Predictive factors for complete and incomplete evaluation of small intestine by endoscopic capsule / Fatores preditivos para avaliação completa e incompleta do intestino delgado pela cápsula endoscópica

ABSTRACT Background: The small-bowel is the most difficult segment to be visualized by traditional endoscopic methods. The need for its exploration led to the development of capsule endoscopy. The percentage of the complete examination varies and still remains uncertain the factors that influence the complete and incomplete examination. Aim: Evaluate the factors that interfere with the completeness of the endoscopic evaluation by the capsule. Methods: A prospective study in which were included 939 patients divided into two groups: complete group (CG) and incomplete group (IG). The studied variables that could interfere were: age, gender, comorbidities, diagnosis of Crohn's disease, previous abdominal surgery, inadequate preparation to compare the groups reached and did not reach the cecum. Results: Of the 939 patients included 879 (93.3%) reached the cecum (CG) and 63 (6.7%) IG no. The IG was composed of 29 (46.0%) men and 34 (54.0%) women with a mean age of 49.7 years; comorbidities this group accounted for 46% of which 15.9% was Crohn's disease, previous abdominal surgery 22.2% and 17.5% inadequate preparation. Conclusion: Factors associated with complete or incomplete outcome of the examination with capsule endoscopy were: associated comorbidities, Crohn's disease, previous abdominal surgery and inadequate preparation.

RESUMO Racional: O intestino delgado é segmento de maior dificuldade na visualização pelos métodos endoscópicos tradicionais. A necessidade de explorá-lo levou ao desenvolvimento da cápsula endoscópica. A porcentagem do exame completo por ela varia e falta identificar fatores que influenciam o exame completo e incompleto. Objetivo: Avaliar os fatores que interfiram na completude do estudo endoscópico pela cápsula. Método: Estudo prospectivo onde foram incluídos 939 pacientes divididos em dois grupos: grupo completo (GC) e grupo incompleto (GI). As variáveis analisadas que pudessem interferir foram: idade, gênero, comorbidades associadas, diagnóstico de doença de Crohn, operações abdominais prévias, preparo inadequado para comparar os grupos que atingiram e não atingiram o ceco. Resultados: Dos 939 pacientes incluídos 879 (93,3%) atingiram o ceco (GC) e 63 (6,7%) GI não. O GI era composto por 29 (46,0%) homens e 34 (54,0%) mulheres com idade média de 49,7 anos; as comorbidades deste grupo corresponderam a 46%, das quais 15,9% era doença de Crohn, 22,2% operação abdominal prévia e 17,5% preparo inadequado. Conclusão: Os fatores associados ao desfecho completo ou incompleto do exame com a cápsula endoscópica foram: comorbidades associadas, doença de Crohn, operação abdominal prévia e preparo inadequado.

Cuerpo extraño en intestino delgado / Foreign Body in the Small Intestine

RESUMEN Se presenta el caso de un paciente masculino de 39 años de edad, que acude al cuerpo de guardia del Hospital General Docente Abel Santamaría Cuadrado por presentar un cuadro de dolor abdominal de tres días de evolución. Se interviene quirúrgicamente con el diagnóstico presuntivo de apendicitis aguda complicada. En el acto quirúrgico se comprobó que el apéndice cecal era normal y al examinar el íleon terminal, a una distancia aproximada de 50 cm se encontró un divertículo de Meckel, y a 5 cm de este, una espina de pescado adherida a la pared intestinal, la cual parecía ser la causante del cuadro, ya que el divertículo también era normal. El tratamiento consistió en trasladar la espina hacia el divertículo y realizar resección intestinal de ese tramo con anastomosis término-terminal. La evolución posoperatoria fue satisfactoria y el paciente fue dado de alta a los 8 días de la operación(AU)

ABSTRACT We present the case of a male patient, 39 years of age, who presents to the emergency room of Abel Santamaría Cuadrado General Teaching Hospital with a clinical picture of abdominal pain of three days of natural history. He is surgically intervened with the presumptive diagnosis of complicated acute appendicitis. In the surgical act, the cecal appendix was verified to be normal and, when examining the terminal ileum, at a distance of approximately 50 cm, a Meckel's diverticulum was found, and, at 5 cm from this, a fish spine adhered to the intestinal wall, which seemed to be the cause of the clinical picture, since the diverticulum was also normal. The treatment consisted of transferring the spine to the diverticulum and performing intestinal resection of that section with end-to-end anastomosis. The postoperative evolution was satisfactory and the patient was discharged 8 days after the operation(AU)

