Endoscopia digestiva en la ingesta de cáusticos / Digestive tract endoscopy in caustic ingestion

La ingesta de productos cáusticos, ácidos o bases, puede producir lesiones digestivas altas, que pueden ir desde el edema y la hiperemia hasta úlceras profundas y extensas áreas de necrosis, con riesgo vital para el paciente. La endoscopia digestiva permite confirmar o descartar la presencia de estas lesiones, clasificarlas en caso de que estén presentes, establecer un pronóstico y contribuir a definir las medidas terapéuticas a aplicar, y sólo está contraindicada cuando se sospecha que hay una perforación digestiva o que ésta podría producirse al practicar esta exploración

The ingestion of caustics, both acids and alkalis, can cause upper gastrointestinal tract lesions ranging from oedema and hyperaemia to life-threatening deep ulcerations and extensive areas of necrosis. Digestive tract endoscopy may confirm or rule out the presence of such lesions, classify them when present, establish a prognosis and contribute to defining the therapeutic intervention. Endoscopy is only contraindicated when viscus perforation is suspected, or when a viscus perforation may occur when carrying out procedure

Endoscopic findings in a biennial follow-up program in patients with pernicious anemia.

BACKGROUND/AIMS: It is known that patients with pernicious anemia have a higher risk of gastric neoplasms. However, the optimal endoscopic follow-up in these patients has not been properly defined. This study was aimed to assess the usefulness of an endoscopic follow-up program. METHODOLOGY: We analyzed the endoscopic and histological findings of the first endoscopy performed in a group of 128 patients with the diagnosis of pernicious anemia who were referred to the Endoscopic Unit, and we evaluated the results of the biannual follow-up endoscopies made to 68 of them. RESULTS: The initial endoscopy did not provide evidence of any lesions in 107 patients (83.5%), and polypoid lesions were found in 12 cases (9.4%). The histological results showed gastric dysplasia in 3 patients (2.3%) and carcinoid tumor in 2 cases (1.6%). No cases of gastric carcinoma were found. During the endoscopic follow-up of 68 patients, in 52 of them (76.8%) there were no endoscopic findings, and raised lesions were detected in 8 patients (11.8%). Three cases of gastric dysplasia were found. No cases of gastric carcinoma or carcinoid were detected during the follow-up. CONCLUSIONS: We suggest that a biannual endoscopic follow-up in not useful for the early detection of gastric neoplasms in patients with pernicious anemia.

Sphincterotomy in the treatment of biliary leakage.

BACKGROUND/AIMS: Endoscopic procedures such as sphincterotomy and endobiliary stenting have proved useful to solve postoperative bile leakage. We have assessed the outcome of a series of such patients initially treated with endoscopic sphincterotomy, having reserved stent placement for treatment failures only. METHODOLOGY: Twenty-five consecutive patients referred for endoscopic assessment of postoperative bile leaks and fistulas after cholecystectomy (n = 15), orthotopic liver transplantation (n = 9) and hepatic resection due to cystic hydatid disease (n = 1) underwent endoscopic retrograde cholangiopancreatography and sphincterotomy using a standard papillotome. Sphincterotomy was followed by stone extraction using a Dormia basket if common bile duct lithiasis were present. RESULTS: Bile leaks healed early after endoscopic sphincterotomy in 22 out of 25 patients (88%). Common bile duct stones were also retrieved in 6 of these patients. Bile duct stenosis due to surrounding pancreatic inflammation was demonstrated in two of the patients in which sphincterotomy failed to stop bile leakage. CONCLUSIONS: Endoscopic sphincterotomy alone should at present be considered a highly effective treatment to resolve postsurgical bile leaks unless bile strictures are present.

Prospective assessment of the risk of bacteremia in cirrhotic patients undergoing lower intestinal endoscopy.

