Multiple Jejunal diverticulosis complicated by perforation: case report and a brief literature review

Background: Multiple small-bowel diverticulosis comprises a rare entity with probable underestimated incidence, and that may be the reason why it is sometimes overlooked when managing cases with peritonitis. Case report: In the present paper, we report the case of a 76-year-old male presenting abdominal pain and fever in an acute setting. Computed tomography (CT) scans revealed jejunal thickening and numerous images of saccular addition that were interpreted as jejunoileal diverticulitis. After an initial period of clinical treatment, surgical management was indicated based on a worsening clinical picture and the presence of an extraluminal focus of gas detected in a subsequent CT scan. Through a laparoscopic approach, multiple small-bowel diverticula and a tamponade perforation were found. A segmental intestinal resection was performed, and the patient was discharged after a ten days. Conclusions: Multiple jejunal diverticulosis is a rare condition that should be remembered in the setting of an acute abdomen. As it prevails among older patients, early diagnosis with radiological aid is crucial to establish the most adequate management, including intestinal resection, if necessary. (AU)

Divertículos duodenales periampulares y el fallo técnico-terapéutico durante colangiopancreatografía retrógrada endoscópica (CPRE) / Periampullary duodenal diverticula and technical-therapeutic failure during endoscopic retrograde cholangiopancreatography (ERCP)

Resumen Introducción y objetivos: los divertículos duodenales periampulares (DDP) son infrecuentes y su hallazgo es incidental. Además, se clasifican en tres tipos según Boix por la cercanía a la ampolla mayor. El objetivo de este estudio fue realizar una descripción de nuestra experiencia con esta anomalía anatómica y demostrar la forma en que esto afecta la tasa de éxito técnica y terapéutica del procedimiento. Material y métodos: se realizó un estudio de corte transversal, con recolección de datos de forma retrospectiva en un período de 5 años de pacientes con divertículos periampulares duodenales. Se evaluó el fracaso terapéutico, complicaciones y dificultad de canulación de la vía biliar. Resultados: se evaluó un total de 214 pacientes, con una relación mujer-hombre de 2,15:1. La distribución de los sujetos por tipo de DDP fue: tipo 1 (29,9 %), tipo 2 (51,9 %) y tipo 3 (18,2 %). La indicación más frecuente de CPRE fue los cálculos del conducto biliar común en un 53,3 %. El DDP tipo 1 presentó mayor dificultad de canulación (11,6 %) y falla terapéutica (28,12 %). Conclusión: la presencia de DDP durante la CPRE se asocia con una mayor falla técnica (falla en la canulación) y falla terapéutica (persistencia de la obstrucción biliar). Además, estas fallas aumentan considerablemente cuando se trata de una papila intradiverticular tipo 1 de la clasificación según Boix. Por lo anterior, se sugiere que los procedimientos endoscópicos biliares en estas condiciones sean realizados por endoscopistas con gran experiencia con el fin de minimizar la probabilidad de falla técnica y terapéutica, y las complicaciones asociadas.

Abstract Introduction and objectives: Periampullary duodenal diverticula are infrequent, and their finding is incidental. They are classified into three types according to Boix due to their proximity to the larger blister. This study aims to describe the experience with this anatomical abnormality and to demonstrate how this affects the technical and therapeutic success rate of the procedure. Materials y Methods: A cross-sectional study was conducted, with retrospective data collection over a 5-year period of patients with periampullary duodenal diverticula. Therapeutic failure, complications, and difficulty of cannulation of the bile duct were evaluated. Results: A total of 214 patients were evaluated, with a female-male ratio of 2.15: 1. The distribution of the subjects by type of PDD was: type 1 (29.9%), type 2 (51.9%), and type 3 (18.2%). The most frequent indication for ERCP was common bile duct stones in 53.3%. Type 1 PDD presented greater difficulty in cannulation (11.6%) and therapeutic failure (28.12%). Conclusion: The presence of PDD during ERCP is associated with greater technical failure (failure in cannulation) and therapeutic failure (persistence of biliary obstruction). In addition, this failures increases considerably when it is a type 1 intradiverticular papilla of the Boix classification. Therefore, it is suggested that biliary endoscopic procedures in these conditions are performed by highly experienced endoscopists to minimize the probability of technical and therapeutic failure and associated complications.

