Endoscopic Retrograde Cholangiopancreatography in Children: Nine Years' Experience at Santa Fe Foundation in Bogota, Colombia.

INTRODUCTION: Experience in the use of diagnostic and/or therapy of endoscopic retrograde cholangiopancreatography (ERCP) in children is limited. This is due to the underdiagnosis of pancreaticobiliary disease in the pediatric population and specialist personnel in this procedure. OBJECTIVE: To determine the safety and success rate of ERCP in children at Hospital Fundación Santa Fe de Bogotá between January 2007 and June 2015. METHODOLOGY: This was an observational, descriptive, retrospective case series study of patients under 18 years, who underwent ERCP between January 2007 and June 2015. The following variables were analyzed: indication, duration, type of procedure, rate of success, and complications. RESULTS: A total of 30 patients were included, in whom 65 ERCP procedures were performed. Successful cannulation was achieved in 52 of the 65 procedures (80%). Among the complications that occurred, there were four cases of pancreatitis (6.2%), two cases of bleeding (3.1%), and one case of bacteremia (1.5%), and in most cases (58 in total, 89.2%), there were no complications. DISCUSSION: The pediatric gastroenterology group of the Fundación Santa Fe de Bogotá has obtained good results in performing ERCP in the pediatric population with a success rate of 80% associated with a null mortality rate. There is enough literature available to conclude that performing ERCP in the pediatric population maintains an adequate success rate and a low complication rate. In all the studies evaluated, a null mortality rate was found, so it is considered that this procedure is safe in patients under 18 years of age.

Annular pancreas in neonate patients Vomiting and weight loss in a 13-day newborn / Pâncreas Anular no período neonatal Vômitos e perda de peso em neonato com 13 dias de vida

Objective: Reinforce that, despite being a rare condition, the annular pancreas must be considered a differential diagnosis for intestinal obstructions in the newborn period. Case description: This case report refers to a 13-days newborn admitted to the emergency room presenting with postprandial vomiting and progressive weight loss since maternity discharge. The patient did not respond to initial interventions that included IV antibiotics and nasogastric tube insertion. A contrast study of the upper digestive tract (esophagus, stomach, and duodenum) found a luminal narrowing on the second duodenal portion. The patient was submitted to an exploratory laparotomy which found a pancreatic-tissue ring involving the second part of the duodenum. Despite rare, we reinforce that the annular pancreas must be considered a differential diagnosis for intestinal obstructions in the newborn period. Comments: Annular pancreas is a rare congenital defect in which a ring of pancreatic tissue encircles the duodenum, causing different degrees of intestinal obstruction. (AU)

Objetivo: Evidenciar que, apesar de condição rara, o pâncreas anular deve se firmar como diagnóstico dife-rencial das obstruções intestinais no período neonatal. Descrição do caso: Este relato aborda o caso de uma paciente de 13 dias de vida admitida no pronto atendimento com queixa de volumosos vômitos pós-prandiais e perda de peso progressiva desde a alta da maternidade. Apesar das medidas iniciais, com ressuscitação volêmica, antibioticoterapia e passagem de sonda nasogástrica para descompressão, a paciente evolui sem melhora. Exame contrastado de esôfago-estômago-duodeno detectou estreitamento luminal da segunda porção duodenal. Paciente submetida à laparotomia exploradora, que evidenciou anel de tecido pancreático estreitando o trânsito intestinal na região. Comentários: O pâncreas anular é uma anomalia congênita rara na qual um anel de tecido pancreático envolve a porção descendente do duodeno, causando graus variados de obstrução intestinal extrínseca. (AU)

Rendimiento diagnóstico del marcador tumoral CA 19-9 en la diferenciación entre patología bilio-pancreática benigna y maligna / Accuracy of the tumor marker CA 19-9 in the differentiation of benign and malignant bilio-pancreatic diseases

Introduction: CA 19-9 has been identified as a derivative of sialic Lewis blood group A and is expressed in 95 percent of the population. Several studies have documented an overproduction of CA 19-9 in malignant pancreatic and biliary tree diseases. The objective of this study is to determine the accuracy of the tumor marker CA 19-9 differentiating benign and malignant bilio-pancreatic diseases. Material and Methods: diagnostic test study. We reviewed the records of all patients with malignant bilio-pancreatic diseases and benign biliary calculous diseases evaluated in Hospital Base Osorno between august 2007 and december 2011, with CA 19-9 as part of their study. Results: 71 patients met the inclusion criteria, 17 men and 54 women, with a mean age of 60.7 +/- 15.3 years old. Twenty nine (40.8 percent) cases were benign and 42 (59.2 percent) cases malignant. For a cutoff level of 37 U/ml the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to differentiate benign from malignant disease was 81 percent, 72.4 percent, 81 percent and 72.4 percent, respectively. For a cut off level of 130 U/ml specificity and PPV increased to 96.6 percent and 96.4 percent, respectively. Conclusions: the use of CA 19-9 is useful in the diagnosis of patients with suspected bilio-pancreatic malignant disease. The optimization of the normal published value can help to improve accuracy.