BACKGROUND: Patients who have prosthetic heart valves, previous history of endocarditis, and surgically constructed systemic-pulmonary shunts or conduits should receive prophylactic antibiotics before colonoscopy. The usefulness of this approach in cirrhotic patients remains unknown. The present study prospectively assesses the incidence of bacteremia in these patients. METHODS: Lower intestinal endoscopy was performed in 58 cirrhotic patients. Two blood samples were obtained from every patient (just before endoscopy and within 5 minutes of withdrawal of the endoscope) and were incubated for 7 days and examined daily for growth of bacteria. Patients were closely monitored for 72 hours after endoscopy to detect the development of infectious complications. RESULTS: Only 6 cultures from 6 patients were positive. Four were obtained post-endoscopy and the remaining 2 before colonoscopy but the corresponding post-endoscopy samples were negative. All organisms recovered were normal skin flora. All patients, including those with positive cultures, remained asymptomatic during the 72 hours after the procedure. CONCLUSIONS: Our findings indicate that lower intestinal endoscopy does not induce bacteremia in cirrhotic patients with or without ascites in the absence of gastrointestinal bleeding and do not support the routine use of prophylactic antibiotics in these patients.

[Endoscopic ultrasonography in the staging of esophageal cancer. Therapeutic implications]. / Ultrasonografía endoscópica y estudio de extensión del carcinoma de esófago. Implicaciones terapéuticas.

Endoscopic ultrasonography (EUS) provides accurate visualization of the different layers of the gastrointestinal wall and surrounding structures, allowing TN staging of tumors prior surgery. The aim of this study was to evaluate the sensitivity, specificity and accuracy of EUS in the staging of esophageal carcinoma as well as its applicability and usefulness in tumors with nontraversable stenoses. EUS was performed in 43 patients with esophageal carcinoma. The technique was carried out with a radial echoendoscope under sedation with i.v. midazolam. Both, the infiltration of the tumor through the layers of the esophageal wall (T staging) and the presence of lymph nodes in different areas (N and M staging) were determined. In cases with nontraversable stenoses, only the proximal tumor margin was assessed by means of EUS. EUS showed T1 stage in only one case and more advanced stages in the remaining patients: T2 (n = 12), T3 (n = 22) and T4 (n = 4). We know the outcome of 28 patients, 14 of whom underwent surgery. In these patients, the sensitivity for T and N staging was 86% and 92% respectively, and the accuracy 86% in both. Both, T and N, were overstaged in one case (7%) and understaged in another (7%). The tumor caused nontraversable stenoses in 59% of patients (n = 26). In 4 patients the staging could not be assessed with sufficient reliability. In the subgroup of patients with nontraversable stenoses who underwent surgery, the accuracy of EUS when comparing with histopathology was 80%. Endoscopic ultrasonography has a high sensitivity and accuracy in the staging of esophageal tumors even in cases with nontraversable stenoses.

Usefulness of laparoscopy with liver biopsy in the assessment of liver involvement at diagnosis of Hodgkin's and non-Hodgkin's lymphomas.

BACKGROUND: Staging of lymphoma at diagnosis determines therapeutic strategy and disease prognosis. Hepatic involvement, demonstrated by laparotomy or laparoscopy, is frequent in Hodgkin's and non-Hodgkin's lymphoma. However, it is unclear whether these procedures are still necessary or whether they should be replaced by less invasive techniques. METHODS: Laparoscopy-assisted liver biopsies, as well as laboratory studies, bone marrow biopsy, and thoracic and abdominal computed tomography, were performed as an initial staging evaluation in 112 consecutive patients who were diagnosed with Hodgkin's or non-Hodgkin's lymphoma. RESULTS: Hepatic lymphomatous involvement was demonstrated in 18 patients (16%). It was more frequent in non-Hodgkin's (24%) than in Hodgkin's (8%) lymphomas (p < 0.04) and among stage III and IV (24%) than stage I and 11 (10%) patients (p < 0.05). The laparoscopic finding of white spots or nodules on the liver surface had a 100% specificity in the diagnosis of lymphomatous liver involvement. Conversely, hepatomegaly on both laparoscopy and computed tomography, as well as laboratory studies, had a low sensitivity and specificity. CONCLUSIONS: Laparoscopy-assisted liver biopsy was a useful technique to establish hepatic lymphomatous involvement, which was not identified by either computed tomography or laboratory studies.

Injection treatment of hemorrhage induced by endoscopic sphincterotomy.