Impacto da enteroscopia por cápsula na anemia ferropénica: influência da idade do doente no rendimento diagnóstico / Impact of small bowel capsule endoscopy in iron deficiency anemia: influence of patient'sage on diagnostic yield

ABSTRACT BACKGROUND: Iron deficiency anemia remains one of the main indications to perform small bowel capsule endoscopy. Literature suggests that diagnostic yield is influenced by patient's age but with conflicting results regarding age cutoff. OBJECTIVE: We aimed to clarify the differences in diagnostic yield and incidence of specific findings according to age. METHODS: Retrospective single-center study including 118 patients performing small bowel capsule endoscopy in the study of iron deficiency anemia. Videos were reviewed and small bowel findings that may account for anemia were reported. Incomplete examinations were excluded. Findings were compared between patients ≤60 and >60 years. RESULTS: Patients had a mean age of 58 years old (SD ±17.9) with 69.5% females (n=82). The overall diagnostic yield was 49% (58/118), being higher among patients >60 years (36/60, diagnostic yield 60%) than those ≤60 years (20/58, diagnostic yield 34%), (P<0.01). Angioectasias were more frequent in patients >60 years (45% vs 9%, P<0.01). Patients ≤60 years presented more frequently significant inflammation (Lewis score >135 in 10.3% vs 1.7%, P<0.05) and other non-vascular lesions (24% vs 10%, P=0.04). CONCLUSION: In our cohort small bowel capsule endoscopy diagnosed clinically relevant findings in the setting of iron deficiency anemia in almost half the patients. Diagnostic yield was higher in patients older than 60 years (60%), with vascular lesions being more frequent in this age group. Despite the lower diagnostic yield in patients ≤60 years, significant pathology was also found in this age group, mainly of inflammatory type.

RESUMO CONTEXTO: A anemia ferropénica constitui uma das principais indicações para realização de enteroscopia por cápsula. A literatura sugere que o rendimento diagnóstico é influenciado pela idade do doente, contudo, não é consensual o grupo etário para o qual o rendimento diagnóstico é maior. OBJETIVO: Clarificar as diferenças de rendimento diagnóstico e incidência de achados específicos de acordo com a idade. MÉTODOS: Estudo retrospetivo unicêntrico. Incluídos 118 doentes que realizaram sistematicamente enteroscopia por cápsula no estudo de anemia ferropénica. Todos os vídeos foram revistos e foram reportados os achados no intestino delgado que pudessem ser a causa da anemia ferropénica. Excluídas enteroscopia por cápsula incompletas. Comparados os achados entre doentes com ≤60 e >60 anos. RESULTADOS: Doentes com idade média de 58 anos (SD ±17,9), 69,5% do género feminino (n=82). O rendimento diagnóstico global foi de 49% (58/118), sendo superior em doentes >60 anos (36/60, rendimento diagnóstico 60%) do que em doentes ≤60 anos (20/58, 34%). As angiectasias foram mais frequentemente reportadas em doentes >60 anos (45% vs 9%, P<0,01). Nos doentes com ≤60 anos foi mais frequentemente reportada inflamação significativa (Score de Lewis >135 em 10,3% vs 1,7%, P<0,05) e lesões não vasculares (24% vs 10%, P=0,04). CONCLUSÃO: Na nossa amostra, a enteroscopia por cápsula revelou-se importante no estudo da anemia ferropénica detectando achados relevantes em cerca de metade dos doentes. O rendimento diagnóstico foi maior em doentes com mais de 60 anos (60%), sendo as lesões vasculares mais frequentes neste grupo. Apesar do menor rendimento diagnóstico em indivíduos até aos 60 anos, foi detectada patologia relevante neste grupo, em especial do tipo inflamatório.

Malrotación intestinal: a propósito de un caso / Intestinal malrotation: a case report

Existen múltiples patologías del abdomen que pueden ser diagnosticadas por parte del especialista en Diagnóstico por Imágenes; entre ellas, la malrotación intestinal es un hallazgo generalmente incidental. El médico imagenólogo debe ser capaz de reconocer los signos de la malrotación intestinal, al tratarse de una entidad patológica con complicaciones graves, como el vólvulo de intestinal. Para el diagnóstico, es clave su sospecha, así como las variantes de la normalidad que pueden conducir a un diagnóstico erróneo.