Introducción: El CA 19-9 se ha identificado como un derivado siálico del grupo sanguíneo Lewis A y se expresa en el 95 por ciento de la población. Numerosos estudios han documentado una sobreproducción de CA 19-9 en tumores malignos del árbol biliar y páncreas. El objetivo de este estudio es determinar la utilidad del marcador tumoral CA 19-9 en la diferenciación de patología bilio-pancreática benigna y maligna. Material y Métodos: estudio de pruebas diagnósticas. Se revisaron los antecedentes de todos los pacientes con patología bilio-pancreática maligna y enfermedad litiásica biliar benigna, evaluados en el Hospital Base de Osorno entre agosto de 2007 y diciembre de 2011, a los que se les haya solicitado CA 19-9 como parte de su estudio. Resultados: 71 pacientes cumplieron los criterios de inclusión, 17 hombres y 54 mujeres, con una media de 60,7 +/- 15,3 años de edad. Veintinueve (40,8 por ciento) casos correspondieron patología benigna y 42 (59,2 por ciento) casos a patología maligna. Para un valor de corte de 37 U/ml la sensibilidad, especificidad, valor predictivo positivo (VPP) y valor predictivo negativo (VPN) para diferenciar enfermedad benigna de maligna fue de 81 por ciento, 72,4 por ciento, 81 por ciento y 72,4 por ciento, respectivamente. Para un valor de corte de 130 U/ ml la especificidad y el VPP aumentaron a 96,6 por ciento y 96,4 por ciento, respectivamente. Conclusiones: el uso del Ca 19-9 es útil en el proceso diagnóstico de pacientes con sospecha de patología bilio-pancreática maligna. La optimización de los valores sobre el valor de normalidad publicado puede ayudar a mejorar su rendimiento.

Tratamiento médico de la pancreatitis aguda / Medical treatment of acute pancreatitis

Se revisan los últimos avances en el manejo médico de la pancreatitis aguda. Estos se basan en los cambios que van desde el mayor conocimiento de la fisiopatología y la clínica y el desarrollo de técnicas para el manejo de las complicaciones. El reconocimiento del mal pronóstico dado por la falla persistente de órganos (mayor a 48 horas) y la evolución lenta pero sin severidad de los pacientes con complicaciones locales, ha hecho redefinir la clasificación de la pancreatitis, estratificándose al paciente con cuadros leves, moderados y severos. De los múltiples scores de severidad disponibles para predecir la severidad, APACHE II y BISAP son los que demuestran mayor valor en los trabajos realizados en el Perú. El uso de hidratación enérgica al inicio del cuadro, para evitar el daño a nivel de la microcirculación pancreática, la nutrición enteral precoz cuando se predice un cuadro severo o prolongado, además de la analgesia con narcóticos, son algunas de las medidas que se preconizan en la actualidad. Se discute además la evidencia de realimentar con sólidos en vez de dieta líquida desde el primer día de inicio de dieta a pacientes con pancreatitis leve. Por último se presenta la evidencia del uso de necrosectomía endoscópica como alternativa a la necrosectomía quirúrgica.

We review recent advances in medical management of acute pancreatitis. These are based on changes ranging from increased knowledge of the pathophysiology and clinical development of techniques for the management of complications. The recognition of poor prognosis given persistent organ failure (more than 48 hours) and the slow evolution without severity of patients with local complications, has redefined the classification of pancreatitis, stratifying the patient with mild, moderate and severe. Of the many available severity scores to predict severity, APACHE II and BISAP are demonstrating greater value on work done in Peru. Using vigorous hydration to avoid damage to the pancreatic microcirculation level, early enteral nutrition when it predicts a severe or prolonged disease in addition to narcotic analgesia, are some of the measures advocated in the present. I also discuss the evidence of refeeding with solid rather than liquid diet to patients with mild pancreatitis. Finally, evidence of safety and good outcomes of endoscopic necrosectomy is presented as an alternative to surgical necrosectomy.

A Mouse Model of Metabolic Syndrome: Insulin Resistance, Fatty Liver and Non-Alcoholic Fatty Pancreas Disease (NAFPD) in C57BL/6 Mice Fed a High Fat Diet.

Diet-induced obesity in C57BL/6 mice triggers common features of human metabolic syndrome (MetS). The purpose is to assess the suitability of a diet-induced obesity model for investigating non-alcoholic fatty pancreatic disease (NAFPD), fatty liver and insulin resistance. Adult C57BL/6 mice were fed either high-fat chow (HFC, 60% fat) or standard chow (SC, 10% fat) during a 16-week period. We evaluated in both groups: hepatopancreatic injuries, pancreatic islets size, alpha and beta-cell immunodensities, intraperitoneal insulin tolerance test (IPITT) and oral glucose tolerance test (OGTT). The HFC mice displayed greater mass gain (p<0.0001) and total visceral fat pads (p<0.001). OGTT showed impairment of glucose clearance in HFC mice (p<0.0001). IPITT revealed insulin resistance in HFC mice (p<0.0001). The HFC mice showed larger pancreatic islet size and significantly greater alpha and beta-cell immunodensities than SC mice. Pancreas and liver from HFC were heavier and contained higher fat concentration. In conclusion, C57BL/6 mice fed a high-fat diet develop features of NAFPD. Insulin resistance and ectopic accumulation of hepatic fat are well known to occur in MetS. Additionally, the importance of fat accumulation in the pancreas has been recently highlighted. Therefore, this model could help to elucidate target organ alterations associated with metabolic syndrome.