BACKGROUND AND STUDY AIMS: Hemorrhage is one of the most common severe complications after endoscopic sphincterotomy (ES) and the mortality after surgical treatment can be as high as 50%. We prospectively evaluated the effect of injection treatment in nine patients with appreciable hemorrhage after ES. PATIENTS AND METHODS: Bleeding was detected immediately after ES in five patients and 48, 72, 120 and 216 hours after the procedure in the remaining four. Patients were treated with a combined injection of epinephrine and polidocanol (1-3 and 3-6 ml, respectively) into the bleeding site. RESULTS: Treatment was effective in arresting hemorrhage in all cases. Two patients had abnormal clotting tests, which emphasizes the importance of identifying risk factors for hemorrhage before ES. No patient required operation and there were no late complications related to the injection during a mean follow-up period of six months. CONCLUSIONS: Our results suggest that bleeding after sphincterotomy can be safely and effectively controlled by a combined epinephrine and polidocanol injection, thereby avoiding operation.

Effects of bolus somatostatin in preventing pancreatitis after endoscopic pancreatography: results of a randomized study.

BACKGROUND: Pancreatitis is a potential problem in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Natural somatostatin reduces pancreatic secretion and has been administered in acute pancreatitis. To establish whether an injection of a single "bolus" of natural somatostatin is useful in preventing pancreatic reactions after endoscopic pancreatography, a randomized study was carried out in 160 patients undergoing pancreatography, associated or not, with endoscopic sphincterotomy. METHODS: Pancreatitis was considered to be present when there was the simultaneous appearance of serum amylase above 600 IU/mL and serum lipase above 200 IU, upper abdominal pain with tenderness, nausea and/or vomiting, and associated ileus, not completely resolved within 18 hours after the procedure and prolonging hospital stay. RESULTS: The incidence of pancreatitis (10% vs. 2.5%, p < 0.05) was higher in the placebo group than in the somatostatin-treated group. The difference in frequency of pancreatitis was statistically significant (18% vs 0%, p < 0.05) in the ERCP plus sphincterotomy subgroup but not significant (6% versus 4%) in the ERCP subgroup. CONCLUSIONS: These results suggest that the administration of a single bolus injection of natural somatostatin just before cannulation of the papilla may be useful in preventing pancreatitis. This procedure is useful in patients undergoing sphincterotomy. Further studies should be performed to determine whether this drug is useful in cases in which cannulation of the papilla is difficult or when therapeutic procedures require prolonged and/or aggressive manipulation of the papilla.

Endoscopic sclerotherapy to arrest uncontrolled variceal bleeding in cirrhotic patients with high surgical risk.

BACKGROUND/AIMS: In 20-50% of patients bleeding from esophageal varices, conservative procedures fail to obtain hemostasis and prevent early recurrence. METHODOLOGY: We retrospectively analyzed the efficacy and safety of endoscopic sclerotherapy in 66 cirrhotic patients with high surgical risk and persistence or recurrence of variceal bleeding in spite of adequate medical treatment (somatostatin and/or balloon tamponade). RESULTS: Emergency sclerosis controlled bleeding in 46 out of 66 patients (70%). The remaining 20 patients underwent additional procedures to arrest the hemorrhage, and 6 died because of massive bleeding. Early rebleeding occurred in 5 patients (10%). The mortality within 2 days, 1 week, and 6 weeks was 9%, 17% and 32%, respectively. Death was attributed to hemorrhage in 9 cases. Sclerotherapy was associated with complications in 9 patients (14%). CONCLUSION: These results suggest that emergency sclerotherapy is a safe and effective procedure in cirrhotic patients with high surgical risk and persistence or recurrence of bleeding after conservative hemostatic procedures.

[Mechanical lithotripsy during retrograde cholangiography in choledocholithiasis untreatable by conventional endoscopic sphincterotomy]. / La litotricia mecánica durante la colangiografía retrógrada en la litiasis coledocal no tratable con esfinterotomía endoscópica convencional.

