Protocol for acquisition of images and measurement of transabdominal ultrasound pancreatic two-dimensional shear wave elastography (2D-SWE). / Protocolo de adquisición de imágenes y medición de la elasticidad pancreática mediante elastografía por onda de cizallamiento bidimensional (2D-SWE) transabdominal.

INTRODUCTION: Transabdominal ultrasound (TU) pancreatic 2D-SWE elastography is a developing technique that needs to be protocolized. OBJECTIVES: Establish a protocol for image acquisition and measurement of TU pancreatic - 2D-SWE elastography and estimate the minimum number of measurements to be performed. MATERIALS AND METHODS: Ten measurements of pancreatic elasticity were taken in healthy volunteers using TU-2D-SWE, following a strict protocol for image acquisition and measurement. RESULTS: The 70% of the participants were women, with an average age, weight, and BMI of 49.5±15.7 years, 65.9±11.9kg, and 24.5±4.2kg/m2, respectively. Measurements were taken from the body (70%), tail (16.7%), and pancreatic head (13.3%). The median mean velocity and elasticity were 1.46±0.25cm/sec and 6.46±2.87KPa, respectively. The ROI depth was 4.12±1cm and the SP-ROI distance was 5.2mm on average. There were no statistically significant differences between the 10 measurements. The reliability analysis of the measurements showed high internal consistency and repeatability. Taking 5-6 measurements ensured high concordance with the ten reference measurements. The measurements were significantly lower when the SP-ROI values were intermediate (0.3-0.6cm). The measurement accuracy was higher when performed at a depth less than 4.8cm. CONCLUSION: To measure pancreatic elasticity using TU-2D-SWE, we propose a strict protocol for image acquisition and measurement, taking a minimum of 5 measurements in the best visualized and accessible pancreatic portion, and preferably at a depth of less than 4.8cm.

Diagnosis of a cystic pancreatic neuroendocrine tumor: is cystic fluid chromogranin A useful?

Cystic pancreatic neuroendocrine tumors (cP-NET) are a diagnostic challenge for clinic, since sometimes nor imaging features, cytology, or the study of biological markers in pancreatic cyst fluid (PCF), are able to provide the nature of the lesion, and therefore the definitive diagnostic is often made in the surgical piece. Is not infrequent that the lesions are wrongly defined as benign, in special when the cytology is negative for malignancy and the PCL is not mucinous and has a high glucose and a low CEA. We could incorporate new markers to improve the diagnostic performance of PCF samples, like chromogranin A, as in our case may be the only specific finding to detect a cP-TNE.

Duodenal pyogenic granuloma: An unusual cause of chronic anemia.

We present the endoscopic finding of a juxtapapillary duodenal pyogenic granuloma in a patient under study for chronic recurrent anemia. The images show the presence of an enlarged papilla, with an exophytic growth of erythematous and friable tissue at its lower border. Although this is a very rare entity, it is necessary to take it into account in the differential diagnosis of refractory anemia because there is an effective endoscopic treatment for it.

A case report of a drug-induced liver injury (DILI) caused by multiple antidepressants with causality established by the updated Roussel Uclaf causality assessment method (RUCAM) and in vitro testing.

A 56-year-old female patient was hospitalized because of a lack of response and poor tolerance to multiple antidepressants, which included an episode of DILI. During hospitalization, the patient suffered another episode of DILI. Causality was assessed both by RUCAM and Lymphocyte Transformation Test, allowing to identify a safer medication.

Reinicio de la actividad ecográfica tras la fase aguda de la pandemia por COVID-19 / No disponible

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Resuming ultrasound activity after the acute phase of the COVID-19 pandemic.

Recently, Dr. Crespo et al. published in your Journal a paper recommending the use of ultrasonography during the current phase of the COVID-19 pandemic whilst wearing only a facial mask for protection, which we deem inadequate. Prevention is key when performing an ultrasound test, since this virus is highly contagious. During the pandemic, every patient should be considered as potentially infected and the procedure requires a close proximity. Therefore, extreme hygiene and a sonographer equipped with the appropriate personal protection (mask, cap, gown, gloves, shoe covers and goggles, with a facial screen and high-efficacy mask for confirmed or highly suspect cases) are of the utmost importance to prevent viral transmission.

Documento de recomendaciones fundamentales para las unidades de Aparato Digestivo del siglo XXI / No disponible

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Digestive services in the Spanish National Health System of the XXI century. Organizational and operational standards for a patient-centered service.

The Spanish Society of Gastroenterology (SEPD) has published a consensus document that discusses the key standards and recommendations for organizing digestive system units (DSUs) in the 21st century. This is aimed at quality, efficient and patient-centered health care.