Jejunal Diverticula Causing a Life-Threatening Lower Gastrointestinal Bleeding: A Case Report

A jejunal diverticulum is a rare and usually asymptomatic disease. More commonly it is usually seen as incidental findings on radiological studies or during surgery. Complications such as bleeding, perforation, abscess formation, obstruction, malabsorption, blind loop syndrome, volvulus, and intussusception may warrant surgical intervention. Herein, we report a case of a 62-year old woman presenting with massive lower gastrointestinal bleeding, she was pale, clammy and hemodynamically unstable, she was initially resuscitated with IV fluids and whole blood, urgent upper endoscopy was normal, colonoscopy revealed sigmoid colon ulcerative lesion with histopathological evidence of adenocarcinoma, there was bleeding coming from upwards. After staging of the tumor, the decision was then made to proceed to exploratory laparotomy with a pre-operative plan of segmental colectomy. Intra-operatively segmental sigmoid colectomy was performed with end to end anastomosis, during formal laparotomy we found 2 giant diverticula in the proximal jejunum, small bowel resection and end to end anastomosis was done with the good postoperative outcome. The aim of this study was to draw attention to jejunal diverticula and their serious complications such as bleeding.

Endoscopic papillary balloon dilation in treatment of choledocholithiasis associated with peripapillary duodenal diverticulum / 中华肝胆外科杂志

Objective To evaluate the use of endoscopic papillary balloon dilation in treatment of choledocholithiasis associated with peripapillary duodenal diverticulum.Methods From January 2017 to July 2018,a retrospective study was conducted on 124 patients with choledocholithiasis associated with peripapillary duodenal diverticula at the Department of Hepatobiliary Surgery,Second Hospital of Hebei Medical University.These patients were divided into the small endoscopic sphincterotomy combined with balloon dilation group (sEST+EPBD,n =60) and the simple papillary balloon dilation group (EPBD n =64).The operation time,one-time success rate of stone removal,complication and hospitalization stay were compared between the two groups of patients.Results The hospitalization expenses of the EPBD group was significantly less than the sEST+EPBD group (P＜0.05).The operation time of the EPBD group was significantly shorten than the sEST+EPBD group (P＜0.05).There were no significant differences in the one-time success rate of stone removal,complication rates and hospitalization stay between the two groups (P＞0.05).Conclusions Compared with sEST+EPBD,treatment of choledocholithiasis in patients with peripapillary duodenal diverticula using simple balloon dilation shortened the operation time,did not increase the complication rates and hospitalization stay.The procedure was safe and effective,and resulted in almost the same one-time success rate of stone removal.

Urological Problems in Patients with Menkes Disease

BACKGROUND: Menkes disease (MD) is a rare X-linked hereditary multisystemic disorder that is caused by dysfunction of copper metabolism. Patients with MD typically present with progressive neurodegeneration, some connective tissue abnormalities, and characteristic “kinky” hair. In addition, various types of urological complications are frequent in MD because of underlying connective tissue abnormalities. In this study, we studied the clinical features and outcomes of MD, focusing on urological complications. METHODS: A total of 14 unrelated Korean pediatric patients (13 boys and 1 girl) with MD were recruited, and their phenotypes and genotypes were analyzed by retrospective review of their medical records. RESULTS: All the patients had early-onset neurological deficit, including developmental delay, seizures, and hypotonia. The girl patient showed normal serum copper and ceruloplasmin levels as well as milder symptoms. Mutational analysis of the ATP7A gene revealed 11 different mutations in 12 patients. Bladder diverticula was the most frequent urological complication: 8 (57.1%) in the 14 patients or 8 (72.7%) in the 11 patients who underwent urological evaluation. Urological imaging studies were performed essentially for the evaluation of accompanying urinary tract infections. Four patients had stage II chronic kidney disease at the last follow-up. CONCLUSION: Urologic problems occurred frequently in MD, with bladder diverticula being the most common. Therefore, urological imaging studies and appropriate management of urological complications, which may prevent or reduce the development of urinary tract infections and renal parenchymal damage, are required in all patients with MD.

A case of esophagopulmonary fistula misdiagnosed as bronchiectasis / 中国综合临床

Esophagopulmonary fistula is a rare disease in clinic, most esophagopulmonary fistula is diagnosed and treated because of typical cough symptoms after eating or drinking. This case reported no typical symptoms of choking and coughing in eating or drinking water, patients with intermittent hemoptysis for nearly 30 years were diagnosed with bronchiectasis, Because of massive hemoptysis for emergency operation, the esophagus and the left lower lung were found to have abnormal muscular conduits during the operation, so diagnosis of esophagopulmonary fistula.

