Nódulos necrobióticos pulmonares: una manifestación excepcional de la enfermedad de Crohn / Pulmonary Necrobiotic Nodules: A Rare Manifestation of Crohn's Disease

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[Gastrointestinal bleeding and acute hepatic failure by leptospirosis: an entity that should not be forgotten]. / Hemorragia digestiva e insuficiencia hepática aguda por leptospirosis: una entidad que no debemos olvidar.

Leptospirosis disease is caused by the spirochete Leptospira. It is a worldwide distribution zoonosis, with predominance in the tropics. In Spain, it is not frequent but some cases have been noticed especially in humid areas surrounded by rivers, lakes or ponds, such as Catalonia, Andalucia or the Valencian Community. It is transmitted by a variety of animals such as cows or rats, that are infected either by direct contact with these animals or their urine, or indirectly by consuming or being in contact with water contaminated by their urine. The clinical manifestations are very variable, being asymptomatic or not very symptomatic in most of the patients. Unusually, leptospirosis presents with a first phase with fever, myalgias, liver injury or different organs hemorrhage, followed by a second phase with the presence of jaundice due to hepatic failure. Weil's disease is a kind of severe leptospirosis characterized by hepatic failure with jaundice and acute renal failure, associated with high mortality rates.The diagnosis is based on serological techniques and DNA detection by PCR. The treatment consists of life support measures and antibiotic therapy. A patient with Weil's disease and leptospirosis digestive bleeding is presented, with a fulminant clinical course. In order to achieve an early diagnosis, the need to keep this entity in mind must be emphasized, especially in favorable epidemiological environments as the one of this patient.

Hemorragia digestiva e insuficiencia hepática aguda por leptospirosis: una entidad que no debemos olvidar / Gastrointestinal bleeding and acute hepatic failure by leptospirosis: an entity that should not be forgotten

La leptospirosis es una enfermedad causada por la espiroqueta Leptospira. Se trata de una zoonosis de distribución mundial, con predominio en los trópicos. En España no es frecuente pero sí se observan casos en zonas más húmedas o con presencia de ríos, lagos o estanques, como son Cataluña, Andalucía o la Comunidad Valenciana, donde se relaciona con los arrozales. Los transmisores son múltiples animales como vacas o ratas, contagiándose el ser humano mediante contacto directo con estos animales o su orina, o bien de forma indirecta al consumir o estar en contacto con agua contaminada por la orina de éstos. Las manifestaciones clínicas son muy variables, siendo asintomática o poco sintomática en la mayoría de los pacientes. Aunque no ocurre siempre, la leptospirosis cursa con una primera fase con fiebre, mialgias, afectación renal o hemorragia de distintos órganos, seguida de una segunda fase con presencia de ictericia por afectación hepática. La enfermedad de Weil es una forma de leptospirosis grave caracterizada por afectación hepática con ictericia e insuficiencia renal aguda, asociada a una considerable mortalidad. El diagnóstico se basa en técnicas serológicas y detección de DNA mediante PCR. El tratamiento consta de medidas de soporte y antibioticoterapia. Presentamos un paciente con enfermedad de Weil y hemorragia digestiva por leptospirosis, con una evolución clínica fulminante, y hacemos hincapié en la necesidad de tener presente esta entidad, especialmente en ambientes epidemiológicos favorables como el de este paciente, con el fin de lograr un diagnóstico precoz.

Leptospirosis disease is caused by the spirochete Leptospira. It is a worldwide distribution zoonosis, with predominance in the tropics. In Spain, it is not frequent but some cases have been noticed especially in humid areas surrounded by rivers, lakes or ponds, such as Catalonia, Andalucia or the Valencian Community. It is transmitted by a variety of animals such as cows or rats, that are infected either by direct contact with these animals or their urine, or indirectly by consuming or being in contact with water contaminated by their urine. The clinical manifestations are very variable, being asymptomatic or not very symptomatic in most of the patients. Unusually, leptospirosis presents with a first phase with fever, myalgias, liver injury or different organs hemorrhage, followed by a second phase with the presence of jaundice due to hepatic failure. Weil's disease is a kind of severe leptospirosis characterized by hepatic failure with jaundice and acute renal failure, associated with high mortality rates. The diagnosis is based on serological techniques and DNA detection by PCR. The treatment consists of life support measures and antibiotic therapy. A patient with Weil's disease and leptospirosis digestive bleeding is presented, with a fulminant clinical course. In order to achieve an early diagnosis, the need to keep this entity in mind must be emphasized, especially in favorable epidemiological environments as the one of this patient.

Current role of capsule endoscopy in Crohn's disease.

Capsule endoscopy (CE) currently plays an important role in Crohn's disease (CD). It is a noninvasive technique that has led to a breakthrough in the endoscopic diagnosis of diseases of the small intestine. Its superior diagnostic performance and excellent safety profile lead to its considerable acceptance on the part of the patient. This paper reviews current indications of CE in three stages of clinical practice: Suspected CD, unclassified colitis and its extensive role in diagnosed CD. The diagnostic and therapeutic impact of the results of CE on the monitoring of this disease is also reviewed. Knowledge of its applications, the interpretation of its results in an appropriate context and the existence of a validated endoscopic activity index could change the way in which these patients are managed. The definition of mucosal healing and postoperative recurrence by means of endoscopic scoring systems will endow CE with new applications in the management of CD in the near future.

