Overhydration, A New Risk Factor for Peritonitis in Peritoneal Dialysis.

INTRODUCTION: Overhydration (OH) remains a recurrent problem in peritoneal dialysis (PD), with deleterious effect in outcomes. Recent evidence suggests a direct relation between OH and increased peritonitis risk. The mechanisms of this connection are not well defined, but gut wall edema and malnutrition are probably involved. METHODS: Our aim was to assess OH as a risk factor for peritonitis in patients on PD. Retrospective study was done in a PD program with a bio impedance analysis. The investigator reviewed patient charts and documents. The Fresenius® Body Composition Monitor was used to obtain hydration parameters. OH was considered when Overhydration/Extracellular Water (OH/ECW) parameter was over 15% of the dry weight. The diagnosis of peritonitis was made according to the International Society of Peritoneal Dialysis guidelines. Associations between peritonitis rate and the collected variables were assessed using Chi-square test and Pearson's correlation. RESULTS: An association between OH and the risk of peritonitis was established. CONCLUSION: OH is prevalent in our patients undergoing PD and it is a modifiable risk factor for peritonitis. The bio impedance analysis is economical and should be used in association with a physical exam and treatment results to achieve the normo-hydrated status in those patients.

Persistent Peristomal Leakage from Percutaneous Endoscopic Gastrostomy Successfully Treated with Argon Plasma Coagulation.

INTRODUCTION: Percutaneous endoscopic gastrostomy is a safe and effective technique and its use is widely spread. Peristomal leakage may occur within the first few days after gastrostomy tube placement and also in the mature gastrostomy tract. The initial treatment involves conservative measures. If the leakage does not resolve, different endoscopic interventions could be necessary with consequent impairing of enteral nutrition and, in some cases, the need of creating a new gastro-cutaneous fistula. CASE REPORT: We present 4 consecutive cases complicated with late peristomal leakage and medical treatment failure. These patients underwent upper digestive endoscopy, and circumferential fulguration of the mucosa surrounding the tube with pulsed argon plasma coagulation (APC) at 50 W and 1 L/min flow rate was performed. Additional long through-the-scope clips were applied in 2 cases, since the inner orifice remained enlarged, in order to obtain a better closure. Complete leakage and skin changes resolution occurred between 2 and 6 weeks after the procedure (mean 3.5 weeks). The overall mean follow-up was 19 months after the endoscopic procedure (maximum 30 months, minimum 10 months). There was no recurrence of leakage. CONCLUSION: The use of APC alone or combined with long through-the-scope clips in large internal stoma orifice resolved persistent leakage from percutaneous endoscopic gastrostomy in all 4 presented cases without complications. In our case series, this technique appeared to be an effective, safe, and relatively low-cost alternative to the treatment of persistent peristomal leakage of the mature gastrostomy tract.

INTRODUÇÃO: A gastrostomia percutânea endoscópica é uma técnica amplamente usada sendo eficaz e segura. O extravasamento persistente é uma complicação possível do procedimento podendo ocorrer precocemente ou apresentar-se de forma tardia. O tratamento inicial passa por medidas conservadoras. Se o extravasamento persistir apesar das mesmas, várias intervenções endoscópicas podem ser necessárias com interrupção subsequente da nutrição entérica e nalguns casos pode ser mesmo necessário a criação de uma nova fístula gastro cutânea. APRESENTAÇÃO DOS CASOS: Relato de quatro casos consecutivos complicados com extravasamento persistente tardio e com falência ao tratamento conservador. A todos os doentes foi realizada uma endoscopia digestiva alta com fulguração circunferencial com coagulação árgon-plasma (APC) a 50 Watts e fluxo 1L/min. Adicionalmente, em dois casos por presença de orifício interno de grandes dimensões foram aplicados clips longos de modo a obter melhor aproximação dos bordos. Foi conseguida resolução completa do extravasamento e consequentemente das alterações cutâneas em 2 a 6 semanas (média 3,5 semanas). O seguimento após o procedimento foi de 19 meses (máximo 30 meses, mínimo 10 meses). Não se verificaram recorrências do extravasamento. CONCLUSÃO: O uso de APC isoladamente ou em combinação com clips longos nos casos de orifício interno de grandes dimensões resolveu o extravasamento persistente após PEG nos quatro doentes sem registo de complicações. Na nossa série, esta técnica parece ser uma alternativa efetiva, segura e de relativo baixo custo para o tratamento do extravasamento persistente tardio.

Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in the Indomethacin Era - A Prospective Study.

BACKGROUND AND AIMS: Although endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure used to treat conditions affecting the biliopancreatic system, it can lead to several complications. Post-ERCP pancreatitis (PEP) is the most frequent one, with an incidence ranging from 3 to 14%. Our aim was to assess the potential risk factors associated with PEP occurrence in patients undergoing ERCP with indomethacin prophylaxis. METHODS: Prospective, single-center, real-world observational study (January to December 2015) with inclusion of patients submitted to ERCP, where relevant patient-related and procedure-related data had been collected. Patients had to have been admitted for a minimum of 24 h in order to establish the presence of early complications. All patients were submitted to PEP prophylaxis with 1 or 2 methods: rectal indomethacin and pancreatic duct (PD) stenting. RESULTS: A total of 188 patients who had undergone ERCP were included (52.7% women; mean age 69.2 ± 16.0 years) and PEP was diagnosed in 13 (6.9%). PEP prophylaxis consisted of indomethacin in all cases (100%) and PD stenting in 7.4%. The pancreatitis was mild in 11 patients (84.6%) and severe in the other 2. One of them died (0.5%). None of the patient-related risk factors were associated with changes in PEP probability. Of all patients, 33.0% had 2 or more procedure-related risk factors. A higher number of synchronous procedure-related risk factors showed a statistically significant correlation with PEP occurrence, p = 0.040. CONCLUSIONS: The 6.9% PEP rate is considered acceptable since 33.0% patients had a medium-high risk for PEP due to challenging biliary cannulation. The total number of procedure-related risk factors seems to play a critical role in the development of PEP despite indomethacin prophylaxis.

INTRODUÇÃO E OBJETIVO: A colangiopancreatografia retrógrada endoscópica (CPRE) é um método terapáutico crucial em doenças biliopancreáticas, mas pode levar a várias complicações. A pancreatite pós-CPRE (PPC) é a complicação mais frequente, podendo atingir uma incidáncia de 3 a 14%. O objetivo foi estudar os fatores de risco associados à PPC em doentes submetidos a CPRE com profilaxia por indometacina. MÉTODOS: Estudo prospetivo e observacional com inclusão (janeiro-dezembro 2015) de doentes submetidos a CPRE num centro terciário, em condições de prática real. Foram registados os dados relevantes do doente e procedimento. Os doentes foram observados em internamento por, pelo menos, 24 horas para deteção de complicações. Todos os doentes incluídos foram submetidos a profilaxia de PPC, com recurso a um ou dois métodos indometacina retal e prótese pancreática. RESULTADOS: Estudados 188 doentes, 52.7% mulheres, com idade média de 69.2 ± 16.0 anos. Profilaxia de PPC envolveu indometacina em todos os casos (100%) e colocação de prótese pancreática em 7.4%. Registou-se PPC em 13 doentes (6.9%), sendo que 11 (84.6% de PPC) tiveram pancreatite ligeira. Os restantes dois apresentaram pancreatite grave e um deles faleceu (0.5%). Nenhum dos fatores de risco do doente se relacionou com maior probabilidade de PPC. Do total de doentes, em 33.0% estiveram presentes 2 ou mais fatores de risco associados ao procedimento. A presença simultânea de um número superior de fatores de risco associados ao procedimento relacionou-se significativamente com a ocorráncia de PPC, p = 0.040. CONCLUSÕES: Considera-se aceitável a taxa de PPC de 6.9%, tendo em conta que 33.0% dos doentes apresentavam risco médio-alto para PPC devido a canulação biliar difícil. O número total de fatores de risco associados ao procedimento parece desempenhar um papel crucial no desenvolvimento de PPC, apesar da profilaxia com indometacina.

Efficacy of Endoscopic Retrograde Cholangiopancreatography in the Treatment of Biliary Complications following Liver Transplant: 10 Years of a Single-Centre Experience.