Imágenes en divertículos del tubo digestivo: localizaciones infrecuentes. serie de casos / Imaging in infrequent digestive diverticula: case series

Los divertículos se pueden localizar en todo el tubo digestivo (TD): esófago, estómago, duodeno, yeyuno, íleon, apéndice, colon. Son infrecuentes, salvo en colon. Sus manifestaciones clínicas son inespecíficas, con difícil diagnóstico y mayor riesgo de complicaciones. Se presenta una serie de divertículos digestivos atípicos, mostrando las características imagenológicas multimodalidad y describir los hallazgos claves. Es una revisión retrospectiva en el archivo computacional de nuestra institución. Selección de casos de divertículos de presentación inhabitual por sus características, localización u origen. En esófago los divertículos de Zenker y Killian-Jamieson. En estómago los divertículos gástricos infrecuentes. Los divertículos en intestino delgado tienen baja prevalencia, el más frecuente en duodeno. Los divertículos colónicos pueden tener una localización o presentación atípica. Los divertículos apendiculares y Meckel presentan baja prevalencia. Los divertículos digestivos son infrecuentes, excepto los colónicos. El radiólogo debe estar familiarizado con las diferentes ubicaciones de ellos, para reconocerlos y poder diagnosticarlos.

Diverticula may occur in any segment of the digestive tract: esophagus, stomach, duodenum, jejunum, ileum, appendix, and colon. Its clinical manifestations are nonspecifi which may turn diffiult an early diagnosis, leading to a higher risk of complications. We present a cases serie of atypical digestive diverticula and to describe the fidings on the different imaging techniques. We performed a retrospective review on the imaging computer archives of our institution. The atypical diverticula were selected. Zenker and Killian-Jamieson's diverticulums in esophagus. In stomach ocasionally gastric diverticula. Diverticula in small intestine have a low prevalence, the most common location is duodenum. Colonic diverticula may present a atypical location or presentation. The appendicular and Meckel diverticuli are uncommon. The digestive diverticula are uncommon, except the colonic ones. The radiologist must be familiar with it's different locations in order to be able to recognize it and diagnose it properly.

Endoscopic papillary small incision combined with balloon dilation in the treatment of choledocholithiasis combined with duodenal papillary diverticulum value / 实用医学杂志

Objective To investigate the value of endoscopic papillary incision combined with balloon di-lation in the treatment of choledocholithiasis with periampullary diverticula(PAD). Methods A total of 118 pa-tients with choledocholithiasis and PAD admitted to our hospital from January 2015 to January 2017 were retrospec-tively analyzed.According to the operation method,all patients were divided into two groups:sEST+EPBD group (60 cases)and EST group(58 cases).The success rate of ERCP and the success rate of one-step stone removal, the changes of serum TBil and DBil before and after operation,and the incidence of postoperative complications were compared between the two groups. Results The successful rates of ERCP and stone removal in sEST+EPBD group were significantly higher than those in EST group(P < 0.05). The levels of serum TBil and DBil in both groups were significantly lower than those before operation(P<0.05).The overall incidence of postoperative com-plications in sEST + EPBD group was significantly lower than that in EST group(P < 0.05). Conclusions The treatment of choledocholithiasis with PAD in patients with endoscopic papillary small incision and balloon dilation treatment effect is significant,which can significantly improve the success rate of ERCP and success rate of one-time stone,benefitting the prognosis of patients.

The application of ultrasound in the diagnosis of Lemmel syndrome / 中华医学超声杂志（电子版）

Objective The aim of this study was to explore the value of ultrasound in the diagnosis of Lemmel syndrome. Methods Ultrasound images of 36 patients with Lemmel syndrome confirmed by ERCP or surgery were retrospectively analyzed, and the image′s feature of ultrasound was explored. Results The ultrasound feature of Lemmel syndrome was showed as cystic protuberance from lesser curvature of duodenum, and three types of ultrasound characteristics were found: hyperechogenicity of gas, solid-cystic echogenicity full filled with fluid and inhomogeneous echogenicity full filled with food residue. The presence of hyperechogenicity (24 cases), solid-cystic echogenicity (8 cases), inhomogeneous echogenicity (4 cases) were found in 36 patients with periampullary diverticulum, and the biggest diameter of periampullary diverticulum was 6 to 32 mm. All of the patients (36 cases) were with mechanical obstruction in the common bile duct, and 12 patients were found mild dilatation of the pancreatic duct. Conclusion Higher clinical application value of ultrasound has been found when ultrasound is used in the diagnosis of Lemmel syndrome.

Hemorragia Digestiva Alta por Dieulafoy intradiverticular: Tratamiento Endoscópico / Digestive Bleeding by Dieulafoy in Duodenal Diverticulum: Endoscopic Treatment

La Lesión de Dieulafoy es una malformación vascular caracterizada por la presencia de un vaso arterial de gran calibre en la submucosa, ocasionalmente en la mucosa que puede erosionarse, provocar una hemorragia grave, recurrente y, en ocasiones mortal. Es una causa rara de hemorragia gastrointestinal y corresponde a menos del 2% de los episodios de sangrado digestivo agudo. La Lesión de Dieulafoy duodenal ha sido comunicada en un número reducido de casos y, la intradiverticular es excepcional. La endoscopía constituye el método diagnóstico de elección y, en las últimas décadas la terapéutica endoscópica es la técnica preferida por su elevada efectividad y escasa incidencia de complicaciones. Presentamos el caso de un paciente de 82 años con hemorragia digestiva alta grave por lesión de Dieulafoy duodenal intradiverticular diagnosticado en la endoscopía de urgencia y, tratado eficazmente mediante ligadura con banda elástica.

