prospective, descriptive study over outpatients from the Health Area of León who took a colonoscopy between 09/09/2012 and 06/30/2013. Patients were asked to fill a semiquantitative food frecuency questionnaire with data such a sociodemographic, toxic and dietetic facts. Differences in diagnosis according to sociodemographic and hygiene-dietetic data were analyzed with a multivariate analysis by forward stepwise logistic regression. Results: data were collected from 1390 patients. Mean age was 57.88 (15.17) years and 47.8 % were male. CRC was diagnosed in 5 % of colonoscopies, and polyps in 20.4 %, with 9.4 % of them being HRA. Risk of polyps and HRA was higher in males (26.9 % vs 14.5 %) and (12.6 % vs 6.3 %), respectively (p < 0.001). Mean age was significantly higher in patients who presented polyps (56.51 (15.45) vs 63.22 (12.69) years; p < 0.001). Among the group who reported intake of smoked and salted food, the risk of polyps doubled (2.9 % vs 6.7 %, p = 0.002). In relation to alcohol intake we found that subjects with daily alcohol consumption showed a higher incidence of polyps whe compared to occasional drinkers and teetotallers (32 % vs 20 % vs 18.6 %, p = 0.002) Conclusions: age correlated with higher risk of polyps, HRA and CRC. Moreover, male gender also was associated with a high risk of polyps and HRA. Alcohol and red and processed meat intake increased polyp risk.

Introducción: Introducción: el cáncer colorrectal (CCR) es un tumor muy frecuente en términos de incidencia y mortalidad. Su patogenia se ha relacionado con diversos factores ambientales y hereditarios. Objetivos: analizar la asociación de edad, sexo y factores dietéticos con el diagnóstico de adenomas y CCR. Métodos: se realizó un estudio descriptivo prospectivo con los pacientes del Área Sanitaria de León que se sometieron a una colonoscopia ambulatoria entre 09/09/2012 y 30/06/2013. Mediante un formulario autoadministrado se recogieron datos sociodemográficos, tóxicos y dietéticos usando un cuestionario alimentario de frecuencia semicuantitativo. Se analizaron las diferencias en el diagnóstico según los datos sociodemográficos e higiénico-dietéticos, con análisis multivariante mediante regresión logística por pasos hacia delante. Resultados: se recogieron datos de 1390 pacientes cuya edad media fue de 57 (15) años; de ellos, el 47,8 % eran varones. Se diagnosticaron CCR en el 5 % de los pacientes y pólipos en el 20,4 % (9,4 % de adenomas de alto riesgo (AAR)). El hallazgo de pólipos y AAR fue más frecuente en los varones (26,9 % vs. 14,5 % y 12,6 % vs. 6,3 %, respectivamente (p < 0,001)). La edad media fue significativamente superior en los pacientes que presentaban pólipos (56.51 (15.45) vs. 63.22 (12.69) años; p < 0,001). En la población que refirió un consumo diario de carnes procesadas se duplicaba la proporción de pólipos detectados (2,9 % vs. 6,7 %; p = 0,02). Aquellos pacientes que consumían alcohol diariamente tenían mayor incidencia de pólipos frente al consumo ocasional y los abstemios (32 % vs. 20 % vs. 18,6 %; p = 0,002). Conclusiones: la edad se relacionaba con un mayor riesgo de pólipos, AAR y CCR. Los varones también tenían más riesgo de pólipos y AAR. El consumo de alcohol, carnes rojas y procesadas incrementaba el riesgo de pólipos.

Oportunistic diagnosis based on age and hepatitis C virus clearance: an essential step to improve the overall health of the liver.

Back in January 2022, an EASL-Lancet Commission on the impact of liver disorders in the European region commissioned by the WHO demonstrated that this condition is, actually, the second leading cause of loss of labor years in Europe after ischemic heart disease (1). This is a very relevant piece of information since this is something that is going to impact the new generations of Europeans unless a significant change is made in public health policies. Despite the advances made over the last few years in hepatitis C virus clearance-understood as a significant reduction of morbidity and mortality associated with Hepatitis B and C viruses-there are still challenges ahead to improve liver health due to the high use of alcohol, and the inseparable triad obesity / diabetes mellitus / metabolic associated fatty liver disease. Also, access to healthcare for several population groups at risk of presenting higher rates of liver disease has become a problem.