There are many diseases of the abdomen that can be diagnosed by the specialist in diagnostic imaging, including the intestinal malrotation is a finding usually incidental. The doctor specialist imaging must be able to recognize the signs of intestinal malrotation is a pathological entity, with serious complications, such as intestinal volvulus. For the diagnosis, it is the key to your suspicion, as well as the variants that can lead to a false diagnosis.

Angioedema intestinal aislado inducido por enalapril / Isolated intestinal angioedema induced by enalapril

El angioedema inducido por inhibidores de la enzima convertidora de angiotensina es una entidad poco frecuente caracterizada por edema en piel y mucosas, debido al aumento de la permeabilidad vascular provocada por la inhibición de la enzima convertidora y el subsiguiente aumento de la bradiquinina. De manera frecuente cursa con compromiso facial y de mucosas, siendo infrecuente el compromiso intestinal o de vía aérea. El angioedema intestinal puede presentarse asociado a angioedema facial o aislado, siendo este último excepcional. Cursa con episodios recurrentes de dolor, distensión abdominal y diarrea acuosa con recuperación completa en dos o tres días. Si bien es una entidad poco frecuente, el hecho de que esté asociada a fármacos utilizados con frecuencia nos hace incluirla en el diagnóstico diferencial del dolor abdominal recurrente. Presentamos un caso de angioedema intestinal aislado, asociado al uso de enalapril.

Angioedema induced by angiotensin converting enzyme inhibitors is a rare entity characterized by skin and mucosal edema, due to increased vascular permeability caused by inhibition of the converting enzyme and subsequent increase in bradykinin. It frequently presents with facial and mucosal involvement, being uncommon the intestinal or airway compromise. Intestinal angioedema may be associated with facial or isolated angioedema, the latter being exceptional. It is associated with recurrent episodes of pain, abdominal distention and watery diarrhea which complete recovery in two or three days. Although it is a rare entity, the fact that it is associated with frequently used drugs makes us include it in the differential diagnosis of recurrent abdominal pain. We report a case of isolated intestinal angioedema associated with the use of enalapril.

Report of a rare case and review of adult intestinal duplication at the opposite side of mesenteric margin

ABSTRACT CONTEXT: To study the previously discovered clinical entity of adult intestinal duplication and its treatment, and propose an extension to its existing classification. CASE REPORT: We report the case of an adult male with abdominal pain, constipation and vomiting. This patient underwent surgical separation of adhesions, reduction of torsion and intestinal decompression. Postoperative pathological findings confirmed the rare diagnosis of intestinal duplication. CONCLUSION: Adult intestinal duplication is quite rare. Its clinical manifestations are nonspecific. From this finding of intestinal duplication originating at the opposite side of the mesenteric margin, a further extension of the existing anatomical classification is proposed.

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.

Magnetic resonance enterography in pediatric celiac disease / A enterografia por ressonância magnética na doença celíaca pediátrica

Abstract Objective: To assess if magnetic resonance enterography is capable of showing evidence/extent of disease in pediatric patients with biopsy-proven celiac disease by comparing with a control group, and to correlate the magnetic resonance enterography findings with anti-endomysial antibody level, which is an indicator of gluten-free dietary compliance. Methods: Thirty-one pediatric patients (mean age 11.7 ± 3.1 years) with biopsy-proven celiac disease and 40 pediatric patients as a control group were recruited in the study. The magnetic resonance enterography images of both patients with celiac disease and those of the control group were evaluated by two pediatric radiologists in a blinded manner for the mucosal pattern, presence of wall thickening, luminal distention of the small bowel, and extra-intestinal findings. Patient charts were reviewed to note clinical features and laboratory findings. The histopathologic review of the duodenal biopsies was re-conducted. Results: The mean duration of the disease was 5.6 ± 1.8 years (range: 3-7.2 years). In 24 (77%) of the patients, anti-endomysial antibody levels were elevated (mean 119.2 ± 66.6 RU/mL). Magnetic resonance enterography revealed normal fold pattern in all the patients. Ten (32%) patients had enlarged mesenteric lymph nodes. Conclusion: Although a majority of the patients had elevated anti-endomysial antibody levels indicating poor dietary compliance, magnetic resonance enterography did not show any mucosal abnormality associated with the inability of magnetic resonance enterography to detect mild/early changes of celiac disease in children. Therefore, it may not be useful for the follow-up of pediatric celiac disease.