Agonistas PPAR (Rosiglitazona, Bezafibrato e Fenofibrato) e alterações bioquímicas e estruturais em órgãos-alvo de camundongos C57BL/6 alimentados com dieta hiperlipídica rica em sacarose / PPAR agonists (Rosiglitazone, Bezafibrate and Fenofibrate) and biochemical and structural alterations in organs target of C57BL/6 mice fed high-fat high sucrose chow

Este trabalho teve o objetivo de estudar o efeito de medicamentos com diferentes ações agonista PPAR (rosiglitazona, fenofibrato e bezafibrato) sobre o perfil lipídico, glicídico e alterações na massa corporal e morfologia do tecido adiposo e pancreático em modelo de diabetes e sobrepeso induzido por dieta. Camundongos C57BL/6 (2 meses de idade) foram alimentados com dieta padrão (SC, n=10) ou dieta hiperlipídica rica em sacarose (HFHS, n=40) por 6 semanas. Logo após, os animais HFHS foram subdividos em: HFHS não tratado e HFHS tratado com rosiglitazona (HFHS-Ro), fenofibrato (HFHS-Fe) ou bezafibrato (HFHS-BZ) (5 semanas). Os camundongos alimentados com dieta HFHS apresentaram maior glicemia e insulina de jejum (+33% e +138%, respectivamente), intolerância à glicose, resistência à insulina, aumento da massa corporal (MC) (+20%) e adiposidade, hipertrofia de adipócitos e redução da imunocoloração para adiponectina no tecido adiposo. No pâncreas houve aumento da massa (+28%), acúmulo de gordura (+700%), hipertrofia da ilhota (+38%) e redução da imunocoloração para GLUT-2 (-60%). A rosiglitazona diminuiu a glicemia e insulina de jejum, porém induziu o ganho de MC e hipertrofia cardíaca. O fenofibrato estabilizou a MC, enquanto o bezafibrato levou a perda de MC. Apenas o bezafibrato impediu a hipertrofia da ilhota. A imunocoloração para GLUT-2 foi aumentada por todos os medicamentos, e não houve alterações na imunocoloração para o PPARalfa. Sinais morfológicos de pancreatite foram vistos no grupo HFHS-Fe, apesar dos níveis normais de amilase e lipase séricos. A rosiglitazona exacerbou a infiltração intrapancreática de gordura (+75% vs. HFHS), e o bezafibrato aumentou a imunocoloração para o PPARbeta/delta nas ilhotas pancreáticas. Em conclusão, o bezafibrato apresentou um efeito mais amplo sobre as alterações metabólicas, morfológicas e biométricas decorrentes da dieta HFHS, sugerindo que a inibição das três isoformas do PPAR seria melhor do que a inibição...

This work aimed to evaluate the effect of peroxisome proliferator-activated receptor (PPAR) agonists (rosiglitazone, fenofibrate and bezafibrate) on lipid and glucose metabolism, body mass, and adipose and pancreatic tissue morphology in a model of diet-induced type 2 diabetes and overweight in mice. Two-month-old male C57BL/6 mice were fed a standard chow (SC, n=10) or a high-fat high-sucrose chow (HFHS, n=40) for 6 weeks, and then HFHS-fed mice were subdivided by treatment: untreated HFHS and HFHS treated with rosiglitazone (HFHS-Ro), fenofibrate (HFHS-Fe), or bezafibrate (HFHS-Bz) (5 weeks on medication). HFHS-fed mice have altered fasting glucose (+33%) and insulin (+138%), GI, IR, increased body mass (+20%) and fat pad weight, adipocyte hypertrophy, and decreased adiponectin immunostain. They also presented increased pancreatic (+28%) mass, intrapancreatic fat (+700%), islet hypertrophy (+38%), and decreased GLUT-2 immunostain (-60%). Rosiglitazone reduced fasting glucose and insulin but induced weight gain and heart hypertrophy. Fenofibrate impaired body mass gain, while bezafibrate induced weight loss. Only bezafibrate impaired islet hypertrophy. GLUT-2 immunostain was improved by all treatments, and there were no alterations in PPAR-alfa stain. There were morphological signs of pancreatitis in fenofibrate-treated mice, although there was no alteration in serum amylase and lipase. Rosiglitazone exacerbated pancreatic fat infiltration (+75% vs. HFHS group), and bezafibrate increased PPAR-beta expression in pancreatic islets. In conclusion, bezafibrate showed a wider range of action on metabolic, morphologic, and biometric alterations due to HFHS intake, suggesting that inhibiting the three PPAR isoforms is better than inhititing each isoform alone. Rosiglitazone exacerbated body mass gain, pancreatic fat infiltration and induced heart hyperthophy as well, thus, precaution has to be taken in prescribing rosiglitazone to obese patients.