Píloro doble. Presentación de un caso y revisión de la literatura / Double pylorus. Case report and literature review

RESUMEN El doble píloro es una comunicación anormal entre el antro gástrico y el bulbo duodenal y representa un raro hallazgo endoscópico. Se presentó un paciente de 80 años de edad, con antecedentes de hipertensión arterial, fumador inveterado, tomador de aspirina, que presentó melena aproximadamente 15 días antes del ingreso. La videoendoscopia reveló la existencia de dos orificios similares en el antro, que se comunicaban con el bulbo duodenal de manera independiente que fueron catalogados como píloros. La comunicación se constató con el paso del endoscopio a su través. Se impuso tratamiento médico con inhibidores de la bomba de protones y la evolución fue favorable. Es el cuarto caso reportado en la literatura en nuestro país y el primero en la provincia de Matanzas.

ABSTRACT Double pylorus is an abnormal communication between the gastric antrum and the duodenal bulb and represents a rare endoscopic finding. It is presented the case of a patient aged 80 years, with a background of arterial hypertension, inveterate smoker, taking aspirin, who presented melena about 15 days before the admission. The video-endoscopy revealed the existence of two similar orifices in the antrum that were independently communicating with the duodenal bulb and they went catalogued like pylori. The communication was proved by passing the endoscope through it. He was treated with IBP (the Spanish acronym for proton bomb inhibitors) and the evolution was favorable. It is the fourth case reported in the literature in Cuba and the first one in Matanzas.

Gastritis enfisematosa como causa infrecuente de abdomen agudo / Emphysematous gastritis as an infrequent cause of acute abdominal pain

La gastritis enfisematosa (GE) es una entidad poco frecuente, descripta por primera vez por Fraenkel en 1889. Se caracteriza por la invasión de la pared gástrica por gérmenes productores de gas, y se asocia a una alta morbimortalidad. Se describen en la bibliografía diferentes factores de riesgo que favorecerían su desarrollo, entre ellos ingesta de cáusticos, diabetes, abuso de alcohol, isquemia gástrica y cirugía de estómago. El cuadro clínico se caracteriza por dolor abdominal agudo y progresivo asociado a repercusión sistémica, sepsis severa, shock séptico, disfunción orgánica múltiple y muerte. Los métodos de diagnóstico por imágenes cumplen un rol fundamental en su abordaje, siendo la tomografía computada multidetector (TCMD) el método de elección, ya que cuenta con la capacidad de mostrar la presencia de gas en el interior de la pared gástrica (neumatosis gástrica) en asociación con el aumento de su espesor, siendo estos dos hallazgos la clave en el diagnóstico. También se encuentra presente un aumento de la densidad del tejido perigástrico compatible con cambios de tipo inflamatorio o infeccioso, y en algunas ocasiones se asocia a neumatosis portal. Se realiza una actualización del tema enfatizando el rol de la TCMD para su diagnóstico.

Emphysematous gastritis (EG) is a rare entity first described in 1889. It is characterized by the invasion of the gastric wall by gas-producing bacteria, and is associated with high morbidity and mortality. The clinical picture is characterized by acute abdominal pain associated with progressive systemic repercussions, severe sepsis, septic shock, multiple organ dysfunction, and death. Imaging methods play a fundamental role in the diagnosis. Multidetector Computed Tomography (MDCT) is the method of choice, since it has the ability to show the presence of gas within the gastric wall (gastric pneumatosis) in association with increased wall thickness. These two features are key findings for diagnosis. Increased density of perigastric tissue is frequently present, due to infectious or inflammatory changes; sometimes portal pneumatosis is present as well. An update on EG is presented, emphasizing the role of MDCT in diagnosis.

Histoplasmosis gastrointestinal: una presentación atipica / [Gastrointestinal histoplasmosis: an atypical presentation].

