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)

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).

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.

Linfangiectasia intestinal primaria: una enfermedad rara como causa de enteropatía pierde-proteínas / Primary intestinal lymphangiectasia: a rare disease as a cause of protein-losing enteropathy

La linfangiectasia intestinal primaria es un trastorno raro asociado a una enteropatía pierde-proteínas. Las principales manifestaciones son las derivadas de la hipoalbuminemia. Para lograr el diagnóstico se necesita la imagen endoscópica típica de la linfangiectasia intestinal y el aumento de las cifras de alfa-1-antitripsina en las heces de 24 horas. El tratamiento es básicamente dietético. (AU)

Outcomes of peroral endoscopic myotomy in patients with spastic esophageal motility disorders that do not fulfill Chicago Classification criteria

Introduction: per-oral endoscopic myotomy (POEM) hasbecome a mainstream treatment for achalasia and is apromising therapy in spastic disorders.Methods: this is a retrospective study of prospectively collected data (case series). We present the first results of theuse of POEM in patients with atypical spastic esophagealmotor disorders that do not satisfy current Chicago Classification criteria. Seven consecutive patients with troublesome and persistent symptoms (12-180 months) relatedto atypical spastic esophageal motor dysfunction weresystematically assessed before and after POEM, the extentof which was tailored by manometric findings. In five ofthe patients, other endoscopic or surgical procedures hadfailed.Results: high-resolution manometry (HRM) showed a spasticesophageal body contractile segment in varying positionsand lengths along the esophageal body which did not meet Chicago Classification criteria. After POEM, dysphagia and/or chest pain had either resolved or was greatly reduced.HRM 3-6 months after myotomy showed that the regions ofspastic contraction targeted by myotomy had been ablated.There were no major complications. The clinical responseswere fully maintained up to the most recent assessmentsafter POEM (range 7-44 months).Conclussion: in our seven patients, POEM was a highly effective treatment for patients with troublesome symptoms related to atypical spastic esophageal motility disorders. (AU)

Primary intestinal lymphangiectasia: a rare disease as a cause of protein-losing enteropathy.

Primary intestinal lymphangiectasia is a rare disorder associated with protein-losing enteropathy. The main manifestations are those resulting from hypoalbuminemia. Diagnosis requires the typical endoscopic image of intestinal lymphangiectasia and increased 24-hour fecal alpha-1-antitrypsin clearance. Treatment is basically dietary.

Outcomes of peroral endoscopic myotomy in patients with spastic esophageal motility disorders that do not fulfill Chicago Classification criteria.

INTRODUCTION: per-oral endoscopic myotomy (POEM) has become a mainstream treatment for achalasia and is a promising therapy in spastic disorders. METHODS: this is a retrospective study of prospectively collected data (case series). We present the first results of the use of POEM in patients with atypical spastic esophageal motor disorders that do not satisfy current Chicago Classification criteria. Seven consecutive patients with troublesome and persistent symptoms (12-180 months) related to atypical spastic esophageal motor dysfunction were systematically assessed before and after POEM, the extent of which was tailored by manometric findings. In five of the patients, other endoscopic or surgical procedures had failed. RESULTS: high-resolution manometry (HRM) showed a spastic esophageal body contractile segment in varying positions and lengths along the esophageal body which did not meet Chicago Classification criteria. After POEM, dysphagia and/or chest pain had either resolved or was greatly reduced. HRM 3-6 months after myotomy showed that the regions of spastic contraction targeted by myotomy had been ablated. There were no major complications. The clinical responses were fully maintained up to the most recent assessments after POEM (range 7-44 months). CONCLUSION: in our seven patients, POEM was a highly effective treatment for patients with troublesome symptoms related to atypical spastic esophageal motility disorders.

Aspectos prácticos para la manometría esofágica de alta resolución / Practical aspects of high resolution esophageal manometry

La manometría esofágica de alta resolución (MAR) está en fase de desarrollo, como se evidencia por las diferentes clasificaciones de Chicago. Con el fin de unificar criterios en algunos aspectos prácticos con limitada evidencia científica se llevó a cabo la Primera Reunión Nacional de Consenso en Manometría de Alta Resolución del Grupo Español de Motilidad Digestiva, en la que participaron un amplio grupo de expertos. Las propuestas se basaron en una encuesta previa con 47 preguntas, la exhaustiva revisión de la bibliografía disponible y la experiencia de los participantes. Se plantearon aspectos metodológicos sobre criterios de análisis poco definidos de algunos nuevos parámetros de alta resolución y otros aspectos no considerados, como la actividad espontánea o las ondas secundarias, elaborándose conclusiones finales con utilidad práctica (AU)

High resolution esophageal manometry (HRM) is currently under development as can be seen in the various Chicago classifications. In order to standardize criteria in certain practical aspects with limited scientific evidence, the First National Meeting for Consensus in High Resolution Manometry of the Spanish Digestive Motility Group took place, bringing together a wide group of experts. The proposals were based on a prior survey composed of 47 questions, an exhaustive review of the available literature and the experience of the participants. Methodological aspects relating to the poorly defined analysis criteria of certain new high resolution parameters were discussed, as well as other issues previously overlooked such as spontaneous activity or secondary waves. Final conclusions were drawn with practical application (AU)

Practical aspects of high resolution esophageal manometry.

