ABSTRACT
77-year-old female with history of cholecystectomy was admitted at emergency department with fever and myalgia, without other complaints. Physical examination revealed fever, and laboratory tests indicated cholestasis (total bilirubin: 1.5xULN, glutamyltransferase: 20xULN, alkaline phosphatase: 5xULN). Computed Tomography revealed common bile duct (CBD) dilation (9mm), with suspected choledocholithiasis. Given the diagnosis of acute cholangitis, antibiotics were started and ERCP was performed. ERCP revealed a short CBD stenosis (< 2mm length), close to surgical clip, with upstream dilation of the CBD; an 8mm stone in the distal CBD was observed and successfully removed. As guidewire advancement failed after multiple attempts, a SpyGlass DS cholangioscopy was performed showing a fibrotic pinehole stenosis. Guidewire was passed through the stenosis under direct visualization, and an 80-mmx10mm fully covered metal stent deployed.
ABSTRACT
An 82-year-old man was admitted for acute cholangitis. He presented with jaundice and elevated hepatic cholestasis enzymes and C-reactive protein. Abdominal ultrasound and CT scan showed no evidence of gallstones and the main bile duct had 6 mm of diameter. Broad-spectrum antibiotic therapy was initiated and the patient was referred for Endoscopic Retrograde Cholangiopancreatography. During duodenoscopy, a pedunculated subepithelial lesion, measuring approximately 20-30 mm, and suggestive of being a lipoma was found, obstructing the papillary orifice and preventing its access. It was then removed using a diathermic snare. Subsequent cholangiography confirmed the absence of gallstones or any other cause of biliary obstruction. Histopathological analysis confirmed that the lesion was a duodenal lipoma. The patient evolved favorably and had no subsequent episodes of jaundice or cholangitis during follow-up.
ABSTRACT
A 49-year-old man presented with a three-week history of abdominal pain, bloody diarrhoea and fever. Reported oral ulcers, weight loss and asthenia, as well as papulo-pustular lesions on his limbs and a recurrent ulcer in the lip (Fig.1) in the previous year. During hospitalization, he developed pathergy at venipuncture sites and painful scrotum ulcers. Laboratory showed pancytopenia and elevated CRP. Viral and autoimmune tests were negative. Abdominal CT revealed thickening of the ileocecal region with adenopathies. Blood smear and myelogram were compatible with Chronic Myeloid Leukemia (CML). Bone marrow culture and BK were negative. Karyotype revealed no changes, namely, no trisomy of the 8th. Ileocolonoscopy revealed aphthoid erosions of the ileocecal mucosa and ovoid punched-out cecal ulcers. Biopsies showed intense chronic inflammation in the lamina propria and submucosa with erosions and ulcers. Thus, presenting 5 points in the International Criteria for Behçet's Disease, this diagnosis was assumed as a paraneoplastic manifestation of CML. Corticosteroids improved symptoms, but the patient died three weeks later due to a blastic crisis. BS has been reported in association with CML, some concurrent with, or following treatment with interferon-a or hydroxyurea. Although the pathogenesis remains unclear, there is increasing awareness of its link to hematological malignancies, and trisomy of the 8th.
ABSTRACT
A 50-year-old woman with a history of bicuspid aortic valve (BAV) and ascending aorta dissection was referred for endoscopic ultrasound (EUS) for suspected choledocholithiasis. Twelve years earlier she had undergone a Bentall-de Bone procedure and 7 years earlier a thoracic aorta aneurysm (TAA) was repaired with an endovascular prosthesis. EUS confirmed choledocholithiasis, however a large aneurysm (60 mm of diameter), was incidentally detected at the distal end of the aortic endoprosthesis. Computed tomography (CT) later confirmed the aneurysm, extending 4.5 cm above the renal arteries. The patient underwent a successful new endovascular repair. This rare incidental finding underscores the usefulness of a systematic approach when performing EUS, enabling the detection of significant abnormalities beyond the initial indication and allowing for early intervention in TTA patients.
