Upper gastrointestinal bleeding and Rigler triad.

Gallstone ileus is a rare complication of cholelithiasis, characterized by mechanical bowel obstruction due to a biliary calculus originating from a bilioenteric fistula. The Rigler triad, consisting of aerobilia, ectopic gallstone, and intestinal obstruction, is rarely observed in its complete form. We present the case of a 92-year-old male with a history of acute lithiasic cholecystitis who presented to the Emergency department with acute epigastric pain. Initial evaluation revealed gallbladder dilatation, gallstones, and gallbladder wall thickening suggestive of acute cholecystitis. During hospitalization, the patient experienced an episode of hematemesis, leading to the diagnosis of a cholecystoduodenal fistula and a large blood clot in the duodenal bulb. Further imaging showed an ectopic gallstone causing small bowel obstruction. The patient underwent urgent surgery for stone extraction, followed by endoscopic intervention for the bleeding vessel identified at a subsequent gastroscopy. Unfortunately, the patient had a poor postoperative course and passed away seven days later. This case report highlights the exceptional occurrence of both the Rigler triad and upper gastrointestinal bleeding in a patient with gallstone ileus. Surgical intervention is crucial for the initial resolution of intestinal obstruction, followed by cholecystectomy and repair of the bilioenteric fistula. Awareness of these rare presentations is important for timely diagnosis and appropriate management of this uncommon complication of cholelithiasis.

Large bowel obstruction secondary to a simple renal cyst: an exceptional complication.

We report the case of an 81-year-old female with large bowel obstruction secondary to a giant simple renal cyst (16 cm), which was producing a compression of the descending colon against the abdominal wall. Percutaneous drainage of the renal cyst was performed by a urologist. The follow-up CT scan revealed a collapsed cyst with resolution of the bowel obstruction. The patient showed resolution of the symptoms with an improvement in blood test results.

McKittrick-Wheelock syndrome: rectal villous adenoma as a cause of acute renal failure.

We report the case of a 67-year-old male with a history of arterial hypertension and atrial fibrillation, who was admitted for acute renal failure (creatinine: 4.41 mg/dl) and hypotension. He also presented hyponatremia (129 mmol/L) and hypokalemia (2.7 mmol/L). The patient referred profuse diarrhea during the previous two months as a possible triggering cause. Physical examination showed signs of dehydration and palpation of a polypoid mass in the rectal ampulla.

Surprises in cecal intubation: foreign bodies in the colon.

We report the case of a 70-year-old male who visited for a colonoscopy on an outpatient basis after being admitted months earlier due to a subocclusive condition that was resolved with conservative treatment. His medical background included a laparotomy for a duodenal ulcer in 1979, as well as a subsequent intervention to debride adhesions. Cecal intubation was achieved with difficulty due to the patient's adhesive syndrome.

Preliminary experience of maintenance treatment with intravenous ustekinumab as a rescue treatment for loss of response to subcutaneous doses.

It has been demonstrated that ustekinumab (UST) is effective as an induction and maintenance therapy in patients with Crohn's disease (CD). However, a significant number of patients experience an insufficient response or a secondary non-response. We report six cases from our center that underwent a rescue treatment by changing maintenance treatment to weight-adjusted intravenous UST, obtaining a subsequent clinical improvement.

A multicentric Spanish study on the characteristics and survival of gastric adenocarcinoma under the age of 60 / Estudio multicéntrico español sobre las características y la supervivencia del adenocarcinoma gástrico en pacientes menores de 60 años