Histoplasmosis is a systemic mycosis caused by Histoplasma capsulatum. It is an endemic disease in the American continent. It is spread hematogenously and any organ can be affected. It is more frequent in immunodeficient patients and the most common opportunist mycosis associated with HIV Exclusive gastrointestinal involvement is rare and invariably mortal without treatment. It is considered to be impossible to diagnose the disease based on the macroscopic aspect of lesions. We report a 43-year-old male in apparent good health status who was admitted with intermittent proctorrhagia of one year of evolution associated to burning proctalgia, without any further symptoms. A videocolonoscopy (VCC) with proctologic exam was conducted The patient was warned about the potential orificial origin of the bleeding and the importance of screening for colorectal neoplasia. The proctologic exam revealed internal congestive hemorrhoids. VCC showed during the routine exploration of the terminal ileon lesions both in that level and rectum, although of a different morphology. The colon had normal endoscopic appearance. Biopsies of both lesions identified Histoplasma. Later studies diagnosed HIV/AIDS and the patient was referred to the infectology department to complete diagnostic tests and begin treatment of both diseases. In conclusion, we present an atypical case of this mycosis because of its exclusive gastrointestinal allocation, in anasymptomatic patient, in apparent good health, with unknown HIV/AIDS, who was admitted because of a proctorrhagia of orificial origin. Endoscopic biopsies of lesions of different morphologies, located in the terminal ileon and rectum, allowed the diagnosis of this disease, that had no clinical expression. This casual endoscopic diagnosis enabled to change the life expectancy of the patient. We consider that the described endoscopic lesions in rectum are of a particular morphology and can rarely be found in other pathologies. The diffusion of these images could warn other endoscopists of these phenomena.

Hallazgos colonoscópicos en una población de pacientes con test de sangre oculta en heces positivos / Colonoscopic findings in a population of patients with positive fecal occult blood test

Los test inmunológicos de sangre oculta en heces (SOH-I) constituyen actualmente una de las estrategias más extendidas para el cribado de cáncer colorrectal(CCR) y lesiones precancerosas avanzadas. Objetivos: Describir los hallazgos colonoscópicos en una población de pacientes con test de SOH-I positivos y conocer además la relación con la presencia de CCR. Métodos: Se recabaron de manera retrospectiva los datos de pacientes con test de SOH positivos, prueba inmunocromatográfica, en el período 2007-2008 que tenían colonoscopia. Se excluyeron aquellos pacientes con colonoscopia previa, enfermedad inflamatoria intestinal, colectomizados o hemicolectomizados,y aquellos con colonoscopia parcial y/o con mala preparación. Resultados:Se incluyeron 89 pacientes, 49 (55%) correspondieron al sexo femenino y 40(45%) al masculino. Respecto a los hallazgos colonoscópicos: 2 (2,2%) presentaronCCR, 33 (37%) tenían pólipos (8 pacientes con pólipos >= 10 mm), y hemorroides internas 54 (60,6%) pacientes. Conclusiones: La verdadera precisión de los test de SOH en términos de sensibilidad y especificidad para la detección de neoplasia colorrectal es difícil de conocer. Según estos hallazgos,la especificidad del test de SOH para el diagnóstico de CCR fue baja.

Upper gastrointestinal bleeding in children in southern Iran.

Objective. To find out whether the causes of upper GI bleeding in our center in a developing country differed from developed countries. Methods. Children presenting to our center with upper GI bleeding from March 2002 to March 2007, were retrospectively evaluated. Informations were retrieved from patient’s history and physical examination and results of upper GI endoscopy regarding etiology of bleeding, managements, use of medications which might predispose patient to bleeding, and the mortality rate. Results. From 118 children (67 boys; with age of 7.7±4.7 yrs) who underwent upper GI endoscopies, 50% presented with hematemesis, 14% had melena and 36% had both. The most common causes of upper GI bleeding among all patients were gastric erosions (28%), esophageal varices (16%), duodenal erosions (10%), gastric ulcer (8.5%), Mallory Weiss syndrome tear (7.8%), duodenal ulcer (6.8%), esophagitis (1.7%) and duodenal ulcer with gastric ulcer (0.8%). The causes of bleeding could not be ascertained in 20.5% of cases. No significant pre-medication or procedure related complications were observed. Endoscopic therapy was performed in 13.5% of patients. In 14.4% of patients, there was a history of consumption of medications predisposing them to upper GI bleeding. Two deaths occurred (1.7%) too. Conclusion. The findings in the present study showed that half of upper GI bleedings in pediatric patients from south of Iran, were due to gastric and duodenal erosions and ulcers. This study concludes that the causes of upper GI bleeding in children in our center of a developing country, are not different from those in developed ones.

