[Digestive hemorrhage caused by duodenal varices]. / Hemorragia digestiva por varices duodenales.

Duodenal varices are uncommon and are frequently diagnosed late. However, they are a potential cause of massive bleeding, with tendency to relapse. We would like to offer as an example a case diagnosed by means of an endoscopy. A patient without oesophageal varices and with obstruction of the splenic-portal axis and venous calcifications is reported. A diminution in the volume of the duodenal varices with inspiratory movements may help in the differential diagnosis during endoscopy. We emphasize the need of avoiding incorrect maneuvers during endoscopy and the value of ultrasonography and CAT scan to confirm the diagnosis. Sclerotherapy appears to be the best therapeutic approach. Percutaneous embolization and surgery are therapeutic alternatives if sclerosis is not effective. However, in some cases with self-limited bleeding and a low tendency to relapse, as with the patient described herein, a conservative attitude should be selected.

[Zieve's syndrome. A case report]. / Síndrome de Zieve. Descripción de un caso clínico.

We report a case of Zieve's Syndrome that developed after an important alcohol consumption in a 32-yr-old female patient. She was admitted to the hospital with anorexia, asthenia and jaundice. Physical examination showed liver stigmata and hepatomegaly. Laboratory tests demonstrated increased aminotransferase levels, hyperbilirubinemia, hyperlipidemia and normocytic and normochromic anemia with dianocytes in peripheral blood smear. Ultrasonography showed a hyperechoic liver and a liver biopsy showed acute and chronic alcoholic liver disease. Clinical evolution was satisfactory and the therapy consisted of blood transfusion, parenteral fluids, B-complex vitamin and a fatty free diet. Jaundice, hyperlipidemia and haemolytic anemia define Zieve's Syndrome (Z.S.) There is a pathogenetic relationship among the clinical and biological phenomena in this syndrome, whose starter is an acute alcohol intake. Haemolysis is the distinctive feature with respect to the classical acute alcoholic hepatitis, and it is due to erythrocyte's metabolic and osmotic instability in relation to lipids abnormalities. Its clinical resolution precedes the normalization of serum lipids levels. Therapy is similar to that for acute alcoholic hepatitis although sometimes the anemia requires blood transfusion.

Endoscopic stenting in the management of malignant biliary obstruction.

UNLABELLED: A relevant percentage of patients with malignant biliary obstruction are not candidates for surgery when the diagnosis is made. Endoscopically placed biliary stents have shown their efficacy in the palliative management of these patients although they do not seem to increase their survival. We report on a retrospective analysis of 37 patients with malignant biliary obstruction treated with endoscopic biliary stents. The distal third (62%) of the main life duct was the most frequent common location for the obstruction, and pancreatic cancer was the most frequent cause of obstruction (64%). Twenty three plastic (13-7F and 10-10F) and 14 metallic stents were placed initially. Forty four percent of the plastic stents (all of them 7F, none 10F) were removed after 39 days against 30% of the metallic stents after a mean period of 60 days. Global survival was 153 days (110 in the plastic stents' group versus 195 in the metallic one, p: NS). We could only make a complete follow up in 52% of the patients. CONCLUSIONS: endoprotheses are a good palliative treatment for malignant biliary obstruction. When plastic stents are used they should have a wide calibre (10F or greater). Metallic stents result in an increase of survival time without statistical significance.

Endoscopic pancreatic stent drainage improves pain in chronic pancreatitis.