High resolution esophageal manometry (HRM) is currently under development as can be seen in the various Chicago classifications. In order to standardize criteria in certain practical aspects with limited scientific evidence, the First National Meeting for Consensus in High Resolution Manometry of the Spanish Digestive Motility Group took place, bringing together a wide group of experts. The proposals were based on a prior survey composed of 47 questions, an exhaustive review of the available literature and the experience of the participants. Methodological aspects relating to the poorly defined analysis criteria of certain new high resolution parameters were discussed, as well as other issues previously overlooked such as spontaneous activity or secondary waves. Final conclusions were drawn with practical applications.

Estudio comparativo del tratamiento médico frente al quirúrgico en el control ácido del esófago de Barrett / A comparison of medical versus surgical treatment in Barrett's esophagus acid control

INTRODUCCIÓN: El esófago de Barrett (EB) es una lesión esofágica ocasionada mayoritariamente por reflujo gastroesofágico ácido. El control del reflujo ácido es uno de los principales objetivos del tratamiento de esta patología. OBJETIVO: Evaluar en nuestra área de salud el grado de control del reflujo ácido en los pacientes con EB en función del tratamiento de mantenimiento recibido, médico o quirúrgico. MÉTODOS: Estudio retrospectivo de pacientes con diagnóstico endoscópico e histológico de EB. Un grupo de pacientes recibió tratamiento médico con inhibidores de la bomba de protones (IBP) y otro grupo fue sometido a intervención quirúrgica (funduplicatura de Nissen). Se compararon datos epidemiológicos y resultados de pHmetría (tiempo de pH < 4, reflujos prolongados > 5 min, puntuación de DeMeester) de cada grupo. La pH-metría se realizó con IBP en el grupo de tratamiento médico y en el grupo de cirugía sin consumo de antisecretores ácidos. Se definió fracaso del tratamiento como un pH < 4 total superior al 5%. RESULTADOS: Fueron incluidos 128 pacientes con EB (tratamiento médico 75, tratamiento quirúrgico 53). Ambas cohortes eran homogéneas respecto a sus características demográficas. Las puntuaciones de DeMeester, fracción de tiempo de pH < 4 y cantidad de reflujos prolongados fueron significativamente inferiores en los pacientes con funduplicatura frente a los que recibían IBP (p < 0,001). De forma global se apreció un fracaso de tratamiento en el 29% de los pacientes, que fue significativamente mayor en el grupo de tratamiento médico (40% vs 13%; p < 0,001). CONCLUSIONES: El grado de control del reflujo ácido gastroesofágico es subóptimo en un elevado porcentaje de pacientes con EB. El tratamiento médico ofrece resultados inferiores a la cirugía antirreflujo y se debería intentar optimizar sus resultados

INTRODUCTION: Barrett's oesophagus (BE) is an oesophageal injury caused by gastroesophageal acid reflux. One of the main aims of treatment in BE is to achieve adequate acid reflux control. OBJECTIVE: To assess acid reflux control in patients with BE based on the therapy employed: medical or surgical. METHODS: A retrospective study was performed in patients with an endoscopic and histological diagnosis of BE. Medical therapy with proton pump inhibitors (PPI) was compared with surgical treatment (Nissen fundoplication). Epidemiological data and the results of pH monitoring (pH time < 4, prolonged reflux > 5min, DeMeester score) were evaluated in each group. Treatment failure was defined as a pH lower than 4 for more than 5% of the recording time. RESULTS: A total of 128 patients with BE were included (75 PPI-treated and 53 surgically-treated patients). Patients included in the two comparison groups were homogeneous in terms of demographic characteristics. DeMeester scores, fraction of time pH < 4 and the number of prolonged refluxes were significantly lower in patients with fundoplication versus those receiving PPIs (P < .001). Treatment failure occurred in 29% of patients and was significantly higher in those receiving medical therapy (40% vs 13%; P < .001). CONCLUSIONS: Treatment results were significantly worse with medical treatment than with anti-reflux surgery and should be optimized to improve acid reflux control in BE. Additional evidence is needed to fully elucidate the utility of PPI in this disease

[A comparison of medical versus surgical treatment in Barrett's esophagus acid control]. / Estudio comparativo del tratamiento médico frente al quirúrgico en el control ácido del esófago de Barrett.

INTRODUCTION: Barrett's oesophagus (BE) is an oesophageal injury caused by gastroesophageal acid reflux. One of the main aims of treatment in BE is to achieve adequate acid reflux control. OBJECTIVE: To assess acid reflux control in patients with BE based on the therapy employed: medical or surgical. METHODS: A retrospective study was performed in patients with an endoscopic and histological diagnosis of BE. Medical therapy with proton pump inhibitors (PPI) was compared with surgical treatment (Nissen fundoplication). Epidemiological data and the results of pH monitoring (pH time <4, prolonged reflux >5min, DeMeester score) were evaluated in each group. Treatment failure was defined as a pH lower than 4 for more than 5% of the recording time. RESULTS: A total of 128 patients with BE were included (75 PPI-treated and 53 surgically-treated patients). Patients included in the two comparison groups were homogeneous in terms of demographic characteristics. DeMeester scores, fraction of time pH<4 and the number of prolonged refluxes were significantly lower in patients with fundoplication versus those receiving PPIs (P<.001). Treatment failure occurred in 29% of patients and was significantly higher in those receiving medical therapy (40% vs 13%; P<.001). CONCLUSIONS: Treatment results were significantly worse with medical treatment than with anti-reflux surgery and should be optimized to improve acid reflux control in BE. Additional evidence is needed to fully elucidate the utility of PPI in this disease.