The lesion of Dieulafoy is a vascular malformation characterized by the presence of a large arterial vessel in the submucosa and occasionally in the mucosa, which can erode and cause severe, recurrent and sometimes fatal hemorrhage. It is a rare cause of gastrointestinal bleeding and responds to less than 2% of episodes of acute gastrointestinal bleeding. The duodenal Dieulafoy lesion has been reported in a small number of cases and the intradiverticular is exceptional. Endoscopy is the diagnostic method of choice and in the last decade endoscopic therapy is the preferred technique due to its high effectiveness and low incidence of complications. We present the case of an 82-year-old patient with severe upper gastrointestinal bleeding due to an intradiverticular duodenal injury diagnosed in emergency endoscopy and treated effectively by rubber band ligation.

Tomografia computada multidetector en la enfermedad diverticular del intestino delgado / Multislice computed tomography in small-bowel diverticulosis

La enfermedad diverticular del intestino delgado constituye una entidad de rara presentación, que suele confundirse con otras patologías más comunes cuando se complica. Los falsos divertículos son de origen primario o secundario, y asientan mayoritariamente en el duodeno. El divertículo verdadero más frecuente es el de Meckel. Las complicaciones aparecen en menos del 15% de los casos. Entre ellas, se destacan, por frecuencia, la perforación y/o inflamación, la obstrucción, el sangrado, y/o la diarrea crónica. El objetivo de este trabajo es mostrar el rol de la tomografía computada multidetector en el diagnóstico y manejo de la enfermedad diverticular del intestino delgado, exponiendo casos de la práctica diaria con correlato quirúrgico de pacientes evaluados en nuestra institución.

Small bowel diverticula is an uncommon and underdiagnosed pathology. False diverticula may be primary or secondary in origin and are frequently located in the duodenum. Meckel's diverticula is the most common true diverticula. Less than 15% of cases suffer complications, of which the following are, with decreasing frequency: inflammation and perforation, obstruction, bleeding, or chronic diarrhoea. In order to contribute to the best diagnosis and management of small-bowel diverticulosis, cases are presented that were initially evaluated with multislice computed tomography and confirmed surgically in our institution.

Clinical effect of endoscopic retrograde cholangiopancreatography for elderly patients with periampullary diverticula accompanied with choledocholithiasis / 中华消化外科杂志

Objective To explore the clinical effect of endoscopic retrograde cholangiopancreatography (ERCP) for elderly patients with periampullary diverticula accompanied with choledocholithiasis.Methods The retrospective cross-sectional study was conducted.The clinical data of 297 elderly patients with age ＞70 years and periampullary diverticula accompanied with choledocholithiasis who were admitted to the Zhongshan Hospital affiliated to Fudan University between January 2013 and January 2016 were collected.All the patients received lithotomy by ERCP after completion of preoperative preparation,and then underwent symptomatic treatment.Observation indicators included:(1) treatment results:cannulation time,success rate of cannulation and success rate of stones removed;(2) surgical complications:hemorrhage,perforation and pancreatitis;(3) follow-up results.All patients were followed up by outpatient examination and telephone interview up to December 2016.Follow-up included postoperative delayed perforation,patients' survival,further attack of acute cholangitis and reoperation for removing stones.Measurement data with normal distribution were represented as x ± s,and measurement data with skewed distribution were described as M (range).Results (1) Treatment results:all the 297 patients underwent successful lithotomy by ERCP,with a cannulation time of (5±4)minutes and a success rate of cannulation of 100.00％ (297/297).Of 297 patients,292 had one-off success of stones removed,with a one-off success rate of 98.32％ (292/297),and 5 received partial stones removed due to choledocholithiasis combined with acute cholangitis.(2) Surgical complications:4 patients were complicated with immediate hemorrhage during intraoperative endoscopic sphincterotomy (EST).Bleeding of 1 patient was cauterized by biopsy forceps,and 3 patients had simplex JHY-BAL compression hemostasis.Two patients with postoperative delayed hemorrhage had successful hemostasis by biopsy forceps with metal hemostatic clip under endoscope after emergency duodenoscopy.One patient with intraoperative perforation was cured by conservative treatment.Two patients with severe acute pancreatitis underwent continuous gastrointestinal decompression combined with maintenance therapy of somatostatin,and then received endoscopic ultrasound-guided puncture and drainage for pseudocyst around the pancreas,with a stable symptoms of pancreatitis after 4 weeks.(3) Follow-up results:all the 297 patients were followed up for 6-12 months,with a median time of 8 months.During follow-up,292 patients had healthy survival,without recurrences of cholangitis and bile duct stone,and no delayed perforation and death were detected.Five patients underwent the second time lithotomy by ERCP after 2-3 months postoperatively.Conclusion Lithotomy by ERCP is safe and effective in the treatment of elderly patients with periampullary diverticula accompanied with choledocholithiasis.