Introduction: In Europe, gastric adenocarcinoma (GADC) is commonly regarded as a disease of the elderly. This study aims to assess the proportion, characteristics, and survival of patients diagnosed with GADC under the age of 60. Materials and methods: This is a retrospective, multicentric, and analytical study conducted at four tertiary Spanish hospitals. All patients diagnosed with GADC between 2008 and 2015 were included. Demographic, clinical, endoscopic, histologic, and survival data were retrieved. A multivariate analysis was performed to compare GADC in young (age≤60 years) and elderly patients. Results: A total of 1374 patients with GADC were included. The mean age was 74 years (SD:11.1); 62.2% were males. There were 177 patients under the age of 60 (12.9%, 95% CI: 11.2-14.8%). GADC was frequently encountered as a metastatic disease in both young and elderly patients (Stage IV: 45.7% and 41%, respectively). In the multivariate analysis, alcohol abuse, ASA functional status I-II, diffuse subtype, neoadjuvant, and palliative therapy were independently associated (P<0.05) with age ≤60 years. No differences were found in 2-year survival (GADC ≤60: 39% vs. 35%, P=0.45). Curative-intent surgery, TNM stage I-II, body mass index<30kg/m2, and better functional status at diagnosis were independent predictors of survival in GADC under the age of 60. Conclusions: One out of eight cases of GADC were diagnosed under the age of 60. Metastatic disease was frequent at diagnosis and overall survival was poor regardless of age. Factors associated with localized disease correlated with improved survival in younger patients. Our results underline the need for early diagnosis strategies in our country

Introducción: En Europa, el adenocarcinoma gástrico (ADCG) afecta principalmente a pacientes de edad avanzada. Este estudio tiene como objetivo evaluar la proporción, las características y la supervivencia de los pacientes diagnosticados de ADCG menores de 60 años. Material y métodos: Estudio retrospectivo, multicéntrico y analítico realizado en 4 hospitales terciarios españoles. Se incluyeron todos los pacientes diagnosticados con ADCG entre los años 2008-2015. Se recogieron datos demográficos, clínicos, endoscópicos, histológicos y de supervivencia. Se realizó un análisis multivariante para comparar el ADCG en pacientes jóvenes (edad≤60 años) y de edad avanzada. Resultados: Se incluyeron un total de 1.374 pacientes con ADCG. La edad media fue de 74 años (DE: 11,1), el 62,2% varones. Ciento setenta y siete pacientes tenían menos de 60 años (12,9%, IC 95%: 11,2-14,8%). El ADCG se diagnosticó con frecuencia como enfermedad metastásica en pacientes jóvenes y ancianos (estadio IV: 45,7 y 41%, respectivamente). En el análisis multivariante, el abuso de alcohol, la clase funcional ASA I-II, el subtipo difuso, el tratamiento neoadyuvante y el tratamiento paliativo se asociaron de forma independiente (p<0,05) con una edad ≤60 años. No se encontraron diferencias en la supervivencia a 2 años (ADCG≤60: 39 vs. 35%; p=0,45). La cirugía con intención curativa, el estadio TNM I-II, el índice de masa corporal <30kg/m2 y un mejor estado funcional al diagnóstico fueron factores predictivos independientes de supervivencia en el subgrupo de pacientes menores de 60 años. Conclusiones: Uno de cada 8 casos de ADCG se diagnosticaron por debajo de los 60 años. Independientemente de la edad, la presencia de metástasis al diagnóstico fue frecuente y la supervivencia global baja. Los factores asociados a enfermedad localizada se correlacionaron con una mejor supervivencia en pacientes más jóvenes. Nuestros resultados apoyan la necesidad de implementar estrategias de diagnóstico temprano en nuestro país

A multicentric Spanish study on the characteristics and survival of gastric adenocarcinoma under the age of 60.