Pseudoaneurisma asociado a pseudoquiste pancreático complicado / Pseudoaneurysm associated with complicated pancreatic pseudocysts

El pseudoaneurisma asociado a pseudoquiste es una complicación grave e infrecuente de la pancreatitis crónica. Su tratamiento es complejo por su elevada mortalidad y la necesidad de un manejo multidisciplinar. La medida inicial consiste en la localización de la hemorragia mediante tomografía computarizada dinámica y arteriografía. El tratamiento de elección es controvertido por la ausencia de estudios controlados. Para el manejo de la hemorragia en pacientes estables, la medida terapéutica inicial más aceptada actualmente es la embolización arterial. Ante fracaso de la misma, inestabilidad hemodinámica o imposibilidad de drenaje del pseudoquiste la cirugía es la siguiente opción terapéutica (AU)

A pseudoaneurysm associated with a pseudocyst is a serious and unusual complication of chronic pancreatitis. Its treatment is complex due to its elevated mortality and the need for multidisciplinary management. Initial measures consist in locating the hemorrhage through computerized dynamic tomography and arteriography. The treatment of choice is controversial due to the lack of controlled studies. For managing hemorrhages in stable patients, the most accepted initial measure currently is arterial embolization. In the event of failure of the same, hemodynamic instability or the impossibility of drainage of the pseudocyst, surgery is the subsequent therapeutic option(AU)

[Duodenal adenocarcinoma: a rare diagnosis]. / Adenocarcinoma duodenal: un diagnóstico poco frecuente.

Duodenal adenocarcinoma is a rare disease whose symptoms are usually vomit, weight loss and lack of appetite; appearing more frequently in men in their sixties. Upper gastrointestinal endoscopy is the technique chosen for its diagnosis, also relying on other techniques such as endoscopic ultrasonography or computed tomography for the extension study. In this regard we report the case of a patient diagnosed of bulbar duodenal adenocarcinoma in our hospital.

Adenocarcinoma duodenal: un diagnóstico poco frecuente / Duodenal adenocarcinoma: a rare diagnosis

El adenocarcinoma duodenal es una entidad poco prevalente que suele cursar con clínica de vómitos, pérdida de peso e hiporexia; presentándose más frecuentemente en varones en la sexta década de la vida. La endoscopia digestiva alta supone la técnica de elección para el diagnóstico, siendo útiles para el estudio de extensión tanto la ecoendoscopia como la tomografía computarizada (TC). En relación a esta rara patología presentamos el caso de un paciente diagnosticado de neoplasia de bulbo duodenal en nuestro centro...

Duodenal adenocarcinoma is a rare disease whose symptoms are usually vomit, weight loss and lack of appetite; appearing more frequently in men in their sixties. Upper gastrointestinal endoscopy is the technique chosen for its diagnosis, also relying on other techniques such as endoscopic ultrasonography or computed tomography for the extension study. In this regard we report the case of a patient diagnosed of bulbar duodenal adenocarcinoma in our hospital...

Pseudoaneurysm associated with complicated pancreatic pseudocysts.

A pseudoaneurysm associated with a pseudocyst is a serious and unusual complication of chronic pancreatitis. Its treatment is complex due to its elevated mortality and the need for multidisciplinary management. Initial measures consist in locating the hemorrhage through computerized dynamic tomography and arteriography. The treatment of choice is controversial due to the lack of controlled studies. For managing hemorrhages in stable patients, the most accepted initial measure currently is arterial embolization. In the event of failure of the same, hemodynamic instability or the impossibility of drainage of the pseudocyst, surgery is the subsequent therapeutic option.

Esprúe colágeno: ¿entidad secundaria o independiente de la enfermedad celíaca? / Collagenous sprue: secondary or independent from celiac disease?

El esprúe colágeno es una entidad poco prevalente que cursa con diarrea persistente con pérdida de peso y malabsorción por afectación del intestino delgado, principalmente duodeno y yeyuno proximal, necesitando para el diagnóstico la presencia de una clínica y una histología compatible con atrofia y depósito subepitelial de colágeno. Su etiología no es totalmente conocida, aunque su origen más propuesto es el autoinmune, ya que está ampliamente relacionada con la enfermedad celíaca e incluso se ha propuesto que se trate de una evolución de celiaquía refractaria a dieta sin gluten. En relación a esta incertidumbre presentamos el caso de una paciente con diarrea malabsortiva e importante repercusión clínica por esprúe colágeno, la cual tuvo una buena respuesta a corticoides orales (prednisona), pero hubo que añadir azatioprina. Además mejoró inicialmente con nutrición parenteral central domiciliaria...

Collagenous sprue is a rare disease that goes with persistent diarrhea, weight loss and bad absortion, because it affects the small intestine, mainly duodenum and proximal jejunum. Diagnosis is made by having clinical signs and histological proof of atrophy and subepitelial deposit of collagenous material. Its etiology is not known completely, it is proposed that the origin is autoimmune because its relationship with celiac disease. Also there is a proposal that is a celiac evolution to gluten free diet. Is because this is not clear that we present a case of a patient with bad absorptive diarrhea and a clinical expression of collagenous sprue, that had a great clinical response to corticosteroids (prednisone) but we had to add azatioprine. Also, initially improved with home parenteral nutrition center...

[Collagenous sprue: secondary or independent from celiac disease?]. / Esprúe colágeno: ¿entidad secundaria o independiente de la enfermedad celíaca?

Collagenous sprue is a rare disease that goes with persistent diarrhea, weight loss and bad absortion, because it affects the small intestine, mainly duodenum and proximal jejunum. Diagnosis is made by having clinical signs and histological proof of atrophy and subepitelial deposit of collagenous material. Its etiology is not known completely, it is proposed that the origin is autoimmune because its relationship with celiac disease. Also there is a proposal that is a celiac evolution to gluten free diet. Is because this is not clear that we present a case of a patient with bad absorptive diarrhea and a clinical expression of collagenous sprue, that had a great clinical response to corticosteroids with home parenteral nutrition center.