Resumo Objetivo: Avaliar se a enterografia por ressonância magnética (ERM) consegue comprovar/mostrar a extensão da doença em pacientes pediátricos com doença celíaca (DC) comprovada por biópsia, comparar com um grupo de controle e correlacionar os achados da ERM com o nível de anticorpo antiendomísio (EMA) indicador de dieta sem glúten. Métodos: Foram recrutados 31 pacientes pediátricos (idade média entre 11,7 ± 3,1 anos) com DC comprovada por biópsia e 40 pacientes pediátricos em um grupo de controle. As imagens da ERM dos pacientes com DC e no grupo de controle foram avaliadas por dois radiologistas pediátricos às cegas para o padrão da mucosa, presença de espessamento da parede, dilatação luminal do intestino delgado e achados extraintestinais. Os prontuários dos pacientes foram revisados para anotação de características clínicas e achados laboratoriais. A avaliação histopatológica das biópsias duodenais foi feita novamente. Resultados: A duração média da doença foi 5,6 ± 1,8 anos (faixa de 3-7,2 anos). Em 24 (77%) dos pacientes, os níveis EMA estavam elevados (média 119,2 ± 66,6 RU/mL). A ERM revelou um padrão de pregas normal em todos os pacientes; 10 (32%) dos pacientes apresentaram gânglios linfáticos mesentéricos aumentados. Conclusão: Apesar de a maioria dos pacientes ter níveis elevados de EMA, o que indica uma dieta pobre, a ERM não mostrou anomalia na mucosa associada à incapacidade de a ERM detectar alterações leves/precoces de DC nas crianças. Portanto, ela pode não ser útil no acompanhamento da DC pediátrica.

Abordaje diagnóstico y terapéutico de las patologías del intestino delgado mediante cápsula endoscópica y enteroscopía de doble balón / Diagnostic and therapeutic approach to small bowel disorders through capsule endoscopy and double-balloon endoscopy

Las múltiples patologías del intestino delgado han supuesto un enorme desafío para gastroenterólogos y endoscopistas debido a las muy bajas tasas de rédito diagnóstico que las diferentes técnicas paraclínicas ofrecían. El advenimiento de la cápsula endoscópica y la enteroscopía de doble balón ha permitido una exploración total, segura y eficiente del intestino delgado lo que ha generado un impacto real en el diagnóstico, tratamiento y pronóstico de nuestros pacientes.La cápsula endoscópica es un procedimiento seguro, mínimamente invasivo, no precisa sedación, no genera dolor y permite observar la totalidad del intestino delgado. Por su parte la enteroscopía de doble balón es la técnica endoscópica complementaria necesaria para brindar una intervención terapéutica (cauterizar angiodisplasias, polipectomías, toma de biopsias) logrando así un abordaje resolutivo de las diversas patologías.

Many small bowel disorders represent a great challenge for gastroenterologists and endoscopists due to the very low rates of success showed by the different diagnosis techniques. The advent of the capsule endoscopy and double-balloon endoscopy has allowed a total, secure and efficient examination of the small bowel, which represents a real impact in diagnosis, treatment, and prognosis of our patients. The capsule endoscopy is a safe, minimally invasive procedure, which does not need sedation, does not cause pain, and allows the observation of the totality of the small bowel. Furthermore, the double-balloon endoscopy is the complementary technique necessary to provide a therapeutic procedure (cauterizing angiodysplasia, polypectomy, biopsies), and hence achieving resolution of various disorders.

A retenção da cápsula endoscópica e suas situações de risco: análise em 215 exames consecutivos e revisão das condutas de prevenção e tratamento / The retention of the endoscopic capsule and its risk situations: analysis in 215 consecutive exams and review of the prevention and treatment conduits