Value of endoscopic sphincterotomy with small incision combined with balloon dilatation in the treatment of choledocholithiasis with juxtapapillary duodenal diverticula / 中华消化杂志

Objective To explore the efficacy of endoscopic sphincterotomy with small incision combined with balloon dilatation (sEST+EPBD)in the treatment of patients with choledocholithiasis and juxtapapillary duodenal diverticula (JPDD).Methods From January 2011 to January 2015 ,149 patients with choledocholithiasis and JPDD who underwent endoscopic retrograde cholangio-pancreatography (ERCP)were enrolled.Among them,60 patients were in sEST+EPBD group and 89 were in endoscopic sphincterotomy (EST)group.Success rate of ERCP and first-time stone removal,changes of total bilirubin (TBil)and direct bilirubin (DBil)levels,as well as the incidence of postoperative complications between the two groups were compared.Chi-square test or t-test was performed for statistical analysis. Results The ERCP success rate sEST+EPBD group was 100.0% (60/60),and the first-time success rate of stone removal was 91 .7%(55/60);correspondingly,ERCP success rate of EST group was 98.9%(88/89),and the success rate of first-time stone removal was 77.5 %(69/89).There was no statistically significant difference in success rate of ERCP between the two groups (χ2 =0.19,P =0.410).The first-time success rate of stone removal of sEST +EPBD group was higher than that of EST group,and the difference was statistically significant (χ2 =5 .53,P =0.020).After operation,the TBil level of sEST+ EPBD group was (152.62 ±109.04 )μmol/L,which was lower than that before operation ((266.02 ± 143.31)μmol/L),and the difference was statistically significant (t =4.88,P <0.01 ).After operation, the DBil level of sEST +EPBD group was (87.13 ±65 .90)μmol/L,which was lower than that before operation ((175 .70 ± 100.53 )μmol/L),and the difference was statistically significant (t = 5 .71 ,P <0.01).After operation,the TBil level of EST group was (251 .90 ±247.90)μmol/L,which was lower than that before operation ((340.20 ±176.20 )μmol/L),and the difference was statistically significant (t=2.74,P <0.05).After operation,the DBil level of EST group was (168.10±140.60)μmol/L,which was lower than that before operation ((228.40 ±139.60 )μmol/L),and the difference was statistically significant (t = 2.87,P = 0.005).The complication rate of sEST + EPBD group after operation was 8.3%(5/60),which was lower than that of EST group (20.2%,18/89 ),and the difference was statistically significant (χ2 =3.88,P =0.049 ).Conclusion sEST+EPBD could increase the first-time success rate of stone removal in patients with choledocholithiasis and JPDD,and it is a safe and effective treatment.

Relationship between duodenal diverticula and cannulation time during ERCP procedures and post ERCP complications / 中华消化内镜杂志

Objective To investigate the influence of duodenal diverticula on cannulation time and complication in patients undergoing ERCP.Methods Data of 3 265 patients undergoing ERCP in Drum Tower Hospital affiliated to Nanjing Medical University between January 1,2008 and December 31,2014 were enrolled.The patients' information and endoscopic pictures/videos were collected.The duodenal diverticula,cannulation time,postoperative complications were analyzed.Results There were 2 599 (79.6％) cases of non-diverticula,445(13.6％) cases of one-diverticula,122(3.7％) patients with two or more diverticula,and 99 (3.0％) intradiverticular papilla.Patients with duodenal diverticula accounted for 20.4％ (666/3 265) of all patients who received ERCP procedure.The mean cannulation time was 6.62 minutes in all cases,6.30 minutes in non-diverticula group,7.63 minutes in one-diverticula group,8.07 minutes in two-or-more group,8.58 minutes in intradiverticular papilla group,respectively.There were significant differences in cannulation time and complication rate between the groups.Conclusion Duodenal diverticula may be one of the factors that affect the cannulation time.It may enhance the cannulation complications and prolong the cannulation time,especially in those with intradiverticular papilla.