INTRODUCTION: In Europe, gastric adenocarcinoma (GADC) is commonly regarded as a disease of the elderly. This study aims to assess the proportion, characteristics, and survival of patients diagnosed with GADC under the age of 60. MATERIALS AND METHODS: This is a retrospective, multicentric, and analytical study conducted at four tertiary Spanish hospitals. All patients diagnosed with GADC between 2008 and 2015 were included. Demographic, clinical, endoscopic, histologic, and survival data were retrieved. A multivariate analysis was performed to compare GADC in young (age≤60 years) and elderly patients. RESULTS: A total of 1374 patients with GADC were included. The mean age was 74 years (SD:11.1); 62.2% were males. There were 177 patients under the age of 60 (12.9%, 95% CI: 11.2-14.8%). GADC was frequently encountered as a metastatic disease in both young and elderly patients (Stage IV: 45.7% and 41%, respectively). In the multivariate analysis, alcohol abuse, ASA functional status I-II, diffuse subtype, neoadjuvant, and palliative therapy were independently associated (P<0.05) with age ≤60 years. No differences were found in 2-year survival (GADC ≤60: 39% vs. 35%, P=0.45). Curative-intent surgery, TNM stage I-II, body mass index<30kg/m2, and better functional status at diagnosis were independent predictors of survival in GADC under the age of 60. CONCLUSIONS: One out of eight cases of GADC were diagnosed under the age of 60. Metastatic disease was frequent at diagnosis and overall survival was poor regardless of age. Factors associated with localized disease correlated with improved survival in younger patients. Our results underline the need for early diagnosis strategies in our country.

Rate of missed oesophageal cancer at routine endoscopy and survival outcomes: A multicentric cohort study.

Background: Missed oesophageal cancer (MEC) at upper gastrointestinal endoscopy (UGE) is poorly documented. Objective: The objectives of this study were: (1) to assess the rate, predictors and survival of MEC; (2) to compare MEC and non-MEC tumours. Methods: This was a retrospective cohort study conducted at four tertiary centres. Oesophageal cancers (ECs) diagnosed between 2008 and 2015 were included. Patients with a premalignant condition (Barrett, achalasia), prior diagnosis of EC or oesophagogastric junction tumour of gastric origin were excluded. MEC was defined as EC detected within 36 months after negative UGE. Results: 123,395 UGEs were performed during the study period, with 502 ECs being diagnosed (0.4%). A total of 391 ECs were finally included. Overall MEC rate was 6.4% (95% confidence intervals (CI): 4.4-9.3%). The interval between negative and diagnostic UGE was less than 2 years in 84% of the cases. Multivariate analysis showed that a negative endoscopy was associated with proton pump inhibitor (PPI) therapy and less experienced endoscopists. MEC was smaller than non-MEC at diagnosis (25 versus 40 mm, p = 0.021), more often flat or depressed (p = 0.013) and less frequently diagnosed as metastatic disease (p = 0.013). Overall 2-year survival rate was similar for MEC (20%) and non-MEC (24.1%) (p = 0.95). Conclusions: MEC accounted for 6.4% of all ECs and was associated with poor survival. High-quality UGE and awareness of MEC may help to reduce its incidence.

Characteristics and consequences of missed gastric cancer: A multicentric cohort study.

BACKGROUND: Missed gastric cancer (MGC) is poorly documented in Mediterranean populations. AIMS: (1) To assess the rate, predictors and survival of MGC. (2) To compare MGC and non-MGC tumors. METHODS: This is a retrospective-cohort study conducted at four centers. MGC was defined as cancer detected within three years after negative esophagogastroduodenoscopy. Gastric adenocarcinomas diagnosed between 2008-2015 were included. Patients with no follow-up were excluded. RESULTS: During the study period 123,395 esophagogastroduodenoscopies were performed, with 1374 gastric cancers being diagnosed (1.1%). A total of 1289 gastric cancers were finally included. The overall rate of MGC was 4.7% (61/1289, 3.7-6%). A negative esophagogastroduodenoscopy in MGC patients was independently associated with PPI therapy (p < 0.001), previous Billroth II anastomosis (p = 0.002), and lack of alarm symptoms (p < 0.001). The most frequent location for MGC was the gastric body(52.4%). MGCs were smaller than non-MGCs (31 vs 41 mm, p = 0.047), more often flat or depressed (p = 0.003) and less likely to be encountered as advanced disease. Overall 2-year survival was similar between MGC (34.1%) and Non-MGC (35.3 %) (p = 0.59). CONCLUSION: MGC accounted for nearly five percent of newly-diagnosed gastric adenocarcinomas. Overall survival was poor and not different between MGC and non-MGC.