Introdução: lesões estenosantes do intestino delgado (ID), e suas neoplasias em especial, são patologias de difícil diagnóstico. A Cápsula Endoscópica (CE) representou notável avanço no reconhecimento das mesmas. Porém a retenção da CE nestas lesões estenosantes representa risco potencial que deve sempre ser evitado. Objetivo: efetuar uma revisão dos aspectos preventivos das situações em que a CE pode vir a ficar retida, das condutas terapêuticas quando a retenção ocorre e, principalmente, analisar, numa sequência de 215 exames com a CE, quais as situações que representaram risco de retenção e quais aquelas em que realmente houve a retenção. Casuística: 215 exames endoscópicos consecutivos do delgado com a cápsula foram objetos de análise. Material e Métodos: endoscopia digestiva alta (EDA) e colonoscopia (CO) foram os exames que todos os 215 pacientes efetuaram antes de se submeterem ao exame da CE. Diversas foram as indicações dos exames com a CE, mas 85% deles foram indicados por hemorragia digestiva de causa obscura (sangramento digestivo com EDA e CO negativas) ou anemia de causa a investigar. Nenhum paciente apresentava queixas ou sinais de suboclusão antes de efetuar o exame. A CE utilizada em todos os pacientes foi da marca GIVEN (Yokenan, Israel), modelos M2A e PillCam SB. Foi considerada retida a CE que, após três semanas da realização do exame, não havia sido eliminada, e exame radiológico comprovava sua presença no intestino delgado. Resultados: 141 lesões foram identificadas nestes 215 exames com a CE, sendo 112 delas no intestino delgado e 29 fora do delgado. Em 26,6% (37 casos) dos 112 casos com lesões no delgado, havia alterações que promoviam algum grau de estreitamento da luz do delgado, a saber: 10 casos de neoplasia maligna (3 linfomas, 2 adenocarcinomas, 2 casos de metástases de melanoma, 2 casos de tumor carcinoide e 1 tumor estromal ­ GIST), 8 casos de Doença de Crohn, 4 casos de úlcera/estenose por uso de AINES, 1 caso de enterite actínica e 14 casos de pólipos do delgado de diâmetro suficiente para promover algum grau de estreitamento luminar. Nestes 38 casos, em 5 deles (13,4%) a CE ficou retida: 2 casos de Doença de Crohn, 2 casos de estenose e úlcera por uso de AINES e 1 caso de enterite actínica. Conclusões: estreitamento do lúmen do intestino delgado pode ter diversas causas, algumas reversíveis outras não, algumas progressivas, outras estáveis, e muitas delas, dependendo de sua causa e de seu grau, podem promover a retenção da CE. As causas de retenção observadas nesta casuística vão ao encontro com as principais causas de retenção apresentadas na literatura e destaca-se o fato de que, dos 10 casos de neoplasia, em nenhum deles a CE ficou retida.

Introduction: stenosing Injury of small intestine (ID), and their tumors in particular, are difficult to diagnose diseases. Endoscopic capsule (EC) represented notable advance in the recognition of same. However the EC in these stenosing lesions represents a potential risk that should always be avoided. Objective: to carry out a review of the preventive aspects of the situations where the EC could be retained, the therapeutical when retention occurs, and, mainly, to analyze, in a sequence of 215 cases with the EC, which the situations that represented retention risk and what those in which really happened to retention. Series: endoscopic examinations of 215 consecutive exams with the capsule were objects of analysis. Material and methods: upper gastrointestinal Endoscopy (UGE) and colonoscopy (CO) were the tests that all 215 patients effected before undergoing the examination. Several were the indications of the exam with the EC, but 85% of them were nominated by obscure cause gastrointestinal bleeding (digestive bleeding with UGE and CO negative) or to investigate cause anemia. No patient presented complaints or sub-oclusion signs before the exam. The EC used in all patients was of the mark GIVEN (Yokenan, Israel), M2A models and PillCam SB .Was considered retained the EC that, after three weeks of the completion of the examination, had not been eliminated, and radiological examination proved their presence in the small intestine. Results: 141 lesions were identified in these exams with 215 EC, 112 of them in the small intestine and 29 out of small intestine. In 26.6% (37 cases) of 112 cases with injuries in small intestine, there were changes that were promoting some degree of narrowing of the light of small intestine, namely: 10 cases of malignant neoplasm (3 adenocarcinomas , 2 lymphomas, 2 cases of metastasis of melanoma, 2 cases of carcinoid tumor and 1 stromal tumor-GIST), 8 cases of Crohn's disease, 4 cases of ulcer/stenosis by use of NSAIDS, 1 case of Actinic enteritis and 14 cases of polyps of small intestine of a suitable diameter to promote some degree of narrowing luminary. In these 38 cases, in 5 of them (13.4%) the EC was retained: 2 cases of Crohn's disease, 2 cases of stenosis and ulcers by use of NSAIDS and 1 case of Actinic enteritis. Conclusions: Narrowing of the lumen of the small intestine can have several causes, some not, some other reversible progressive other stable, and many of them, depending on their cause and their degree, can promote EC retention. The causes of observed retention in this series meet with the main causes of retention presented in the literature and highlights the fact that the 10 cases of neoplasia, in none of them the EC was retained.

