Right-side diverticulitis.

Colonic diverticula develop at specific weak spots, where the vasa recta enter the colonic circular smooth muscle layer.1 They are usually seen in the left colon. Their most common complication is diverticulitis, with mild cases resolving even without antibiotic therapy.2 Right-side diverticulitis develops in only 1.5% of cases, primarily on the anterior aspect of the cecum, proximal to the ileocecal valve (80%).4 Given its low incidence, location, and the fact that it involves younger patients, a differential diagnosis is needed to rule out abdominal inflammatory conditions such as appendicitis or ileitis, as well as gynecological disorders. Diverticulitis is diagnosed using imaging modalities. Computed tomography (CT) is the modality of choice,5 and confirmation is required after clinical remission, primarily using colonoscopy. We studied a series of 3 cases of patients initially diagnosed with acute, uncomplicated right-side diverticulitis who were admitted to the Gastroenterology Department, Hospital de León, from January to December 2023. Our goal was to confirm a presumptive diagnosis of right-side diverticulitis using delayed endoscopy or barium enema to ascertain the presence of right-side diverticulosis and rule out other conditions manifesting with abdominal pain in the right iliac fossa. Cases 1 and 3 were admitted with an accurate diagnosis of right-side diverticulitis. Case 1 was confirmed by ambulatory colonoscopy, and case 3 was confirmed by barium enema because of a history of previous colonoscopy without findings. All three patients required surgical assessment to rule out appendicular involvement. The imaging technique of choice was CT, using the WSES scale for severity grading. Case 2 was diagnosed with right-side diverticulitis by means of ultrasonography, and its origin was later confirmed to be in the sigmoid colon. The remaining clinical, laboratory, and diagnostic characteristics are listed in Table 1.

Ogilvie, when medical and endoscopic treatment fail.

Ogilvie syndrome is a functional disorder of colonic motility that causes acute and progressive dilation, which can lead to necrosis and perforation. Early diagnosis and management are essential to avoid serious complications. The case of a patient with Ogilvie syndrome refractory to medical and endoscopic treatment that required surgery is presented. This is a 68-year-old man with decreased level of consciousness and abdominal distension for 3 days. Last bowel movement 4 days ago. The data and tests appear in table 1. We are faced with a patient with neurological alteration and hemodynamically unstable secondary to complicated Ogilvie syndrome. After admission to the ICU, where a 2.5 mg bolus of neostigmine was administered, he was transferred to the ward. Despite 250 mg of intravenous erythromycin every 6 hours together with metoclopramide every 8 hours, high doses of polyethylene glycol and daily cleansing enemas and rectal catheterization, only a brief and mild improvement is achieved. Given the failure of conservative measures, colectomy was performed, achieving complete resolution. Ogilvie syndrome is a functional disorder1 that usually associates predisposing factors that impact intestinal motility 2 ; In our case: bedridden, the use of anticholinergics, hydroelectric alteration both due to the use of antidepressants and the creation of a third space secondary to colonic dilation and severe intestinal ischemia². In one third it is resolved by early correction of the triggering factors, adding neostigmine if necessary with high rates of effectiveness¹. In our case, a second bolus of neostigmine could have been administered or even as an infusion since greater efficacy has been demonstrated in this way given its short half-life². Electrolyte imbalance is a predictor of poor response to neostigmine, a factor that was associated with our patient 3. Colonic decompression and finally surgery are reserved as a last measure, being necessary in a very small percentage as in this case 1. As a preventive measure, the administration of 29.5 g of oral polyethylene glycol per day has been effective 4. Therefore, we should suspect Ogilvie syndrome in patients with predisposing factors who present acute dilation of the colon without mechanical obstruction, and although it usually resolves with medical and endoscopic treatment, we should not delay surgery to avoid complications.

Cuando la obstrucción intestinalno es quirúrgica / When intestinal obstruction is not a surgical condition

We report the case of a middle-aged man who had undergone two diagnostic laparoscopies with no significant findings after he was attended at the emergency department with cramping pain, abdominal distention and vomiting, with radiological images simulating a small bowel obstruction. After multiple hospitalisations and an extensive set of tests, including a genetic study, he was diagnosed with chronic pseudo-obstruction, an uncommon, unrecognides syndrome with high morbidity. Being aware of this pathology can make it easier to diagnose, and thereby, we can avoid unnecessary surgical interventions, because its management and treatment are mainly based on pharmacological therapy. After a proper diagnosis our patient's progression was satisfactory due to the treatment introduced, with no further hospitalisations.(AU)

Retirform purpura, a rare chemoembolization adverse outcome.

