Acute pancreatitis as the initial manifestation of an ampullary neuroendocrine tumor.

Acute pancreatitis is a common condition in Gastroenterology. Among its possible etiologies are ampullary tumors, rare neoplasms whose growth can hinder pancreatic drainage. Although they are usually epithelial, adenomas and adenocarcinomas, less commonly other histological types have been reported, such as neuroendocrine tumors. They constitute a small percentage of both ampullary tumors and neuroendocrine tumors of the digestive tract, classified into three histological grades based on mitotic count and Ki-67. Although the diagnosis is usually incidental, its main form of presentation is clinical or analytical cholestasis, with acute pancreatitis being an exceptional initial presentation. Endoscopic resection is the treatment of choice for well-differentiated tumors without evidence of local infiltration of the duodenal wall or intraductal growth greater than 10mm, with endoscopic ultrasound playing a key role in this assessment. We present the case of a 45-year-old cholecystectomized woman who was admitted to our service with a condition compatible with acute pancreatitis, initially suspected to be of biliary origin. After several radiological and endoscopic studies, an enlargement of the duodenal papilla suggestive of ampulloma was detected. Histological examination demonstrated a well-differentiated neuroendocrine tumor of the duodenal papilla which, lacking evidence of local duodenal infiltration or intraductal growth, was successfully resected endoscopically.

Immuno-mediated colitis induced by nivolumab that mimics endoscopically and histologically an ulcerative colitis.

Immunotherapy has revolutionized the management of oncological pathology, demonstrating effectiveness in treating various cancers by stimulating the immune system against tumor cells. Among the immunotherapy drugs are programmed cell death protein 1 (PD-1) inhibitors, such as Nivolumab, which, by blocking this receptor on the surface of T lymphocytes, enhance the immune response. Despite their significant benefits, these agents present specific adverse effects on healthy tissues that need to be understood. One of these effects is immune-mediated colitis, a potentially serious gastrointestinal disorder that may require the permanent discontinuation of the drug. Although it can occur with various immunotherapy regimens, it occurs more frequently with anti-CTLA4 agents like Ipilimumab, with its incidence much lower with anti-PD1 agents. We present the case of a 62-year-old male diagnosed with metastatic clear cell renal carcinoma treated with radical nephrectomy and subsequent palliative systemic treatment with Nivolumab. After the third cycle of immunotherapy, he developed abdominal pain and diarrhea. Colonoscopy revealed continuous mucosal inflammation up to the cecum, erosions, exudates, and loss of the vascular pattern. Biopsies showed signs of active colitis, cryptic abscesses, and focal cryptitis, all consistent with a case of immuno-mediated colitis induced by Nivolumab that mimics, both endoscopically and histologically, the findings found in ulcerative colitis.

Torsade de pointes secondary to long QT syndrome after intragastric balloon placement. A rare but severe complication.

The obesity pandemic is becoming one of the most prevalent diseases nowadays. There is a wide spectrum of treatment, ranging from hygienic-dietary measures to bariatric surgery. Endoscopic intragastric balloon placement is becoming increasingly more frequent, due to its technical simplicity, safety and short-term success(1). Although complications are rare some can be severe, so pre-endoscopic evaluation must be carried out carefully. A 43-year-old woman with a history of grade I obesity (BMI 32.7) had an Orbera® intragastric balloon implanted successfully. After the procedure she presented frequent nausea and vomiting, partially controlled with antiemetics. She attended the Emergency Department(ED) with a persistent emetic syndrome - oral intolerance and short-term loss of consciousness(syncope), for which she was admitted. Lab tests showed metabolic alkalosis with severe hypokalemia(K+ 1.8mmol/L), so fluid therapy was initiated for hydroelectrolytic replacement. During the patient's stay in the ED, two episodes of polymorphic ventricular tachychardia "Torsades de Pointes" (PVT-TDP) occurred, leading to cardiac arrest and requiring electrical cardioversion to restore sinus rhythm, in addition to a temporary pacemaker placement. Telemetry showed a corrected QT interval of >500ms, compatible with Long QT Syndrome(LQTS). Once the patient was hemodynamically stabilized a gastroscopy was performed. The intragastric balloon located in the fundus was removed using an extraction kit, puncturing and aspirating 500ml of saline solution, and extracting the collapsed balloon without any complications. The patient achieved an adequate oral intake afterwards, and no recurrence of emetic episodes were noticed. Previous ECGs revealed a prolonged QT interval and a genetic study confirmed a congenital type 1 LQTS. Treatment was initiated with beta-blockers and a bicameral automatic defibrillator was implanted in order to prevent recurrences. Intragastric balloon placement is generally a safe procedure, serious complications present in 0.70% of cases(2). It is essential to have a proper pre-endoscopic evaluation, including patient's medical history and comorbidities. Episodes of PVT-TDP may present precipitated by certain medications (eg. metoclopramide) or hydroelectrolytic imbalances (eg, hypokalemia)(3). A standardized evaluation of ECG before intragastric balloon placement may be useful to prevent these rare but serious complications.