BACKGROUND AND AIMS: Biliary tract complications following liver transplant remain an important source of morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) has become a common therapeutic option before other invasive procedures. The aim of this study was to evaluate ERCP efficacy in managing this type of complications. METHODS: Retrospective study of all patients who underwent therapeutic ERCP due to post-liver transplant biliary complications between September 2005 and September 2015, at a deceased donor liver transplantation centre. RESULTS: Therapeutic ERCP was performed in 120 patients (64% men; mean age 46 ± 14 years). Biliary complications were anastomotic strictures (AS) in 70%, non-anastomotic strictures (NAS) in 14%, bile leaks (BL) in 5.8%, and bile duct stones (BDS) in 32%. The mean time between liver transplant and first ERCP was: 19 ± 30 months in AS, 17 ± 30 months in NAS, 61 ± 28 months in BDS, and 0.7 ± 0.6 months in BL (p < 0.001). The number of ERCP performed per patient was: 3.8 ± 2.4 in AS, 3.8 ± 2.1 in NAS, 1.9 ± 1 in BDS, and 1.9 ± 0.5 in BL (p = 0.003). The duration of the treatment was: 18 ± 19 months in AS, 21 ± 17 months in NAS, 10 ± 10 months in BDS, and 4 ± 3 months in BL (p = 0.064). Overall, biliary complications were successfully managed by ERCP in 46% of cases, either as an isolated procedure (43%) or rendez-vous ERCP (3%). Per complication, ERCP was effective in 39% of AS, in 12% of NAS, in 91% of BDS, and in 86% of BL. Globally, the mean follow-up of the successful cases was 43 ± 31 months. Percutaneous transhepatic cholangiography and/or surgery were performed in 48% of patients in whom ERCP was unsuccessful. The odds ratio for effective endoscopic treatment was 0.2 for NAS (0.057-0.815), 12.4 for BDS (1.535-100.9), and 6.9 for BL (0.798-58.95). No statistical significance was found for AS (p = 0.247). CONCLUSIONS: ERCP allowed the treatment of biliary complication in about half of patients, avoiding a more invasive procedure. Endoscopic treatment was more effective for BDS and BL.

INTRODUÇÃO: As complicações biliares após transplante hepático são uma fonte importante de morbilidade e mortalidade. A colangiopancreatografia retrógrada endoscópica (CPRE) é a primeira opção de tratamento em muitos casos, previamente a procedimentos mais invasivos. O objetivo deste trabalho foi avaliar a eficácia da CPRE no tratamento destas complicações. DOENTES E MÉTODOS: Estudo retrospetivo de todos os doentes submetidos a CPRE terapêutica devido a complicações biliares após transplante hepático, entre setembro de 2005 e setembro de 2015. RESULTADOS: Incluídos 120 doentes submetidos a CPRE terapêutica, sendo 64% do sexo masculino, com idade média de 46 ± 14 anos. Complicações biliares: estenose da anastomose (EA) em 70%, estenose não anastomótica (ENA) em 14%, coledocolitíase em 32% e fuga biliar (FB) em 5,8%. Tempo entre transplante e primeira CPRE (meses): 19 ± 30 nas EA, 17 ± 30 nas ENA, 61 ± 28 na coledocolitíase e 0,7 ± 0,6 na FB (p < 0,001). Número de CPRE por doente: 3,8 ± 2,4 nas EA, 3,8 ± 2,1 nas ENA, 1,9 ± 1 na coledocolitíase e 1,9 ± 0,5 na FB (p = 0,003). Duração do tratamento (meses): 18 ± 19 nas EA, 21 ± 17 nas ENA, 10 ± 10 na coledocolitíase e 4 ± 3 nas FB (p = 0,064). Globalmente, a CPRE terapêutica foi eficaz em 46% dos casos (como procedimento isolado em 43% e por rendez-vous em 3%). Eficácia por complicação: 39% nas EA, 12% nas ENA, 91% na coledocolitíase e 86% nas FB. O tempo médio de follow-up foi de 43 ± 31 meses. Em 48% dos doentes, foi realizada terapêutica por colangiografia percutânea e/ou cirurgia por ineficácia da CPRE. Odds ratio para um tratamento endoscópico eficaz: 0,2 para ENA (0,057­0,815), 12,4 para coledocolitíase (1,535­100,9) e 6.9 para FB (0,798­58,95). Não houve diferenças estatisticamente significativas para a presença de uma EA. CONCLUSÕES: A CPRE foi eficaz no tratamento de complicações biliares após transplante hepático em cerca de metade dos casos, evitando outros procedimentos invasivos. O tratamento endoscópico foi particularmente eficaz em casos de coledocolitíase e FB.