UNLABELLED: Pain in chronic pancreatitis is due to intraglandular neural affection and to pancreatic duct drainage obstruction with an increased intraductal pressure. To achieve pain relief, medical, surgical and endoscopic procedures have been developed. AIM: To evaluate the efficacy of pancreatic duct stenting in patients with narcotic-dependent pain due to chronic pancreatitis. PATIENTS AND METHOD: From May-1994 to May-1996, ten patients (medium age: 47.5 yr) with alcoholic chronic pancreatitis were selected for this procedure. Pancreatography showed single or multiple Wirsung strictures in all cases. Papillotomy and pancreatic duct sphincterotomy were performed before stenting. Strictures were negotiated with a 7F dilating catheter over a guide wire, and intraductal calculi were removed as well. We used 7F plastic stents with variable lengths (5-10 cm), that were exchanged when the patient presented pain recurrence. Stent survival time was defined as the patient's pain-free time. RESULTS: In 6 of the 10 patients stent placement was carried out successfully. A single distal Wirsung stricture was diagnosed in 3 patients while in the remaining 3 there were several strictures associated to ductal lithiasis in two of them. Mean time to achieve pain relief was 3 days and mean stent survival time was 166.5 days. There were no complications due to the procedure. CONCLUSIONS: When placed through the stricture, endoscopic pancreatic stent drainage is effective in achieving pain relief. It is a safe procedure with no complications in our short series.

[A retroperitoneal abscess after endoscopic sphincterotomy: a severe and infrequent complication]. / Absceso retroperitoneal tras esfinterotomía endoscópica: una complicación grave y poco frecuente.

We report the case of a 55-year-old female patient, previously cholecystectomized, who was admitted to the Hospital because of recurrent biliary abdominal pain, cholestasis and common bile duct enlargement by ultrasonography. 48 hours after an endoscopic sphincterotomy the patient developed abdominal pain and fever. CT scan demonstrated air and an infected liquid collection in the retroperitoneum. Although a percutaneous drainage was attempted, the persistence of the symptoms and the low drainage outflow of the infected material made surgical treatment necessary. Duodenal perforation in endoscopic sphincterotomy is an unusual but severe complication that leads to a high mortality rate if surgical treatment is not applied promptly. Sometimes retropneumoperitoneum can be satisfactory solved just with a conservative medical therapy, but if there is a suspected or confirmed infected collection surgical treatment must be applied promptly.

[Pyoderma gangrenosum with an atypical location and a rapid response to cyclosporin A]. / Pioderma gangrenoso de localización atípica y rápida respuesta a la ciclosporina A.

Pyoderma gangrenosum is an unusual neutrophilic dermatosis associated to different rheumatologic, haematologic and inflammatory bowel diseases which generally responds to the therapy of the underlying disease. We report a case of pyoderma in a 44-years-old woman with paucisymptomatic, distal, ulcerative colitis which appeared simultaneously in her forehead and hands. We think it of general interest because of its localization, its importance, the failure of response to steroids and the need of cyclosporine A for regression.

[Isolated jejunal Crohn disease]. / Enfermedad de Crohn yeyunal aislada.

Crohn Disease (CD) is a chronic granulomatous inflammatory disorder of not well known etiology. It may affect the whole digestive tract, segmentally, from the mouth to the anus although the rectum is usually not involved. Digestive symptoms of CD depend on the location and extension of the disease, its fistulating or stenosing evolution as well as the presence of local or systemic complications. 40% of the patients affected with CD have simultaneous terminal ileal and colonic involvement, 30% have terminal ileitis and 25% have granulomatous colitis. Isolated esophageal, gastroduodenal and perianal affection reach no more than 5% of the patients. We describe a case of a patient affected with CD with isolated jejunal involvement who was admitted to the hospital because of iron deficiency anemia and bowel subocclusion as an atypical clinical manifestation of the disease. After surgical resection of the affected segment of the bowel, the patient became asymptomatic up to now.

[Collagenous colitis]. / Colitis colágena.

We present in this article the cases of two women afflicted with aqueous chronic diarrhea with normal analysis, radiology, and endoscopy, but presenting sigmoid biopsy of collagenous colitis. One of them was treated with omeprazol and the other with corticoids. Despite not having found anomalies in the endoscopy, we recommend the practice of rectosigmoid biopsy in all cases of chronic diarrhea.

Íleo biliar en paciente de edad avanzada / No disponible

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Enfermedad por reflujo gastroesofágico: características de los pacientes derivados desde Atención Primaria / Gastroesophageal reflux: characteristic of the patients derived from primary attention

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