Torsade de pointes secondary to long QT syndrome after intragastric balloon placement. A rare but severe complication

The obesity pandemic is becoming one of the most prevalent diseases nowadays. There is a wide spectrum of treatment, ranging from hygienic-dietary measures to bariatric surgery. Endoscopic intragastric balloon placement is becoming increasingly more frequent, due to its technical simplicity, safety and short-term success(1). Although complications are rare some can be severe, so pre-endoscopic evaluation must be carried out carefully. A 43-year-old woman with a history of grade I obesity (BMI 32.7) had an Orbera® intragastric balloon implanted successfully. After the procedure she presented frequent nausea and vomiting, partially controlled with antiemetics. She attended the Emergency Department(ED) with a persistent emetic syndrome - oral intolerance and short-term loss of consciousness(syncope), for which she was admitted. Lab tests showed metabolic alkalosis with severe hypokalemia(K+ 1.8mmol/L), so fluid therapy was initiated for hydroelectrolytic replacement. During the patient’s stay in the ED, two episodes of polymorphic ventricular tachychardia “Torsades de Pointes” (PVT-TDP) occurred, leading to cardiac arrest and requiring electrical cardioversion to restore sinus rhythm, in addition to a temporary pacemaker placement. Telemetry showed a corrected QT interval of >500ms, compatible with Long QT Syndrome(LQTS). Once the patient was hemodynamically stabilized a gastroscopy was performed. The intragastric balloon located in the fundus was removed using an extraction kit, puncturing and aspirating 500ml of saline solution, and extracting the collapsed balloon without any complications. The patient achieved an adequate oral intake afterwards, and no recurrence of emetic episodes were noticed. Previous ECGs revealed a prolonged QT interval and a genetic study confirmed a congenital type 1 LQTS. Treatment was initiated with beta-blockers and a bicameral automatic defibrillator was implanted in order to prevent recurrences. ... (AU)

Sigmoid volvulus management, only endoscopic devolvulation?

Intestinal obstruction due to sigmoid volvulus (SV) represents a relevant percentage of abdominal diseases presenting at the emergency department. Treatment is based on early endoscopic devolvulation (ED), followed by elective surgery as definitive treatment. A 78-year-old man institutionalized with Lewy body dementia presents with abdominal pain, distention, and absence of stool in 72 hours. Coffee bean sign was seen in abdominal x-ray. Previously, he had been admitted three times last year with recurrent SV, managed with ED succesfully. Despite the recurrence, no surgical treatment was indicated after resolution of the acute situation and recovery of intestinal transit. This time, urgent colonoscopy was performed and a 20 cm length of purplish-black (isquemic) sigmoid mucosa was observed. With these findings of stablished intestinal ischemia urgent surgical intervention was performed (sigmoidectomy and terminal "Hartmann" colostomy). Histologically, necrosis, severe ulceration and mixed inflammation was noticed in the surgical piece. The patient develops favorably during a postoperative period without incidents. Therefore, he is discharged to his center. At the moment he is asymptomatic one year after the intervention with no new episodes. Recurrency of SV after ED is up to 86% of cases. In every episode, the incidence of complications such as intestinal ischemia or perforation increases significantly, as well as urgent surgery and mortality. Definitive treatment must be surgical, sigmoidectomy and terminal anastomosis is the choice technique.

Recurrent abdominal pain as the only clinical manifestation of hereditary angioedema type II.

Recurrent abdominal pain is a common reason for consultation in Gastroenterology. The differential diagnosis includes hereditary angioedema (HAE), a rare disorder characterized by recurrent episodes of angioedema, without urticaria or pruritus, which most often affects the skin, but also mucosal tissues of the gastrointestinal tract, triggered by diverse factors such as infections, trauma, surgery, drugs, or stress. It is a disease with a difficult diagnosis due to its heterogeneous and transitory clinical features, so having a clinical suspicion in the appropriate context would allow the administration of a specific treatment and avoid unnecessary examinations. We present the case of a 19-year-old male followed-up for recurrent abdominal pain that, after numerous microbiological, endoscopic, and radiological examinations, complement tests were requested, obtaining low levels of C4 with increased levels of C1 inhibitor and reduced functional activity, being diagnosed with HAE type II.