ABSTRACT
Introduction: Malignant biliary obstruction drainage is essential, since jaundice is associated with morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended procedure for biliary drainage, with percutaneous biliary drainage being the classic alternative in cases of unsuccessful ERCP. Recently, endoscopic ultrasound-guided biliary drainage has been emerged as a new option, with EUS-guided choledochoduodenostomy (EUS-CDS) being considered an effective and safe method in the drainage of distal obstructions of the common bile duct. Aim: The aim of the study was to evaluate the efficacy and safety of EUS-CDS performed in patients with distal malignant biliary obstructions, after failed ERCP. Methods: Single-center retrospective cohort study between July 2017 and June 2022 including all consecutive patients submitted to EUS-CDS in our center. The primary outcomes were "technical success" and "clinical success," defined as "resolution of jaundice or improvement in total serum bilirubin level above 50% at 7th day and above 75% at 30th day after the procedure." Secondary outcomes were procedure-related adverse events, endoscopic reintervention, and survival time. Results: EUS-CDS was performed in 20 patients (65.0% male; median age 76 years). The most frequent etiology for the biliary obstruction was pancreatic adenocarcinoma (n = 17; 85.0%), and most patients presented at advanced stages of cancer (12/60% in stages III or IV). ERCP failure was mainly due to the presence of obstruction in the duodenal lumen (n = 11; 55.0%). Fully covered metallic stents were used in all patients, mostly HotAxiosTM (n = 15; 75.0%). The technical success rate was 100%, and the clinical success rate was 89.5% (n = 17/19) at 7th day and 93.3% (n = 14/15) at 30th day. Four patients (20.0%) developed cholangitis within the first 30 days after the procedure; there were no late complications, and no patient died as a complication of the procedure. In 2 patients (10.0%), endoscopic reintervention was necessary due to stent migration, incidentally detected. Median survival was 93 days (minimum 5-maximum 751). Conclusion: EUS-CDS was effective in biliary decompression of malignant obstructions of the common bile duct, with high clinical success and a favorable safety profile.
Introdução: A drenagem das obstruções biliares malignas é essencial, uma vez que a icterícia está associada a morbimortalidade. A colangiopancreatografia retrógrada endoscópica (CPRE) é o procedimento recomendado para a drenagem biliar, sendo a drenagem biliar percutânea (DBP) a alternativa clássica, se verificado insucesso. Recentemente, a drenagem da via biliar guiada por ecoendoscopia tem-se apresentado como uma nova opção, sendo a coledocoduodenostomia guiada por ecoendoscopia (CGE) considerado um método eficaz e seguro na drenagem de obstruções da via biliar distal. Objetivo: Avaliar o sucesso técnico e clínico e a segurança da CGE em doentes com obstrução da via biliar distal, após falência da CPRE. Métodos: Estudo de coorte retrospetivo, entre Julho/2017 e Junho/2022, de todos os doentes submetidos a CGE no nosso centro. Determinaram-se como outcomes primários o "sucesso técnico" e o "sucesso clínico" ("melhoria ≥50% na bilirrubinemia ao 7.º e ≥ 75% ao 30.º dias após o procedimento"). Os outcomes secundários incluíram a frequência de eventos adversos, necessidade de reintervenção e taxa de sobrevida. Foram utilizadas curvas de Kaplan-Meier para descrever a sobrevida. Resultados: A CGE foi realizada em 20 doentes (65.0% do sexo masculino; idade mediana 76 anos). A etiologia mais frequente para a obstrução foi o adenocarcinoma pancreático (n = 17; 85.0%) e a maioria dos doentes apresentava- se em estadios avançados da neoplasia (12/60% em estadios III ou IV). A falência da CPRE deveu-se à presença de obstrução no lúmen duodenal em 55.0% dos doentes (n = 11). Em todos os doentes foram utilizadas próteses metálicas totalmente cobertas, maioritariamente HotAxiosTM (n = 15; 75.0%). A taxa de sucesso técnico foi de 100% e de sucesso clínico foi de 89.5% ao 7.º dia (n = 17/19) e 93.3% ao 30.º dia (n = 14/15). Quatro doentes (20.0%) desenvolveram colangite nos primeiros 30 dias após o procedimento; não se verificaram complicações tardias e nenhum doente faleceu como complicação do procedimento. Em 2 doentes (10.0%) foi necessária reintervenção por migração da prótese, detetada incidentalmente. A sobrevida mediana foi de 93 dias (mínimo 5 - máximo 751). Conclusões: A CGE foi efetiva na descompressão biliar de obstruções malignas da via biliar distal, com elevado sucesso clínico e um perfil de segurança favorável.