Cribado de infección por virus de la hepatitis B y C en pacientes hospitalizados con infección por SARS-CoV-2 / Hepatitis B and C screening in hospitalized patients with SARS-CoV-2 infection

Objetivo: Evaluar el resultado del cribado de hepatitis B y C en pacientes ingresados con COVID-19.Pacientes y métodos: Estudio transversal, prospectivo, realizado en dos hospitales españoles de tercer nivel. Se estudiaron marcadores de hepatitis B (HBsAg, anti-HBc) y C (anti-VHC, ARN VHC) a todos los pacientes hospitalizados con COVID-19 del 1 de marzo al 31 de diciembre de 2020.Resultados: En este periodo ingresaron 4662 pacientes con COVID-19: 56,3% fueron varones, la edad mediana fue 76 (0-104) años. Se realizó serología de hepatitis B a 2915 (62,5%) pacientes; 253 (8,75%) presentaban anti-HBc+y 11 (0,38%) HBsAg+. De los 11 pacientes, 4 desconocían el diagnóstico, 7 recibieron esteroides y uno recibió profilaxis. Hubo un caso de reactivación del VHB. Se determinaron anticuerpos anti-VHC a 2895 (62%) pacientes; 24 (0,83%) fueron positivos. De ellos, 13 pacientes estaban diagnosticados: 10 habían recibido tratamiento, uno se había curado espontáneamente y dos no habían sido tratados. De los 11 restantes, 10 tenían ARN VHC indetectable. En total, solo 3 (0,10%) pacientes tenían carga viral detectable. Sin embargo, ninguno recibió tratamiento (2> 90 años con comorbilidades, uno falleció por COVID-19).Conclusiones: El cribado de hepatitis C en pacientes ingresados por COVID-19 en nuestro medio ha mostrado menor utilidad de la esperada. La baja prevalencia de infección activa tras los tratamientos antivirales y la alta edad mediana de nuestra población limitan la detección de potenciales candidatos a tratamiento. El cribado de hepatitis B debería dirigirse a prevenir la reactivación en pacientes que precisen tratamientos inmunosupresores.(AU)

Aims: To evaluate the results of a hepatitis B and C screening program in hospitalized COVID-19 patients.Method: Transversal prospective study conducted in two Spanish hospitals. Patients admitted from March 1st to December 31st 2020 with a diagnosis of COVID-19 were tested for markers of hepatitis B (HBsAg, anti-HBc) and C (anti-HCV, HCV RNA) infection.Results: In this period, 4662 patients with COVID-19 were admitted to our centers: 56.3% were male, median age was 76 (0–104) years. Data regarding HBV infection was available in 2915 (62.5%) patients; 253 (8.75%) were anti-HBc+ and 11 (0.38%) HBsAg+. From these, 4 patients did not have a previous diagnosis of hepatitis B, 7 received corticosteroids and one received prophylaxis. There was one HBV reactivation. Anti-HCV was available in 2895 (62%) patients; 24 (0.83%) were positive. From these, 13 patients had a previous hepatitis C diagnosis: 10 patients had been treated with SVR, one achieved spontaneous cure and 2 did not receive treatment. From the 11 previously unknown anti-VHC+patients, 10 had a negative HCV RNA. Overall, only 3 (0.10%) patients tested RNA HCV+. However, none received HCV treatment (2 older than 90 years with comorbidities, 1 died from COVID-19).Conclusion: Screening of hepatitis C infection in hospitalized COVID-19 patients seems less useful than expected. The low prevalence of active infection after antiviral treatments and the high age of our population limit the detection of potential candidates for treatment. HBV screening should be aimed to prevent reactivation under immunosuppressive treatments.(AU)

Misplacement of the PEG tube through the transverse colon, an uncommon but possible complication.