Oclusión intestinal mecánica por fitobezoar / Mechanical intestinal occlusion by phytobezoar

Los bezoares son recolecciones de material orgánico no digerible, que luego de ser ingerido, se acumulan con el tiempo en el estómago o intestino delgado. La presentación más común del bezoar es en la forma de fitobezoar, el cual es causado por la acumulación de partículas sin digerir de origen vegetal. Los fitobezoares son responsables de sólo 0,4-4 por ciento de todas las obstrucciones intestinales. Se presenta un paciente masculino de 51 años hospitalizado e intervenido quirúrgicamente por presentar una oclusión intestinal que en el acto operatorio se constató que la causa fue por fitobezoar. La presentación como oclusión intestinal es muy rara, dado que sigue un curso insidioso y progresivo. El diagnóstico de oclusión intestinal por bezoar puede resultar muy difícil, ya que es una entidad muy poco frecuente y la historia de la ingesta de estos materiales es rara vez expresada espontáneamente. El diagnóstico de oclusión intestinal secundaria a fitobezoar requiere de tratamiento quirúrgico precoz, ya que su retraso conlleva a una elevada morbimortalidad. El fitobezoar es una causa rara de obstrucción de intestino delgado. Su sospecha clínica es frecuentemente pasada por alto. Es importante conocer la conducta a seguir en estos casos para garantizar un correcto tratamiento(AU)

Bezoars are collections of indigestible organic material, which accumulate in the stomach or small intestine after being ingested. The most common presentation of bezoar is in the form of phytobezoar, which is caused by the accumulation of undigested particles of vegetable origin. Phytobezoars are responsible for 0.4-4 percent of all intestinal obstructions. A 51-year-old male patient was hospitalized and operated, after presentation with an intestinal occlusion. During the surgical procedure, the cause was found to be fitobezoar. This type of intestinal obstruction is much rare; it follows an insidious and progressive course. Its diagnosis can be much difficult; history of disagreement regarding these materials is rarely expressed by patients spontaneously. The diagnosis of intestinal secondary occlusion by phytobezoar requires early surgical treatment because the delay has led to high morbidity and mortality. The phytobezoar is a rare cause of small bowel obstruction. Ii is often ruled out as clinical suspicion. It is important to know how to perform in these cases, in order to ensure proper treatment(AU)

Nueva técnica de diagnóstico y tratamiento en intestino delgado en Uruguay: primeras 20 enteroscopías de doble balón / New diagnostic and treatment technique in the small intestine in Uruguay. First 20 double balloon enteroscopies

Introducción: la video cápsula endoscópica (VCE) y la enteroscopía de doble balón (EDB) han cambiado radicalmente el diagnóstico y tratamiento de las patologías del intestino delgado (ID). Objetivo: valorar la utilidad diagnóstica y terapéutica de la EDB en enfermedades del ID. Pacientes, material y método: se realizó un estudio retrospectivo, descriptivo, de las primeras 20 EDB realizadas en nuestro servicio de endoscopía. Los pacientes fueron referidos por sospecha de patología del ID y contaban con estudios endoscópicos o imagenológicos previos. Se utilizó un videoenteroscopio EN-450, Fujinon, de 2.000 mm de longitud y sobretubo TS-12140 Fujinon. Resultados: se realizaron 20 EDB en 19 pacientes (14 hombres con edad promedio de 52,2 años y 5 mujeres con edad promedio de 58,6 años). El abordaje oral fue de elección en 15 procedimientos y el anal en cuatro, un paciente requirió doble abordaje. La indicación más frecuente fue la búsqueda de sangrado intestinal de origen desconocido y el hallazgo más común fueron las angiodisplasias, que fueron tratadas con coagulación con gas argón. Conclusiones: la EDB es una herramienta útil y necesaria para el diagnóstico y tratamiento de las patologías del ID, pudiendo brindar a nuestros pacientes una solución terapéutica que hasta hace pocos años no era posible en nuestro país.

Abstract Introduction: the capsule endoscopy video and the double balloon enteroscopy have dramatically changed diagnosis and treatment of small intestine pathologies. Objective: to assess the diagnostic and therapeutic usefulness of double balloon enteroscopy in small intestine diseases. Patients, material and method: we conducted a retrospective, descriptive study on the first 20 double balloon enteroscopies performed in our endoscopy service. Patients were referred for suspicion of small intestine pathology, and they had previous endoscopic exams or imagenology. An EN-450, 2,000 mm long Fujinon and TS-12140 overtube videoenteroscopy was used. Results: 20 double balloon enteroscopies were performed in 19 patients (14 men, average age was 58.6 years old). Oral approach was chosen in 15 procedures and the anal in four, a patient required double approach. The most frequent indication was search for intestine bleeding of unknown origin, and the most common finding was angiodysplasias, which were treated with argon gas coagulation. Conclusions: double balloon enteroscopies is a useful and necessary tool for the diagnosis and treatment of small intestine pathologies, and we were able to provide our patients with a therapy solution that was not available until recently.

