Dolor abdominal agudo / Acute abdominal pain

Acute abdominal pain is one of the most frequent causes of medical consultation in emergency urgent care centers. ER doctors must be capable of recognizing those cases requiring medical treatment and those requiring emergency surgery. Clinical history and physical examination are still the basis for diagnosis, and will guide decisions regarding lab tests and more safe and specific imaging. There are diagnosis such as abdominal pain of unknown origin, gastritis and constipation proven to be associated to error, therefore a stricter follow-up is recommended for these cases. Appendicitis still poses a challenge for diagnosis and if there is clinical suspicion, particularly in young patients and/or women in reproductive age, the recommended approach is ultrasound followed by CT scan (pelvis and abdomen), in case the former is not conclusive. There are special conditions for pregnant and elderly patients regarding imaging tests. During pregnancy, ultrasound and MRI are preferred, whereas CT scan is preferred in case of the elderly, except when biliary disease is suspected, in this case ultrasound is the preferred approach.

El dolor abdominal agudo es una de las causas más frecuentes de consulta a los servicios de urgencia. Los médicos de urgencia deben tener presente su amplio diagnóstico diferencial, y ser capaces de distinguir aquellos casos que requieren un manejo médico o quirúrgico de urgencia. La historia clínica y examen físico siguen siendo las armas fundamentales para el diagnóstico, que guiarán el estudio de laboratorio y la selección de imágenes más segura y de mejor sensibilidad y especificidad. Existen diagnósticos como el dolor abdominal no precisado, gastritis y constipación, que han demostrado estar asociados a error, por lo que se sugiere un seguimiento más estricto en estos casos. La apendicitis sigue siendo un desafío diagnóstico y frente a sospecha clínica, especialmente en jóvenes y/o mujeres en edad fértil, el enfrentamiento diagnóstico con imágenes recomendado es el ultrasonido, seguido de la tomografía computarizada (TC) de abdomen y pelvis, si el primero es no concluyente o negativo. La embarazada y el adulto mayor tienen condiciones especiales, y en cuanto a imágenes, se prefiere el ultrasonido y la resonancia magnética en la primera y la TC precoz en el adulto mayor, excepto cuando hay sospecha de patología biliar donde siempre es de elección el ultrasonido.

Colangiopancreatografía retrograda endoscópica (CPRE) precoz y pancreatitis aguda biliar (PAB) / Early endoscopic retrograde cholangiopancreatography (ERCP) and acute biliary pancreatitis (ABP)

For over 20 years we have discussed the indication of early endoscopic retrograde cholangiopancreatography (ERCP) (72 h before the onset of symptoms) in acute biliary pancreatitis (ABP), seeking to stop the inflammatory process, reducing complications and mortality, taking into account that ERCP can cause pancreatitis and other complications such as perforation and hemorrhage. To elucidate this problem, there have been multiple meta-analyses based on the same 3 or 5 randomized controlled trials of early ERCP versus conventional treatment (including elective ERCP) in ABP, which have produced conflicting results. There is agreement regarding that it is not indicated in mild ABP, and it is indicated in ABP associated with cholangitis and persistent obstruction of the ampulla of Vater. There is controversy in severe presentation of ABP, since current evidence does not definitely show the usefulness of early ERCP. No more complications related to ERCP have been reported in this situation.

Desde hace más de 20 años se discute la indicación de la colangiopancreatografía retrógrada endoscópica (CPRE) precoz (antes de 72 h del inicio de los síntomas) en la pancreatitis aguda biliar (PAB), buscando detener el proceso inflamatorio, disminuyendo sus complicaciones y su mortalidad, tomando en cuenta que la CPRE puede ser causa de pancreatitis y otras complicaciones como perforación y hemorragia. Para dilucidar este problema se han realizado múltiples meta-análisis basados en los mismos 3 ó 5 estudios aleatorizados y controlados de CPRE precoz versus el tratamiento convencional (que incluye CPRE electiva) en PAB, los cuales han dado resultados discordantes. En lo que hay acuerdo es en que no está indicada en la PAB leve y sí está indicada en la PAB asociada a colangitis y a obstrucción persistente de la ampolla de Vater. En la PAB de presentación grave hay controversia; la evidencia actual no demuestra en forma definitiva la utilidad de una CPRE precoz. No se ha reportado mayor número de complicaciones relacionadas a la CPRE en esta situación.