Aneurismas y divertículos cardíacos congénitos: reporte de una serie pediátrica / Congenital cardiac aneurysms and diverticula: a pediatric series

Introduccion: Los aneurismas y divertículos cardíacos congénitos constituyen malformaciones poco frecuentes y generalmente comprometen el ventrículo izquierdo. Pueden presentarse en forma asintomática, causar embolización, arritmia, insuficiencia cardíaca, rotura o muerte súbita. La ecocardiografía Doppler color realiza el diagnóstico y detecta malformaciones asociadas. La terapia puede ser médica o quirúrgica dependiendo de la presentación clínica y de los hallazgos en cada paciente. Método: Estudio retrospectivo de 5 pacientes durante un período de diez años, uno con divertículo, cuatro con aneurismas, en los cuales se analizó sexo, edad, motivo de consulta, sintomatología, hallazgos al examen físico, malformaciones extracardíacas o cardíacas asociadas. La ecocardiografía confirmó el diagnóstico y analizó la localización, efecto sobre la función cardíaca y presencia de complicaciones. Se estudió el tipo de tratamiento elegido como terapia antiplaquetaria, antiarrítmica o quirúrgica, además del seguimiento. Resultados: De un total de 5 pacientes, tres eran hombres, la mediana de edad al diagnóstico fue de 13 meses; dos de diagnóstico antenatal. Soplo cardíaco (3/5) fue el principal hecho que motivó el estudio. La ubicación más frecuente fue en el ventrículo izquierdo y la malformación cardíaca asociada la comunicación interventricular (2 pacientes). La terapia elegida fue médica en todos los pacientes con aspirina y en un caso se agregó atenolol por taquicardia ventricular no sostenida. Ningún paciente falleció. Conclusion: Constituye la primera publicación sobre esta patología en nuestro país; si bien es una serie pequeña, aporta aspectos clínicos, diagnósticos y de seguimiento que ayudan a sospechar esta rara malformación en el paciente pediátrico.

Introduction: Congenital cardiac aneurysms and diverticula are rare cardiac malformations which mainly affects the left ventricle. Clinically, most are asymptomatic or may cause systemic embolization, arrhyth-mia, heart failure, ventricular wall rupture or sudden cardiac death. Doppler echocardiography establishes the diagnosis and can detect associated malformations. Treatment may be medical or surgical, depending on findings. Patients and Methods: Retrospective study of 5 patients followed for ten years. One patient presented with a diverticulum and four with aneurysms. We analyzed sex, age at diagnosis, symptoms, physical examination, and associated cardiac and extracardiac malformations. Echocardiography confirmed the diagnosis and established location, cardiac function, and presence of complications. We analyzed the treatments used: antiplatelet, anti-arrhythmic or surgical therapy, and follow up. Results: Three were males, the median age at diagnosis was 13 months; in two patients the diagnosis was made before birth. Heart murmur in 3 of 5 patients was the main presenting finding. The most frequent location was the left ventricle and the associated cardiac malformation was ventricular septal defect in 2 patients. All patients were treated with aspirin. One patient with non-sustained ventricular tachycardia received ateno-lol. There were no deaths. Conclusion: This is the first report of this disease in our country. Although it is a small series it provides important clinical aspects for the diagnosis, treatment and follow-up that help us suspect this rare malformation in pediatric patients.

Limited endoscopic sphincterotomy plus balloon dilation (ESBD)for large choledocholithiasis ac-companied with periampullary diverticula / 中华消化内镜杂志

Objective To explore the effectiveness and safety of limited endoscopic sphincterotomy plus endoscopic papillary balloon dilation (ESBD)for patients with large common duct stones and periampul-lary diverticula (PAD).Methods Data of 40 patients with large common duct stones (diameter ≥10 mm) and PAD who underwent ESBD were retrospectively reviewed.The clinical feature,operation method,suc-cess rates of stone removal and early complications rates during hospitalization were evaluated according to PAD subtypes.Results The stone removal rate in first session was 90.0%(36 /40,with a median time of 29 minutes per procedure.Three patients underwent a second procedure to remove residual stones.The over-all stone removal rate was 97.5% (39 /40).The early complications rate was 15%(6 /40),including mild pancreatitis in two cases(5%),hyperamylasemia in two (5%),postoperative late bleeding in two (5%), which were cured with conservative treatment.No perforation,massive hemorrhage or death occurred.No significant differences in success stone removal rate and early complication rate were found between PAD sub-types.Conclusion ESBD is an effective and safe procedure for removing choledocholithiasis in patients with PAD,regardless of PAD subtypes.

