[Cholecistocolic fistula: an uncommon cause of lower gastrointestinal bleeding]. / Fístula colecistocólica: una causa poco frecuente de hemorragia digestiva baja.

Cholecystocolic fistula is an uncommon biliary-enteric fistula with a variable clinical presentation that usually appears as a rare complication of gallstone disease. It can present with abdominal pain, nausea, weight loss, diarrhoea with or without associated steatorrhea, and dyspeptic symptoms. Rare cases have been reported with lower gastrointestinal haemorrhage and even with a gallstone ileous. The most useful techniques for diagnosis are CT, barium studies, and ERCP. We report a case of a cholecistocolic fistula in an elderly woman with multiple medical comorbidities that presented as lower gastrointestinal bleeding. She was explored with colonoscopy, abdominal CT and barium enema. She required a total of 4 units of whole blood and because of her comorbidities a decision was made not to proceed with invasive treatment. She had a good evolution and was asymptomatic two months later.

Estadificación prequirúrgica del cáncer de recto mediante RM y correlación radiopatológica / Preoperative staging MRI for rectal cancer and pathologic correlation

Fundamento. El objetivo de este trabajo es revisar lautilidad de la RM pélvica para la estadificación del cáncerde recto y establecer una correlación radiopatológica.Material y métodos. Se realizó un análisis retrospectivode 120 pacientes con una edad comprendida entre 43 y87 años a los que se realizó una RM pélvica para el estadiajede cáncer rectal en nuestro hospital entre los años2005 y 2010. Se catalogaron los pacientes de acuerdo ala clasificación TNM.Resultados. De los 120 pacientes, 80 fueron tratadoscon RT y/o QT neoadyuvante debido a que presentabanenfermedad localmente avanzada (T3-T4), afectaciónganglionar (N1-N2) o metástasis resecables. Con los40 pacientes que no fueron sometidos a tratamientoneoadyuvante se realizó una correlación entre los hallazgosde la RM y de la anatomía patológica con unaprecisión diagnóstica para predecir el estadio T del72%, el estadio N del 60% y la distancia a la FMR del87,5%.Conclusión. La RM pélvica es una técnica útil para laestadificación locorregional del cáncer de recto, obteniendouna buena correlación radiopatológica aunquela identificación de la afectación ganglionar es todavíaun problema diagnóstico(AU)

Background. Our aim is to asses the accuracy of MRIfor preoperative rectal cancer staging and to establisha histopathologic correlation.Material and methods. A retrospective analysis wasperformed on 120 patients aged between 43 and 87 withhistologically proven rectal cancer who underwent MRIfor preoperative staging in our hospital between 2005and 2010. Patients were categorized according to theTNM classification.Results. Eighty of 120 patients underwent adjuvantchemoradiotheraphy because they had advanceddisease (T3-T4), lymph node involvement (N1-N2) orresectable metastases. With 40 patients who didn’tundergo neoadjuvant therapy we performed a correlationbetween MRI and histopathological findings witha diagnostic accuracy in predicting T stage of 72%, Nstage of 60% and distance to the mesorectal fascia of87,5%.Conclusion. Pelvic MRI is a useful technique for locoregionalstaging of rectal cancer with a good radiopathologiccorrelation although the identification of nodaldisease is still a diagnostic problem(AU)

[Low-molecular-weight heparin without oral anticoagulants for the treatment of deep vein thrombosis]. / Tratamiento de la trombosis venosa profunda con heparinas de bajo peso molecular. Estudio comparativo con anticoagulación oral.

BACKGROUND AND METHODS: The available data on the utility of low-molecular-weight heparins (LMWH) in the secondary prophylaxis of deep vein thrombosis (DVT) are limited. We compared two cohorts of patients diagnosed of DVT. One group followed treatment with LMWH and the other group did with oral anticoagulants (acenocoumarol). Safety was evaluated by the rate of major hemorrhage and 2.5-years period fracture rate, and efficacy was evaluated as the rate of early recurrence and one-year recurrence rate. RESULTS: Of 65 patients treated with LMWH, the hemorrhagic rate was 1.5% (95% CI 0.08-9.40), fracture rate was 7.7% (95% CI 2.87-17.75), early recurrence was 1.5% (95% CI 0.08-9.40) and one-year recurrence was 3% (95% CI 53-11.64). In 118 patients treated with oral anticoagulants the hemorrhagic rate was 3.4% (95% CI 1.09-8.97), odds ratio 0.33, the fracture rate was 11% (95% CI 16.23-18.44), odds ratio 0.66, the early recurrence rate was 5% (95% CI 2.08-11.20), odds ratio 0.60 and one-year recurrence was 3.4% (95%CI 1.09-8.97), odds ratio 0.33. CONCLUSIONS: Secondary prophylaxis of DVT with LMWH is as safe and effective as classical treatment with oral anticoagulants. In this study the 2.5-year period fracture rate was similar in both groups of treatment.

[Heterotaxy syndrome (polysplenia) in an adult]. / Síndrome de heterotaxia (poliesplenia) en un adulto.

We present the case of a 63-year-old woman with heterotaxy syndrome and polysplenia who presented with clinical signs and symptoms of recurrent acute pancreatitis in which the biliary origin had been seen in the most recent episode. This syndrome is rare in adult patients because it is associated with congenital heart defects. It is important to know the visceral anomalies that are common in this syndrome to avoid confusing them with pathological processes.

[Utility of the clinical models for predicting pulmonary thromboembolism]. / Utilidad de los modelos clínicos en la predicción de tromboembolia pulmonar.