Resumo Introdução: a cápsula endoscópica (VCE) e a enteroscopia de balão duplo (EDB) mudaram radicalmente o diagnóstico e o tratamento das patologias do intestino delgado (ID). Objetivo: avaliar a utilidade diagnóstica e terapêutica da EDB nas patologias do ID. Pacientes, material e método: um estudo retrospectivo, descritivo, das primeiras 20 EDB realizadas no nosso serviço de endoscopia foi realizado. Os pacientes foram referidos por suspeita de patologia do ID e já haviam realizado estudos endoscópicos ou imagenológicos. Utilizou-se um enteroscópio EN-450, Fujinon de 2.000 mm de comprimento e overtube TS-12140 Fujinon. Resultados: foram realizadas 20 EDB em 19 pacientes (14 homens com idade média 52,2 anos e 5 mulheres com idade média 58,6 anos). A abordagem de eleição foi por via oral em 15 procedimentos e por via anal em quatro sendo que foi necessário realizar uma dupla abordagem em um paciente. A indicação mais frequente foi a pesquisa de sangrado intestinal de origem desconhecida e o achado mais comum foi angiodisplasia; estas foram tratadas com coagulação com gás argônio. Conclusões: a EDB é uma ferramenta útil e necessária para o diagnóstico e tratamento das patologias do ID, podendo oferecer a nossos pacientes uma solução terapêutica que não estava disponível no nosso país até pouco tempo atrás.

Conservative Management of Adult Small Bowel Intussusception Detected at Abdominal Computed Tomography / 대한소화기학회지

BACKGROUND/AIMS: The incidence of adult small bowel intussusception detected at CT has increased with advanced imaging techniques and universal utilization of CT scan. We aimed to identify factors that could predict the necessity of surgical intervention in adult patients with small bowel intussusception detected at CT during the past decade. METHODS: There were 39 cases of adult small-bowel intussusception detected at CT from January 2004 to June 2014. The data on clinical factors, radiological factors and outcomes were collected by retrospectively reviewing all available medical records. Patients were classified as surgical group and conservative group according to the outcome. Association between predictive factors and outcome was assessed by Fisher's exact test and logistic regression models. RESULTS: Among a total of 39 patients, there were 32 patients (82%) in the conservative group and 7 patients (18%) in the surgical group. Spontaneous reduction was confirmed at short-term follow-up studies (abdominal ultrasonography [n=14], single contrast small bowel series [n=14], CT [n=4]) in the conservative group. No recurrence occurred during the median follow-up period of 14.1 months (range, 0-67.5 months). Patients in the surgical group had significantly higher white blood cell (WBC) counts (OR 1.001, p=0.048), more frequent obstruction (n=4 vs. n=4, p=0.022) or leading point (n=5 vs. n=0, p<0.001) and longer intussuception length (OR 1.929, p=0.032). CONCLUSIONS: Factors associated with the necessity to resort to surgical intervention in adults with small bowel intussusceptions were higher WBC counts, presence of obstruction or leading point, and longer intussuception length. Conservative management can be considered with short-term follow-up for those without these predictive factors.

A Case of a Jejunal Ectopic Pancreas Presenting as Obscure Gastrointestinal Bleeding / 대한소화기학회지

A jejunal ectopic pancreas, where pancreatic tissue is found outside of the usual anatomical location, is a rare submucosal tumor that may cause obscure gastrointestinal (GI) bleeding. After initial negative endoscopic evaluation of the obscure GI bleeding, including colonoscopy and/or upper endoscopy, it is reasonable to proceed with further evaluation of the small bowel. Diagnostic options for the evaluation of the small bowel may include capsule endoscopy, push enteroscopy, or barium contrast small bowel studies. Here, we report a case of obscure GI bleeding caused by a jejunal ectopic pancreas, diagnosed through capsule endoscopy and barium contrast small bowel studies, which was treated successfully with single incision access laparoscopy.