Endoscopic papillotomy followed by the removal of stones with the Dormia basket is the treatment of choice in residual choledocolithiasis after cholecystectomy and in choledocolithiasis in patients with a high surgical risk. Nonetheless, the size of the stones may, occasionally, impede removal by this procedure. Mechanical lithotripsy may resolve this clinical situation. The authors present the results of this technique in 40 consecutive patients in whom the elimination of the stones was not possible by conventional methods and thus mechanical lithotripsy was performed. This procedure was found to be effective in 32 out of 40 patients (80%). In 22 cases (55%) lithotripsy was effective in one session performed during the first ERCP, 8 (20%) required two procedures and in 2 (5%) three sessions were necessary. In 9 cases the stones were spontaneously eliminated with lavage using physiologic serum or diluted contrast, in 6 the stones were extracted by lithotripsy, in 16 they were eliminated by a conventional Dormia basket and in the remaining case the Fogarty balloon was used. Lithotripsy could not be carried out in 8 out of the 40 patients (20%) due to inability to pick the stone up in 7 cases and because of the impossibility of breaking the stone up with the lithotripsy basket in the remaining case. No complications directly related to lithotripsy were observed. In conclusion, mechanical lithotripsy in an effective and safe therapeutic alternative in large size choledocolithiasis and can be performed during endoscopy.

[Pathology of the retina in patients with AIDS]. / Patología de la retina en pacientes con SIDA.

Changes in the fundus oculi are usually seen in patients with well-defined clinical features of the acquired immunodeficiency syndrome (AIDS). The commonest pathology of the retina, seen in 40-75% of the patients with advanced AIDS, is known as 'the microvascular complex of the retina associated with AIDS', and is characterized by the presence of cotton-wool exudates and retinal haemorrhages. Many of these lesions are casual findings on examination of the fundus oculi. Cytomegalic (CMV) retinitis appears in 20-30% of AIDS patients, and diagnosis is important so that treatment with foscarnet or ganciclovir may be started early to conserve vision. Occasionally necrotizing retinitis appears due to the varicella zoster virus, following the typical skin condition. There is little response to acyclovir treatment. Retinitis due to toxoplasma is much less common than cerebral toxoplasmosis. The retinal lesions are predominantly neuritic and respond well to treatment with antitoxoplasma. Other rarer causes of ocular disorders in AIDS are syphilis, tuberculosis, cryptococcus and lymphoma.

A prospective randomized trial of heater probe thermocoagulation versus injection therapy in peptic ulcer hemorrhage.

BACKGROUND: A prospective, randomized study was performed to compare the hemostatic effect of injection therapy and heater probe thermocoagulation in the treatment of peptic ulcer bleeding. METHODS: This study includes 104 patients with upper gastrointestinal bleeding in whom endoscopy revealed a gastric or duodenal ulcer with nonbleeding or bleeding vessel (n = 66), oozing hemorrhage (n = 21), or adherent red clot (n = 17). Patients with other stigmata or clean ulcers were excluded. Patients were randomly assigned during endoscopy to receive injection therapy (adrenaline and polidocanol) (n = 51) or heater probe thermocoagulation (10F probe, at setting of 30 J (n = 53). Therapy was considered successful if there was no further hemorrhage or only minor rebleeding that was controlled with a second endoscopic procedure. Patients with major rebleeding or failure of retreatment underwent emergency surgery. RESULTS: There were no significant differences in effectiveness between injection therapy and thermocoagulation in any of the assessed parameters: the percentage of patients with major recurrent hemorrhage (4% vs 6%) or minor rebleeding (16% vs 17%), need for emergency surgery (two patients from each group), transfusion requirement (0.45 +/- 0.9 units vs 0.51 +/- 1.1 units), the mean number of hospitalization days (7.1 +/- 4.2 vs 6.9 +/- 4.9), and mortality (one patient from each group died). CONCLUSION: Injection therapy and heater probe have similar efficacies in the treatment of bleeding peptic ulcers.

Giant cephalhematoma in a 15-year-old boy. Unilateral amaurosis as the main complication.

BACKGROUND: The term "cephalhematoma" is applied to a collection of blood under the periosteum of a skull bone. It most frequently occurs in the neonatal period and is rare at other times of life. METHODS AND RESULTS: We report on a 15-year-old boy with a subperiosteal hematoma involving the whole cranial surface. Surgical drainage was performed. In the immediate postoperative course, the patient developed a progressive decrease in the right eye visual acuity. An orbital computed tomographic scan revealed the retro-orbital subperiosteal extension of the hematoma. A second surgical procedure was necessary to obtain visual recovery. CONCLUSIONS: The occurrence of cephalhematoma in adults is exceptional. However, it may lead to serious complications. Surgical treatment should be aimed to avoid retro-orbital extension of the hematoma.