OBJECTIVE: We considered to evaluate the efectivity of the clinical models for predicting pulmonary thromboembolism (PE). METHODS: Retrospective application of three published clinical models (Wells or Canadian model, Geneva model and Pisa model) to patients unequivocally diagnosed of acute PE. RESULTS: We evaluate 120 patients [Mean age 71+/-13 years, males 63 (52%)]: Nineteen (16%) diagnosed with pulmonary arteriography and 101 (84%) diagnosed with helical computed tomography. In the Canadian model 24% patients were of high clinical probability, 59% intermediate and 17% low clinical probability. In Geneva model 21% patients belonged to high clinical probability, 69% intermediate and 10% low clinical probability. In Pisa model 49% patients were of high clinical probability, 45% intermediate and 6% of low clinical probability. Sensitivity was 0.59, 0.67 and 0.89 respectively. Factors associated with low probability were in Canadian model the heart rate, the absence of signs of deep venous thrombosis, the presence of an alternative diagnosis and the low rate of cancer. In Geneva model, age, normal heart rate and PaO2 higher 70 mm Hg were associated with low probability, while in Pisa model normal chest X-Ray and radiological signs of pulmonary oedema were also associated with low clinical probability. CONCLUSIONS: Although all three clinical model showed deficiencies Pisa model was the most suitable clinical model for predicting PE. An intermediate clinical probability in the three models, should not serve to rule out PE, besides it is remarkable that patients with low clinical probability still could have PE, providing for clinical models with a limited value.

[Acute lung embolism: a prospective study from May 1992, to May 2002]. / Embolismo pulmonar agudo. Un registro de 10 años: de mayo de 1992 a mayo de 2002.

INTRODUCTION: To define de prevalence, the clinical profile, the predisposing factors and the hospital evolution of clinical acute lung thromboembolism episodes. MATERIAL AND METHODS: A prospective study from May 1992, to May 2002, of acute lung embolism in an Internal Medicine ward with 8 beds in Hospital of Navarra (EPHONA). Clinical acute lung thromboembolism is defined by the clinical characteristics together the demonstration of thrombi in the lung arteries with arteriography, helicoid computerized axial tomography, or high or average probability lung gammagraphy, together the demonstration of deep venous thrombosis with doppler ultrasound or phlebography. We compared the clinical spectrum with that of international clinical series, evaluated the possibility of clinical syndromes according to the size of the affected vessel (central vs. peripheral), and compared the characteristics of patients with manifest deep venous thrombosis with those of the patients with clinical acute lung thromboembolism and without a known emboli source. RESULTS: In the period of 10 years, and with 2,493 patients admitted, 106 clinical acute lung thromboembolism were diagnosed (prevalence: 4.25%; CI: 3.51-5.14; p < 0.05); these patients were 72 +/- 11 years, in other words, an age 5 years higher than the rest of the patients (p < 0.001). There was a delay of 10 days from the beginning of the symptomatology up to the hospitalization. The clinical spectrum was similar to that of other reported series except by the presence of cough and pleural rub (p < 0.001). The main predisposing factors were immobility (41%) and cancer (25%). Hospital mortality was 3.77%. In 70 (66%) patients we obtained information on the affected vessel, not being fulfilled the association of specific clinical syndromes with the size of the vessel, although the patients with central clinical acute lung thromboembolism showed higher deterioration of gas exchange (p = 0.002) and higher activation of the fibrinolysis (p = 0.012) than patients with peripheral clinical acute lung thromboembolism. 35% of episodes of clinical acute lung thromboembolism developed without simultaneous deep venous thrombosis and showed higher disturbance of gas exchange (p = 0.03) and arterial hypotension (p = 0.02). CONCLUSIONS: Clinical acute lung thromboembolism is a frequent condition that occurs in patients of advanced age and that shows low hospital mortality when is diagnosed and treated even with a 10-day delay up to the diagnosis. The clinical spectrum is similar to that observed in other parts of the world, but the cough as a prominent a symptom and the pleural rub should propose other diagnostic alternatives. The size of the affected pulmonary vessel is not related with a specific clinical syndrome, although the central clinical acute lung thromboembolism evolves with higher disturbance of the gas exchange. In the third of clinical acute lung thromboembolism episodes an emboli source is not demonstrated, perhaps because all emboli has migrate to the pulmonary arteries; these episodes give rise to higher hypotension and disturbance of the gas exchange.

[Cystic pancreatic tumours and pseudo-tumoural lesions]. / Tumores quísticos pancreáticos y lesiones pseudotumorales.

Cystic lesions of the pancreas are infrequent, estimated at only some 1% of all pancreatic tumours and at some 10% of all pancreatic cysts. The pre-operational diagnosis is important for a suitable treatment, with valuable radiological techniques available today such as ultrasound, computerised tomography and magnetic resonance. In spite of this we have to accept that we are facing a group of tumours whose diagnosis is difficult, due to the great variety of cellular types existing within them.

Tumores quísticos pancreáticos y lesiones pseudotumorales / Cystic pancreatic tumours and pseudo-tumoural lesions

Las lesiones quísticas de páncreas son infrecuentes, estimándose en sólo un 1 por ciento de todos los tumores pancreáticos y en un 10 por ciento de todos los quistes pancreáticos. El diagnóstico preoperatorio es importante para un adecuado tratamiento, existiendo en la actualidad valiosas técnicas radiológicas como son los ultrasonidos, la tomografía computarizada y la resonancia magnética. A pesar de todo tenemos que aceptar que nos encontramos ante un grupo de tumores de difícil diagnóstico, debido a la gran variedad de tipos celulares que existen en los mismos. (AU)