A Case of Isolated Small Intestinal Wall Calcification on Patient with Continuous Ambulatory Peritoneal Dialysis / 대한소화기학회지

The metastatic calcification is defined as the deposition of calcium salt in normal tissue with an abnormal serum biochemical environment, such as chronic kidney disease, hyperparathyroidism, and hypercalcemia related with malignancy. Although the metastatic calcification can develop in any organs and tissues, presenting its symptoms and complications are rare. Thus a few cases have been reported. This case shows the metastatic calcification of the small intestine without any peritoneal and mesenteric vascular calcification which was early diagnosed by computed tomography and mesenteric angiography in a patient with abdominal pain, receiving continuous ambulatory peritoneal dialysis due to end stage renal disease. The clinician should early consider the metastatic calcification as differential diagnosis when unidentified calcifications are noted in simple abdominal X-ray such as in the present case, and promptly confirm it by using appropriate diagnostic tests in order to prevent its complications and progression.

Evaluation of a simple belly-board device for reduction of small bowel inside rectal cancer radiotherapy fields

We evaluated the efficacy of a simple belly-board device [BED] designed and made in our department for reduction of small bowel inside the post-operative pelvic radiotherapy fields of rectal carcinomas. A very simple BBD was designed and manufactured in our department. It was made of acrylic glass, and was 128 cm long, 40 cm wide, and 9 cm high, with a 25x25 cm square opening, the lower border of which was set to be positioned about 3 cm above patients' iliac crest. Patients to be treated post-operatively for rectal cancers were simulated using oral contrast with and without the BBD for postero-anterior [PA] and lateral fields. The small bowel surface area [SBSA] inside the fields was measured and compared in the films with and without the BBD. Twenty-one patients, mean age 56 years, male-to-female ratio 2:1, 12 abdominoperineal [APR] and 9 low anterior resection [LAR], gave consent for this study. The mean SBSA were 7 and 13 cm[2] in the lateral fields and 29 and 60 cm[2] in the PA fields with and without the BBD, respectively [p = 0.001]. The mean reduction in SBSA was 61% in the lateral fields, 53% in the PA fields, and 57% in both lateral and PA fields [p<0.001]. The mean reduction in SBSA in lateral fields was 77% after LAR and 49% after APR [p=0.08]. This difference was not significant for PA fields. The only factor with a significant effect was operation type [LAR versus APR] for reduction of SBSA in lateral fields [p=0.05]. Gender, age, body mass index, and field sizes did not have a significant effect. The simple BBD could significantly reduce the SBSA inside the pelvic radiotherapy fields of rectal cancers. This reduction seems more pronounced after LAR in the lateral fields, compared to APR

Role of water soluble contrast agents in assigning patients to a non-operative course in adhesive small bowel obstruction

Adhesive small bowel obstruction [SBO] is a common surgical emergency. It is estimated that at least 60% of SBO are due to post-operative adhesions. Water soluble contrast agents [gastrografin] have been used to identify patients who might be treated non-operatively. This study aims to determine the role of gastrografin in adhesive intestinal obstruction patients. In this prospective study, 27 patients admitted between 1[st] August 2004 and 1[st] July 2006 with clinical signs suggestive of postoperative adhesive SBO met the inclusion criteria. After intravenous hydration, nasogastric tube insertion and complete suctioning of the gastric fluid, 100 ml of gastrograsfin was given and plain abdominal radiography was taken 6 hours and 24 hours if the contrast is not seen in the colon. Those in whom the contrast reached the colon in 24 hours were considered to have partial SBO and started oral intake. If gastrografin failed to reach the colon in 24 hours and the patient did not improve in the following 24 hours, laparotomy was performed. Conservative treatment was successful in 31 cases [91%] and 3 [9%] required operation. Patients treated conservatively had short hospital stay [mean=4 days] and tolerated oral feeding with no morbidity or mortality. Oral gastrografin helps in the management of patients with postoperative adhesive SBO

Small Bowel Volvulus Induced by Mesenteric Lymphangioma in an Adult: a Case Report

Mesenteric lymphangiomas are rare abdominal masses that are seldom associated with small bowel volvulus, and especially in adult patients. We report here on an unusual case of small bowel volvulus that was induced by a mesenteric lymphangioma in a 43-year-old man who suffered from repeated bouts of abdominal pain. At multidetector CT, we noticed whirling of the cystic mesenteric mass and the adjacent small bowel around the superior mesenteric artery. Small bowel volvulus induced by the rotation of the mesenteric lymphangioma was found on exploratory laparotomy. Lymphangioma should be considered as a rare cause of small bowel volvulus in adult patients.