A comparative study on three endoscopic methods for removal of common bile duct stones accompa-nied with periampullary diverticula / 中华消化内镜杂志

Objective To evaluate the safety and effectiveness of three endoscopic methods for re-moval of common bile duct stones (CBDs)accompanied with periampullary diverticula(PAD).Methods A total of 154 patients hospitalized at Taizhou Hospital and Taizhou No.1 People′s Hospital of Zhejiang prov-ince from December 2012 to July 2013 were divided randomly into three groups,i.e.,EST,EPBD and ES-BD group,and received the treatment of EST,EPBD and limited EST plus EPBD (ESBD)to extract CBDs, respectively.After 12 months of follow-up,the rate of full stone clearance,stones clearance rate in one time,the rate of mechanical lithotripsy,the rate of urgent lithotripsy,the average procedures,the average removal time and the complication incidence among three groups were compared.Results The rates of stone clearance in one time in group ESBD was higher than those of group EST and group EPBD (94.12% VS 78.43%,73.08%;P <0.05)with significant difference.The average procedures in group ESBD was lower than that of group EPBD (1.08 VS 1.31,P <0.05),which also showed significant difference.The occur-rence rates of early complication in group ESBD was lower than that of group EPBD (15.69% VS 34.61%, P <0.05).The occurrence rates of post-ERCP hyperamylasemia in group ESBD was lower than that of group EPBD (5.88% VS 21.15%)with significant difference (P <0.05).The incidence of pneumobilia in group EST was higher than those of group EPBD (52.27% VS 26.19%,P =0.013)and group ESBD (52.27%VS 27.66%,P =0.016).Conclusion The stone extraction efficiency of ESBD is better than that of EST and EPBD.Compared with conventional EST,ESBD shows similar safety level,and is safer than EPBD.So ESBD is a safe and effective method to remove CBDs with PAD.

Sindrome de Lemmel: Ictericia obstructiva intermitente: A propósito de un caso / Lemmel syndrome: Intemittent obstructive jaundice: Clinical case

La formación divertícular del tubo digestivo es una enfermedad frecuente, el duodeno constituye la segunda localización en frecuencia de los divertículos en el tubo digestivo, generalmente se observan entre los 50 y 65 años, pero pueden estar presentes en todas las edades y afectar a ambos géneros, con discreto predominio en las mujeres. Su sintomatología es vaga y ocurre en menos de 10% de los casos, pero cuando se presenta da síntomas y complicaciones como diverticulitis, obstrucción, perforación o incluso condiciones graves pancreatobiliares, como ictericia obstructiva, colangitis y coledocolitiasis. Presentamos el caso de paciente femenino que ingresa al IVSS Hospital Dr. Miguel Pérez Carreño con dolor abdominal, tinte ictérico en piel y mucosas, coluria y acolia, además de hipertermia no cuantificadas. Alteración del perfil colestásico. Ultrasonido abdominal: dilatación de vías biliares intra y extrahepáticas, Colecistectomizada. Colangioresonancia: 1.- Dilatación de vías biliares intra y extrahepáticas. 2.- Estenosis abrupta del colédoco “en punta de lápiz”. Ultrasonido endoscópico: 1.- Dilatación de vías biliares intra y extrahepáticas. 2.- Divertículo duodenal? Endoscopia digestiva superior: Divertículos (2) duodenales. En vista de mejoría clínica y paraclínica y con evidencia divertículos yuxtapapilares se plantea el diagnóstico de síndrome ictéricoobstructivo intermitente por relación con divertículos duodenales.

Diverticular formation of the digestive tract is a common disease, the duodenum is the second most common site of diverticula in the digestive tract, usually seen between 50 and 65, but may be present in all ages and affect both genders with slight predominance in women. Its symptoms are vague and occurs in less than 10% of cases, but when presented gives symptoms and complications such as diverticulitis, obstruction, perforation or even pancreabilliary serious conditions such as obstructive jaundice, cholangitis and choledocholithiasis. We report the case of a female patient admitted to IVSS Dr. Miguel Perez Carreño Hospital with abdominal pain, jaundiced skin and mucous membranes, and acolia coluria further increases thermal unquantified. Alteration of cholestatic profile. Abdominal ultrasound: dilatation of intra- and extrahepatic bile duct, cholecystectomy. Colangioresonancia: 1. Dilated intrahepatic and extrahepatic bile ducts. 2. abrupt stenosis of the common bile "pencil-point". Endoscopic Ultrasound: 1. Dilated intrahepatic and extrahepatic bile ducts. 2. duodenal diverticulum? Superior Digestive Endoscopy: Diverticula (2) Duodenal. In view of clinical and paraclinical improvement and evidence Juxtapapillary diverticula diagnosis of intermittent ictéricobstructivo syndrome arises by relation to duodenal diverticula.