Neoplasia papilar intraductal de los conductos biliares, una enfermedad recurrente / Intraductal papillary neoplasm of the bile duct: a recurring disease

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Intraductal papillary neoplasm of the bile duct: a recurring disease.

Intraductal papillary neoplasm of the bile duct (IPNB) is a premalignant disease characterized by a low incidence, a high risk of malignant transformation, and an uncertain prognosis. We hereby present the case of an 8-mm IPNB in the left liver lobe detected by endosonography in a 76-year-old woman followed for a dissociated asymptomatic cholestasis who was treated with a left hepatectomy. The resected IPNB had low-grade dysplasia and no nodal involvement in the surgical piece; however, signs of recurrence of the disease were observed in the right liver lobe a year and a half later. Therefore, given that it can be multifocal and recurrent, IPNB is a disease that requires close follow-up.

Formación en Ecografía de los Médicos Residentes de Aparato Digestivo: encuesta y proyecto docente de la Asociación Española de Ecografía Digestiva / Training in Ultrasound for Resident Physicians in Gastroenterology: a survey and training project by the Spanish Association of Digestive Ultrasound (Asociación Española de Ecografía Digestiva - AEED)

Antecedentes: el programa de formación de la Especialidad de Aparato Digestivo, que deben seguir los Médicos Internos y Residentes de Aparato Digestivo, obliga a que estos dominen la ecografía digestiva diagnóstica y terapéutica. Métodos: la Asociación Española de Ecografía Digestiva ha realizado una encuesta a los 93 Servicios de Aparato Digestivo con programa de formación de Médicos Internos y Residentes de Aparato Digestivo para conocer la situación exacta de la docencia en ecografía digestiva. Resultados: solo 31 de los 93 (33%) Servicios de Aparato Digestivo podían dar formación en Ecografía Digestiva. Un 33% (48 de 148) de los Médicos Internos y Residentes de Aparato Digestivo no recibían una formación específica en ecografía digestiva, y otro 31% (46 de 148) recibían una formación específica pero en condiciones mejorables. Estas deficiencias afectaban a todas las Comunidades Autónomas de España, 8 de las cuales carecían totalmente de Servicios de Aparato Digestivo con capacidad para formar en Ecografía Digestiva. Conclusiones: existe un déficit importante de Servicios de Aparato Digestivo que puedan dar formación en Ecografía Digestiva a los Médicos Internos y Residentes de Aparato Digestivo y ello provoca una notable desigualdad formativa. Hasta que se pueda revertir esta situación, la Asociación Española de Ecografía Digestiva ha diseñado un proyecto formativo en Ecografía Digestiva dirigido a dar una docencia adecuada a todos los Médicos Internos y Residentes de Aparato Digestivo que lo necesiten

Background: the training program of the gastroenterology specialty that is mandatory for resident physicians, obliges them to be proficient in diagnostic and therapeutic digestive ultrasound tools. Methodology: the Asociación Española de Ecografía Digestiva (AEED) performed a survey of the 93 Departments of Gastroenterology with training programs for resident physicians in gastroenterology, in order to assess the exact situation of training in digestive ultrasound in Spain. Results: only 31 of the 93 (33%) Departments of Gastroenterology were able to provide training in Digestive Ultrasound. Moreover, 33% (48 out of 148) of the residents in gastroenterology did not receive specific training in digestive ultrasound. Whereas, 31% (46 out of 148) had received some specific training, but with ample room for improvement. These deficiencies were spread throughout the Spanish regions (Autonomous Communities) in an uneven manner, with almost half totally lacking gastroenterology departments that were capable of providing digestive ultrasound training. Conclusions: there is a significant deficit of gastroenterology departments capable of providing training in digestive ultrasound to residents, causing a significant training inequality. Until this situation can be reversed, the AEED has designed a training project in digestive ultrasound aimed at providing adequate training to all residents in gastroenterology as required

Training in Ultrasound for Resident Physicians in Gastroenterology: a survey and training project by the Spanish Association of Digestive Ultrasound (Asociación Española de Ecografía Digestiva - AEED).

BACKGROUND: the training program of the gastroenterology specialty that is mandatory for resident physicians, obliges them to be proficient in diagnostic and therapeutic digestive ultrasound tools. METHODOLOGY: the Asociación Española de Ecografía Digestiva (AEED) performed a survey of the 93 Departments of Gastroenterology with training programs for resident physicians in gastroenterology, in order to assess the exact situation of training in digestive ultrasound in Spain. RESULTS: only 31 of the 93 (33%) Departments of Gastroenterology were able to provide training in Digestive Ultrasound. Moreover, 33% (48 out of 148) of the residents in gastroenterology did not receive specific training in digestive ultrasound. Whereas, 31% (46 out of 148) had received some specific training, but with ample room for improvement. These deficiencies were spread throughout the Spanish regions (Autonomous Communities) in an uneven manner, with almost half totally lacking gastroenterology departments that were capable of providing digestive ultrasound training. CONCLUSIONS: there is a significant deficit of gastroenterology departments capable of providing training in digestive ultrasound to residents, causing a significant training inequality. Until this situation can be reversed, the AEED has designed a training project in digestive ultrasound aimed at providing adequate training to all residents in gastroenterology as required.