Diagnóstico y tratamiento de las várices esófago gástricas en Chile: realidad nacional / Management of bleeding esophageal varices in public and private institutions in Chile

Background: The better treatment modalities for bleeding esophageal varices have improved the prognosis of cirrhosis. Aim: To inquire about diagnostic and treatment modalities for esophageal bleeding in Chile. Material and methods: An enquiry about diagnosis and treatment of esophageal bleeding was designed and electronically sent to public and private health institutions that could admit patients and were located in cides with more than 100,000 inhabitants. Results: The enquiry was answered by 31 of 35 public and 17 of 19 private health institutionis that were consulted. Emergency endoscopy was available in 6 of 27 public and in the 16 private institutionis that had an emergency room. Rubber band ligation was available in 16 public (52 percent) and in all private institutions. Cyanoacrylate injections were done in 10 public (32 percent) and 11 (65 percent) private institutions. No public institution installed transjugular intrahepatic portosystemic shunts, but 8 had occasional access to this technique. This procedure was done in 7 (41 percent) private institutions and all had access to it. Surgical treatment was feasible in 20 public (65 percent) and all private institutions. Primary prophylaxis was done in 18 public (58 percent) and 14 private (82 percent) institutions. Secondary prophylaxis was carried out in 26 public (84 percent) and 16 private (94 percent) institutions. Conclusions: Public health institutions have poor access to adequate diagnostic and treatment methods for esophageal bleeding. The primary and secondary prophylaxis of esophageal varices must be improved in both types of institutions.

Ligadura elástica complementada de esclerosis en el tratamiento de várices esofágicas: experiencia en la hemorragia activa y en el tratamiento electivo / Endoscopic ligation plus sclerotherapy in the treatment of bleeding esophageal varices

Background: Endoscopic ligation is the treatment of choice for bleeding esophageal varices. The usefulness of additional sclerotherapy is not clear. Aim: To assess the effectiveness of ligation followed by sclerotherapy in the treatment of variceal bleeding. Patients and methods: Forty eight patients with variceal bleeding admitted for emergency treatment and 73 patients admitted for elective treatment were studied. Varices were ligated until a significant reduction in size was achieved. Eradication was completed with the injection of 1 per cent polidocanol. Results: In 34 of 48 patients admitted for emergency treatment, the site of variceal rupture was identified. In all these subjects, and in 13 of 14 patients in whom the rupture site was not identified, hemorrhage was stopped with the procedure. Varices were eradicated in 108 of the 121 patients. Hemorrhage recidivated in 12.5 per cent of patients admitted for emergency treatment, in a period of 14 months of follow up and in 9.6 per cent of those admitted for elective treatment, in a period of 16 months follow up. Mortality was 14, 18 and 57 per cent among patients classified as Child Pugh A, B or C, respectively. Conclusions: Endoscopic ligation is effective in the treatment of variceal bleeding. Adding sclerotherapy, variceal eradication is achieved in a high percentage of patients. Survival depends on hepatic function

Hemorragia por várices esofagogástricas: experiencia con cianoacrilato y polidocanol en 68 pacientes con hemorragia activa / Hemorrhage by esophageal gastric varices: experience with cianoacrylate and polidocanol in 68 patients

Background: Sclerosis, injection of cianoacrylate and rubber band ligation are the most commonly used endoscopic techniques for the treatment of bleeding esophageal varices. Aim: To assess the effectiveness of cianoacrylate and polidocanol in the treatment of bleeding esophageal varices. Patients and methods: Sixty eight patients with active variceal bleeding were studied. Bleeding varices were classified as thin, thick or gastric. Bleeding from thin varices was treated with polidocanol. Bleeding from thick or gastric varices was treated with cianoacrylate. Variceal erradication was done with polidocanol. Results: Bleeding came from thin esophageal varices in 23 percent of patients and endoscopic treatment stopped bleeding in 95 percent of them, from thick esophageal varices in 62 percent and endoscopic treatment was successful in 94 percent of these, and from gastric varices in 12 percent and treatment stopped bleeding in 87 percent of these (in 3 percent bleeding was considered subcardial). Twenty five percent of patients bled again during variceal erradication, 12 percent died due to uncontrollable bleeding and 20 percent died due to liver failure. During variceal erradication 59 percent of patients classified as Child Pugh C, died. Conclusions: Treatment of bleeding esophageal varices with cianoacrylate or polidocanol is effective. Patients classified as Child Pugh C have a bad prognosis