Endoscopic Management of Colonic Perforation due to Ventriculoperitoneal Shunt: Case Report and Literature Review.

The authors report the case of a 41-year-old woman with a colonic perforation due to a ventriculoperitoneal shunt (VPS) catheter. Left-sided colonic perforation was diagnosed by abdominal computed tomography 28 years after shunt placement, following acute meningitis caused by Escherichia coli. The proximal end of the VPS was exteriorized and it was decided to remove the distal end by colonoscopy. After pulling out the catheter with a polypectomy snare, it broke at the site where it was entering the colon, leaving a small perforation in the colonic wall which was closed with 2 endoclips. The endoluminal fragment of the catheter, being 20 cm in length, was removed through the rectum. The patient is asymptomatic at the 12-month follow-up. A review of the literature regarding 9 endoscopically managed cases of digestive tract perforation caused by VPS is presented.

Os autores descrevem o caso de uma mulher de 42 anos com perfuração do cólon por cateter de derivação ventrículo-peritoneal (DVP) colocado 28 anos antes. No contexto de meningite aguda a Escherichia coli, o estudo complementar com tomografia computadorizada abdominal identificou a extremidade distal do cateter de DVP no interior do lúmen do cólon esquerdo. Após remoção da extremidade ventricular do cateter, optou-se pela tentativa de extração da extremidade intra-cólica por colonoscopia. Durante a extração do cateter com ansa de polipectomia, constatou-se secção do mesmo no local de entrada na parede cólica, observando-se um pequeno orifício. Procedeu-se ao encerramento da perfuração com 2 endoclips e extração do fragmento livre endoluminal do cateter, com cerca de 20 cm, pelo reto. A doente permanece assintomática após 12 meses de seguimento. Uma revisão da literatura identificou 9 casos de perfuração do tubo digestivo por cateter de DVP tratados com endoscopia.

Endoscopic management of afferent loop syndrome caused by enteroliths and anastomotic stricture. A case report.

Afferent loop syndrome (ALS) is a rare complication of Billroth-II gastrojejunostomy. Causes of afferent loop obstruction include adhesions, internal hernias, intestinal strictures or malignancy. Obstruction caused by enteroliths is rare and usually requires surgery. We present the case of a 90-year-old man with a Billroth-II performed 50 years earlier and three acute pancreatitis. He presented with acute abdominal pain, without signs of pancreatitis. Upper digestive endoscopy revealed a punctiform anastomotic stricture of the afferent loop. Fluoroscopy-guided contrast injection showed a dilated loop with multiple filling defects. After through-the-scope balloon dilation, multiple calculi similar to gallstones were observed in the afferent loop and were removed with a basket. There were no signs of choledochoduodenal fistula or abnormalities in the ampulla of Vater, leading us to assume the formation of intestinal calculi. This case represents a rare cause of ALS, emphasizing the possibility of solely endoscopic treatment. The stone was removed and the anastomotic stricture which was the underlying cause of the enterolith formation was treated by endoscopy. Endoscopic management of enterolith-related ALS is technically difficult and rarely reported. To our knowledge, there are two cases in which electrohydraulic lithotripsy was used to fragment a large enterolith in the afferent loop. This includes one report of failed endoscopic retrieval of an enterolith and in another case a perforation after an attempt to grasp the stone with a basket. ALS has multiple causes and non-specific clinical manifestations. We highlight the importance of high clinical suspicion and individualized treatment according to the patient's condition, severity, ALS etiology and locally available treatment possibilities.

Endoscopic management of afferent loop syndrome caused by enteroliths and anastomotic stricture. A case report

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