La calidad en ecografía digestiva: un aspecto que urge consensuar / The quality of abdominal ultrasound: a much-needed consensus

La ecografía digestiva (ED) es una técnica pendiente de ser implantada en la mayoría de servicios de Aparato Digestivo (AD) de nuestro país, en buena parte debido a los problemas que el especialista de AD encuentra para una adecuada formación ya desde la residencia. En muchos servicios de AD donde si se lleva a cabo ED, no se han destinado en realidad los recursos necesarios para desarrollar verdaderas unidades de ED, los equipos ecográficos están obsoletos y no se adaptan a las necesidades asistenciales del especialista de AD. Por todo lo anteriormente expuesto, la ED ocupa un lugar en nuestra especialidad que no le corresponde, fruto probablemente de una inadecuada promoción y/o apoyo a la técnica, que ha infraestimado su utilidad y restado recursos a su implantación definitiva en los servicios de AD. Para que la ED pueda superar estos obstáculos necesita ser considerada con urgencia como un proceso o una sucesión de actividades sustentadas en la evidencia científica y en la experiencia de los profesionales, para conseguir un resultado que satisfaga plenamente las necesidades e implique un mínimo riesgo para el paciente. En el artículo se defiende la necesidad de potenciar la ED como disciplina clave en el proceso diagnóstico de las enfermedades digestivas, considerando a la calidad como el elemento estratégico en el que se fundamenta esta transformación y su mejora

The abdominal ultrasound (AU) is a diagnostic imaging modality that is yet to be established in most Gastrointestinal (GI) Units in Spain. This is largely due to the difficulties that GI specialists face with regard to the appropriate training received when starting the specialty. Insufficient resources have been allocated to develop AU units in many GI units where AUs are performed. The equipment is obsolete and there are no adaptations to the needs of the GI specialist to provide good medical care. Thus, due to all the above, the AU does not hold the position it deserves in our specialty. This probably stems from a lack of impulse and/or support to the technique, which has underestimated its usefulness and has limited the implementation of resources in the GI units. For the AU to overcome these obstacles, it needs to be considered as a process or a series of activities based on scientific evidence and the experience of professionals that achieves a result that covers the patients' needs with minimal risk. In this article, we defend the need to boost AU as a key discipline for the diagnosis of digestive diseases. Quality is considered as the key aspect on which this transformation and improvement is founded

The quality of abdominal ultrasound: a much-needed consensus.

The abdominal ultrasound (AU) is a diagnostic imaging modality that is yet to be established in most Gastrointestinal (GI) Units in Spain. This is largely due to the difficulties that GI specialists face with regard to the appropriate training received when starting the specialty. Insufficient resources have been allocated to develop AU units in many GI units where AUs are performed. The equipment is obsolete and there are no adaptations to the needs of the GI specialist to provide good medical care. Thus, due to all the above, the AU does not hold the position it deserves in our specialty. This probably stems from a lack of impulse and/or support to the technique, which has underestimated its usefulness and has limited the implementation of resources in the GI units. For the AU to overcome these obstacles, it needs to be considered as a process or a series of activities based on scientific evidence and the experience of professionals that achieves a result that covers the patients' needs with minimal risk. In this article, we defend the need to boost AU as a key discipline for the diagnosis of digestive diseases. Quality is considered as the key aspect on which this transformation and improvement is founded.

A veces las cosas son lo que parecen / Sometimes things are what they seem

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Sometimes things are what they seem.

Accessory spleen is a frequent congenital abnormality (10-20%) resulting in the fusion failure of splenunculi. We present a case report of a 74 year-old man with a nodule identified in the tail of the pancreas of 1.8 cm x 1.5 cm in size. The CT scan showed soft tissue attenuation and arterial hyperenhancement with a lower uptake in the central area, low 18-FDG affinity and no evidence of 111-In-octretide uptake. A solid, round and well-circumscribed nodule was defined as an intrapancreatic accessory spleen (IPAS) by endoscopic ultrasound (EUS), due to shared ultrasonographic characteristics and a pattern of contrast enhancement with the spleen. The material obtained by EUS guided puncture was consistent with a lymph node. A distal pancreatectomy confirmed the presence of an IPAS.