Experiencia clínica con la cápsula endoscópica de colon (PillCam© Colon) en el estudio de la patología colónica en la Clínica Universitaria San Juan de Dios, en Cartagena / Clinical experience with colon capsule endoscopy (PillCam© Colon) in the study of colonic pathologies at the Clínica Universitaria San Juan de Dios in Cartagena

Introducción: La cápsula colónica, PillCam© Colon fue utilizada por primera vez en el mundo en octubrede 2006 para la exploración no invasiva del colon. Estudios recientes han demostrado su buena rentabilidaddiagnóstica, comparada con la colonoscopía convencional, en el estudio de la patología colónica.Objetivo: Determinar el rendimiento diagnóstico de la PillCam© Colon en la detección de lesiones colónicas,comparada con la colonoscopia convencional, en pacientes de la ciudad de Cartagena con sintomatología de los intestinos medio y bajo. Materiales y métodos: Estudio observacional, prospectivo de pruebas diagnósticas, en el cual se evaluóla validez (la sensibilidad, la especifi cidad y los valores predictivos) de la PillCam© Colon, comparada con lacolonoscopia, en la detección de lesiones colónicas, en una cohorte de pacientes que consultaron a la clínicaUniversitaria San Juan de Dios por sintomatología de los intestinos medio y bajo en Cartagena, durante elperiodo junio de 2011-enero de 2013. Los análisis se realizaron utilizando el software STATA 11.0.Resultados: Se estudió a 25 pacientes: 14 mujeres (56%) y 11 hombres (44%); todos ellos, con colonoscopiaprevia, y a quienes se les practicó una panendoscopia con la PillCam© Colon activada. Se logró la exploración completa del colon en el 76% de los casos (19 pacientes). El tiempo del tránsito colónico fue de 2,4 horas (DE±1,3 horas), y el del tránsito oroanal, de 6,2 horas (DE± 1,18). Conclusión: La PillCam© Colon es una técnica no invasiva, altamente sensible y segura en la detección delesiones colónicas, y que puede ser de utilidad en la práctica clínica en grupos de alto riesgo para la deteccióntemprana del cáncer colorrectal y en los casos donde la colonoscopia sea incompleta o esté contraindicada.

Introduction: In October 2006 the PillCam© Colon colonic capsule was used for the fi rst time ever for noninvasive colon. Recent studies have shown that is diagnostic performance is good in comparison with conventional colonoscopy for the study of colonic pathologies.Objective: The objective of this study was to compare the diagnostic yield of PillCam© Colon in detecting colonic lesions with the yield of conventional colonoscopy for patients with symptoms in the mid and lowerintestinal regions in a hospital in Cartagena. Materials and methods: This was a prospective observational study of diagnostic tests which assessed the validity (sensitivity, specifi city and predictive values ) of the PillCam© Colon and compared them with colonoscopy for the detection of colonic lesions in a cohort of patients at the University Clínica Universitaria San Juan de Dios in Cartagena. Patients had symptoms in the mid and lower intestinal regions. Patients were examined from June 2011 to January 2013. Analyses were performed using STATA 11.0 software.Results: We studied 25 patients: 14 women (56 %) and 11 men (44 %). All had previously undergonecolonoscopies. Panendoscopies were performed on these patients using an activated PillCam© Colon. Weachieved complete colon examinations in 76% (19 patients). Colonic transit time was 2.4 hours (SD ± 1.3hours) and oral-anal transit time was 6.2 hours (SD ± 1.18). 78.9% of the fi ndings of the PillCam© Colon andcolonoscopy agreed. Conclusion: PillCam© Colon is a highly sensitive and reliable non-invasive method for detection of lesionsin the colon. It may be useful in clinical practice for early detection of colorectal cancer in high risk groups and in cases that colonoscopy is incomplete or contraindicated.

Diverticulitis exclusiva de ciego / Unique diverticulitis of the cecum

La diverticulitis cecal es una rara entidad de difícil diagnóstico que con frecuencia se confunde con un proceso apendicular agudo. Los divertículos primarios o de origen congénito, generalmente son únicos, suelen presentarse en una edad más temprana que la enfermedad diverticular cólica (divertículos secundarios). La presencia de estos en el colon derecho se reporta con menor frecuencia, su diagnóstico es en muchas ocasiones indistinguible de la apendicitis aguda y se realiza en la mayoría de los casos durante la laparotomía, el tratamiento es variable, según la literatura abarca desde la resección del divertículo hasta la hemicolectomía derecha. El objetivo de esta presentación es referir la dificultad diagnostica y la alta frecuencia de error diagnóstico que presenta esta entidad

The cecal diverticulitis is a strange disease, difficult to be diagnosed, frequently confused with acute appendicular process. The primary diverticula or those of congenital origin are generally unique; they usually appear at younger age than the colic diverticular disease (secondary diverticula). Their presence in the right colon is less frequently reported, the diagnosis is often confused with that of acute appendicitis and most of cases undergo laparatomy. According to the scientific literature, the treatment is variable, ranging from diverticular resection to right hemi-cholectomy. The objective of this paper was to present the difficulties and the high frequency of errors in diagnosing this disease