Misplacement of the Percutaneous Endoscopic Gastrostomy (PEG) tube through the transverse colon mainly by traction is an uncommon complication probably due to inadvertent puncture of colon during PEG placement, resulting in gastrocolocutaneous fistula. Stool drainage through the stoma is usually the only symptom. We report a 52-year-old male with Wernicke-Korsakoff syndrome and PEG tube placement 7 months earlier and replacement one month ago. Due to stool drainage through the stoma was observed, he was performed a computed tomography (CT) in which PEG tube was visualized lodged in transverse colon without pneumoperitoneum associated. Due to important morbility, endoscopic management was decided. Balloon was removed through cutaneous orifice and Ovesco clip was placed simultaneously, achieving a complete closure of wall defect. Although spontaneous closure of the fistula usually happens, surgery is sometimes required, with endoscopic treatment being a less invasive and effective alternative to solve this complication.

Gastrointestinal lymphoma, a rare endoscopic lesion.

We present the case of a 77-year-old male patient with iron deficiency anemia. His personal medical history is: dyslipidemia, high-grade diffuse centrofollicular lymphoma localized in the tonsil in 1984 and metastatic prostate cancer treated with hormone therapy.

Hepatitis B and C screening in hospitalized patients with SARS-CoV-2 infection. / Cribado de infección por virus de la hepatitis B y C en pacientes hospitalizados con infección por SARS-CoV-2.

AIMS: To evaluate the results of a hepatitis B and C screening program in hospitalized COVID-19 patients. METHOD: Transversal prospective study conducted in two Spanish hospitals. Patients admitted from March 1st to December 31st 2020 with a diagnosis of COVID-19 were tested for markers of hepatitis B (HBsAg, anti-HBc) and C (anti-HCV, HCV RNA) infection. RESULTS: In this period, 4662 patients with COVID-19 were admitted to our centers: 56.3% were male, median age was 76 (0-104) years. Data regarding HBV infection was available in 2915 (62.5%) patients; 253 (8.75%) were anti-HBc+ and 11 (0.38%) HBsAg+. From these, 4 patients did not have a previous diagnosis of hepatitis B, 7 received corticosteroids and one received prophylaxis. There was one HBV reactivation. Anti-HCV was available in 2895 (62%) patients; 24 (0.83%) were positive. From these, 13 patients had a previous hepatitis C diagnosis: 10 patients had been treated with SVR, one achieved spontaneous cure and 2 did not receive treatment. From the 11 previously unknown anti-VHC+patients, 10 had a negative HCV RNA. Overall, only 3 (0.10%) patients tested RNA HCV+. However, none received HCV treatment (2 older than 90 years with comorbidities, 1 died from COVID-19). CONCLUSION: Screening of hepatitis C infection in hospitalized COVID-19 patients seems less useful than expected. The low prevalence of active infection after antiviral treatments and the high age of our population limit the detection of potential candidates for treatment. HBV screening should be aimed to prevent reactivation under immunosuppressive treatments.

Gran úlcera rectal secundaria a fotocoagulación con argón plasma en paciente con proctitis actínica / No disponible

No disponible

A huge rectal ulcer due to argon plasma coagulation in a patient with radiation proctitis.

Radiation proctitis (RP) is a complication of radiotherapy in patients with pelvic cancer. A 64-year-old male underwent brachytherapy 2 years previously due to prostate cancer. Subsequently, he developed RP which was treated with argon plasma coagulation (APC). He was subsequently hospitalized due to rectal bleeding and underwent a colonoscopy. A large deep ulcer was seen in the anterior rectum wall, in the same place where APC was performed 3 months earlier. A perforated rectal ulcer was seen via pelvic MRI. However, it was contained by the mesorrectum. Rectal ulcers after APC are uncommon, but they can develop as a result of thermal damage to an ischemic mucosa due to radiotherapy. The treatment of choice of large ulcers is surgery, with a temporary colostomy in order to aid re-epithelialization.