ABSTRACT
BACKGROUND: Patients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold-standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other ß-lactams. METHODS: We performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta-analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses. RESULTS: We included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%-0.13%; I2 = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non-immediate index reactions (OR = 0.05; 95% CrI = 0-0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7-21.5; I2 = 0.3%). Performance of direct DPTs in low-risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions. CONCLUSIONS: In patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life-threatening index reactions or patients with positive skin tests-who were mostly not assessed in this analysis -, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.
ABSTRACT
BACKGROUND: Having a penicillin allergy label associates with a higher risk for antibiotic resistance and increased health care use. OBJECTIVE: We sought to assess the accuracy of skin tests and specific IgE quantification in the diagnostic evaluation of patients reporting a penicillin/ß-lactam allergy. METHODS: We performed a systematic review and diagnostic accuracy meta-analysis, searching on MEDLINE, Scopus, and Web of Science. We included studies conducted in patients reporting a penicillin allergy and in whom skin tests and/or specific IgE quantification were performed and compared with drug challenge results. We quantitatively assessed the accuracy of diagnostic tests with bivariate random-effects meta-analyses. Meta-regression and subgroup analyses were performed to explore causes of heterogeneity. Studies' quality was evaluated using QUADAS-2 criteria. RESULTS: We included 105 primary studies, assessing 31,761 participants. Twenty-seven studies were assessed by bivariate meta-analysis. Skin tests had a summary sensitivity of 30.7% (95% CI, 18.9%-45.9%) and a specificity of 96.8% (95% CI, 94.2%-98.3%), with a partial area under the summary receiver-operating characteristic curve of 0.686 (I2 = 38.2%). Similar results were observed for subanalyses restricted to patients reporting nonimmediate maculopapular exanthema or urticaria/angioedema. Specific IgE had a summary sensitivity of 19.3% (95% CI, 12.0%-29.4%) and a specificity of 97.4% (95% CI, 95.2%-98.6%), with a partial area under the summary receiver-operating characteristic curve of 0.420 (I2 = 8.5%). Projected predictive values mainly reflect the low frequency of true penicillin allergy. CONCLUSIONS: Skin tests and specific IgE quantification appear to have low sensitivity and high specificity. Because current evidence is insufficient for assessing the role of these tests in stratifying patients for delabeling, we identified key requirements needed for future studies.
Subject(s)
Drug Hypersensitivity/diagnosis , Drug Hypersensitivity/immunology , Penicillins/adverse effects , Drug Hypersensitivity/pathology , Humans , Immunoglobulin E/immunology , Penicillins/therapeutic use , Skin TestsABSTRACT
La laceración hepática es una complicación poco frecuente de la resucitación cardiopulmonar.La reanimación cardiopulmonar puede originar lesiones de vísceras abdominales.Las complicaciones del masaje cardiaco externo, en especial referencia a las lesiones hepáticas,son escasamente descritas. Es importante usar una técnica correcta con el fin deevitar lesiones en órganos próximos. A pesar de que la laceración hepática es rara los serviciosmédicos deben estar alerta de dicha complicación. Describimos un caso de laceraciónhepática descubierta en el estudio post morten. [Emergencias 2009;21:148-150](AU)
Laceration of the liver is a rare complication of cardiopulmonary resuscitation, which can damage nearby abdominalorgans. Complications of external cardiac massage, particularly those affecting the liver, are rarely reported, however. Itis important to apply the correct techniques in order to avoid damaging nearby organs; although liver laceration is a rarecomplication, emergency physicians should be aware that it might occur. We describe a case of liver lacerationdiscovered during autopsy. [Emergencias 2009;21:148-150](AU)
Subject(s)
Humans , Male , Middle Aged , Cardiopulmonary Resuscitation/adverse effects , Liver/injuries , Lacerations/etiology , Fatal OutcomeABSTRACT
El traslado neonatal constituye, dentro de lo que llamamos transporte secundario, un campo muy específico para la enfermería de UVI-móvil debido a que reúne unas características específicas: a) Peculiaridades del neonato a trasladar. b) Relativa baja frecuencia del número de traslados. El trabajo se apoya en un soporte estadístico de dicha actividad realizada en Bizkaia a lo largo de los años 1998 y 1999, estudiándose el motivo del traslado. Planteamos el procedimiento y el plan de cuidados a seguir en el traslado neonatal por parte de la enfermería de UVI-móvil (AU)