Transcatheter arterial chemoembolization (TACE) is currently one of the standards of treatment for unresectable hepatocellular carcinoma in the intermediate stage. It is a minimally invasive procedure whose adverse outcomes are well documented. Among those considered uncommon, we find skin outcomes. We report a 73-year-old man who, after undergoing TACE, develops a necrotic retiform purpura due to occlusion of the microcirculation of the cutaneous and subcutaneous tissue caused by migration of doxorubicin spheres. This is an infrequent complication, which presents with pain in the affected area. Its management is based on prevention, which is the reason why awareness of this condition is so important.

Benign intestinal pneumatosis associated with congenital Morgagni-Larrey diaphragmatic hernia.

Intestinal pneumatosis (IN) is an uncommon radiological finding defined as the accumulation of air in the gastrointestinal tract wall. Its clinical signs are nonspecific and include symptoms such as diarrhea or abdominal pain. It includes benign entities (with subtle symptoms and the accumulation of air in the form of cysts that appear as clustered nodular lesions on the endoscopy, collapsible and soft); or severe cases (symptoms indicative of general health compromise and linear accumulation of air or free fluid suggestive of hollow viscus perforation); which require different management. We present the case of a patient diagnosed with benign intestinal pneumatosis (BIN), associated with anatomical changes due to a diaphragmatic hernia. CASE REPORT We report the case of an 86-year-old woman with a Morgani-Larrey congenital diaphragmatic hernia (HML) (2) admitted due to exacerbation of chronic baseline diarrhea. A colonoscopy with biopsies was performed, but the study was incomplete due to colonic torsion at the hepatic angle deriving from HML, with uncomplicated colonic mucosa and absence of cystic nodulations. Figure 1a. Biopsies ruled out organicity. The abdominal computed tomography (CT) scan performed revealed the accumulation of pneumoperitoneum bubbles in the distal ileum and suprahepatic wall without identification of continuity changes, or signs of visceral perforation. Figure 1b-c. The patient was diagnosed with BIN associated with an anatomical change (HML). Medical treatment was initiated with metronidazole at a dose of 1500 mg/day for 1 week, along with the patient's usual probiotics, and commercial compounds containing xyloglucan (pea protein) to restore the intestinal barrier function. (3). The patient was discharged with complete resolution of the diarrhea. No surgical intervention for her HML was required. DISCUSSION The clinical and radiological data in the presence of IN help us differentiate between severe cases and BIN, the latter being managed conservatively without the need for medical or surgical treatment. The intestinal barrier restoration measures implemented in our patient may have contributed to this resolution, although there is not enough scientific evidence to support this. The endoscopic image of nodular cysts is not always present in these cases, and the diagnosis of choice for this condition is radiological and based on exclusion. (4).

Hematoma post-endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures in the treatment of biliary-pancreatic diseases. Hematoma after ERCP is an infrequent and highly serious complication. We present three cases with hepatic hematoma after a CPRE.

When intestinal obstruction is not a surgical condition.

We report the case of a middle-aged man who had undergone two diagnostic laparoscopies with no significant findings after he was attended at the emergency department with cramping pain, abdominal distention and vomiting, with radiological images simulating a small bowel obstruction. After multiple hospitalisations and an extensive set of tests, including a genetic study, he was diagnosed with chronic pseudo-obstruction, an uncommon, unrecognides syndrome with high morbidity. Being aware of this pathology can make it easier to diagnose, and thereby, we can avoid unnecessary surgical interventions, because its management and treatment are mainly based on pharmacological therapy. After a proper diagnosis our patient's progression was satisfactory due to the treatment introduced, with no further hospitalisations.

Gastrointestinal lymphoma, a rare endoscopic lesion.

We present the case of a 77-year-old male patient with iron deficiency anemia. His personal medical history is: dyslipidemia, high-grade diffuse centrofollicular lymphoma localized in the tonsil in 1984 and metastatic prostate cancer treated with hormone therapy.