A Case of Ischemic Skin Necrosis after Glypressin Therapy in Liver Cirrhosis / 대한소화기학회지

Terlipressin is a synthetic analogue of vasopressin, which has been used in the treatment of acute variceal hemorrhage. In contrast to vasopressin, terlipressin can be administered as intermittent injections instead of continuous intravenous infusion. Thus, it has a less adverse reaction than vasopressin. We report a case of ischemic skin complication in a cirrhotic patient treated with terlipressin. A 71-year-old man with liver cirrhosis was admitted because of hematemesis and melena. He was commenced on terlipressin at a dose 1 mg every 6 hours for the treatment of varicieal bleeding. After 36 hours of treatment, skin blistering and ecchymosis was noted on the skin of his upper thigh, scrotal area and trunk. We found that terlipressin was a possible cause of ischemic skin complication based on the skin biopsy finding. Terlipressin may induce a complication of the ischemic event. In spite of rarity, special attention needs to paid on the peripheral ischemic complication of terlipressin.

Large Brunneroma presenting with bleeding.

Brunner's gland adenoma (Brunneroma) is a rare entity. We report a patient who presented with severe anemia due to bleed from a large Brunneroma arising from the duodenal bulb, and was managed successfully by surgical excision of the tumor.

Malignant duodenal stromal tumor: the first case report in Thailand and review of the literature.

The authors presented a middle aged Thai patient with malignant duodenal stromal tumor identified at a tertially care centre in Thailand. The patient presented with obscure gastrointestinal bleeding and the small bowel endoscopy revealed a bleeding tumor mass at the fouth part of the duodenum. The patient underwent segmental duodenectomy with end to end anstosomis. The histopathology of the tumor composed of interlacing bundles of spindle cells with oval to elongated pleomorphic nuclei and eosinophilic cytoplasm. The immunohistochemistrical study confirmed the diagnosis of malignant stromal tumor with smooth muscle differentiation. The computer tomography scan (CT scan) of the abdomen showed no evidence of metastasis. Postoperatively, the patient's clinical condition showed continuous improvement without further gastrointestinal bleeding. The patient has remained healthy up to present (six months of follow-up). A high level of suspicion to detect this malignant tumor especially in a patient presenting with obscure gastrointestinal bleeding and effective surgical treatment allow better clinical outcome in this rare and fatal malignancy.

Leucemia promielocítica aguda infantil: documentación de un caso clínico / Infantile acute promyelocytic leukemia: documentation of a clinical case

Se presenta el caso de una niña de 9 años, eutrófica, que ingresa con astenia, anorexia, hipertrofia gingival, hepatoesplenomegalia y petequia y hematomas. La citología de médula ósea es característica de Leucemia promielocítica aguda, confirmada por citoquímica y cariotipo con la característica translocación de brazos largos entre los cromosomas 15 y 17. A pesar de las graves complicaciones infecciosas que presentó, la respuesta terapéutica fue buena, hallándose en remisión hasta la actualidad.

Ectasia vascular del antro (EVA) o watermelon stomach (WS): poco frecuente causa de anemia / Gastric vascular ectasia (GAVE) or wartemelon stomach (WS): unfrequent cause of anemia

La ectasia vascular del antro (EVA) o watermelon stomach (WS) es una causa poco frecuente de anemia o hemorragia digestiva alta manifesta en pacientes de edad avanzada. Presentamos 5 apcientes, todas mujeres, edad promedio 79 años, 4 anémicas de larga evolución y 1 con melena. Tres tenían endoscopía típica de WS, 2 tenían patente difusa. Las 5 con anatomía patológica positiva: ectasias vasculares y/o microtrombos fíbrinosos y proliferación fibromuscular en la l mina propria. La biopesia esdoscópica es tan fiel como el estudio de la pieza de antrectomía. Ninguna tenía hipertensión portal, aunque la EVA sería una entidad diferente a la gastropatía vascular del cirrótico. El tratamiento conssitió en electrocoagulación monopolar de las lesiones tras fracaso del tratamiento médico en 1 caso, corticoterpia mas ferroterapia en 3, mientras que el restante no requiere tratamiento por el momento. Conclusiones: la EVA debe tenerse presente en pacientes anémicos crónicos sien diagnóstico, de edad avanzada. Las im genes endoscópicas no siempre son las típicas del estómago en sandía (WS). Se debe biopsiar el antro gastrico ante la duda. Si no responden al tratamiento con corticoides y/o hierro, el tratamiento de elección es el laser o el "heat electrocoagulación monopolar o la esclerosis. La cirurgía es el último recurso a aplicar.