Esophageal Pseudotumor Secondary to Treatment with a Potassium Binder Resin: A Case of Severe Esophagitis Mimicking a Malignancy.

Background. Sodium polystyrene sulfonate is a resin used to treat hyperkalemia. Colonic mucosal injury, intestinal ischemia, necrosis, and perforation have been widely reported in the literature, but few cases have reported upper gastrointestinal injury and identify the endoscopic features. Case Presentation. We describe a case of an 83-year-old male, with no prior esophageal symptoms, who developed dysphagia after being treated with sodium polystyrene sulfonate for hyperkalemia. Endoscopic features consistent with severe esophagitis and a mass in the lower esophagus mimicking a malignancy were found, and pathology confirmed resin-induced esophagitis. Discussion. The identification of basophilic crystals in the epithelium with surrounding inflammation is a hallmark of sodium polystyrene sulfonate-induced mucosal injury. Several direct and indirect mechanisms by which SPS may cause mucosal injury have been identified. Prolonged stasis of crystals in the lumen has the potential of developing erosions and ultimately necrosis. The internalization of these crystals to the underlying intestinal mucosa with the combination of the inflammatory response may give an appearance of a luminal mass that can mimic a malignancy. Recognizing the wide-ranging endoscopic findings of resin-induced mucosal injury in the esophagus is fundamental to consider a potential side effect of sodium polystyrene sulfonate. The use of this resin should be avoided in patients with suspected esophageal motility disorder.

Cardiac safety and clinical efficacy of high-dose domperidone for long-term treatment of gastroparesis symptoms.

Domperidone is an effective antiemetic used worldwide, but there have been reports of possible cardiotoxicity. Our goal was to explore the cardiac safety and clinical efficacy of long-term domperidone, titrated as high as 120 mg/day, in patients not responding or unable to tolerate other therapies for gastroparesis (GP).This retrospective cohort study was conducted at a single tertiary care academic center. We objectively assessed the safety and efficacy of domperidone through questionnaires, clinical follow-up and frequent ECGs as mandated by the Food and Drug Administration. We excluded patients with a history of dangerous arrhythmias, prolonged QTc, clinically significant electrolyte disturbances, gastrointestinal hemorrhage or obstruction, presence of a prolactinoma, pregnant or breastfeeding females, or allergy to domperidone. A total of 21 patients met the inclusion criteria for eligibility in this study (52.4% white, 42.9% Hispanic; mean age 50.1 years; 90.5% female). The mean duration of domperidone therapy was 52.3 (range 16-97) months with a mean highest dose of 80 mg/day (range 40-120 mg). Two patients (9.5%) taking 120 mg/day experienced asymptomatic meaningful QTc prolongation (>450 ms in males, >470 ms in females). One-third of patients had asymptomatic non-meaningful QTc prolongation. Palpitations or chest pain was reported in 19% of patients without ECG abnormalities or adverse cardiac events. The mean severity of vomiting and nausea was improved by 82% and 55%, respectively.Long-term treatment with high doses of domperidone (40-120 mg/day) improved GP symptoms in patients previously refractory to other medical therapies and with a satisfactory cardiovascular risk profile.

Endoscopic Bariatric Interventions in Patients with Chronic Liver Disease.

Obesity and its associated comorbidities are rapidly increasing in the US population. Therefore, metabolic associated fatty liver disease (MAFLD), previously known as nonalcoholic fatty liver disease (NAFLD), has become a leading indication for liver transplantation. Lifestyle modifications as a sole therapy have been insufficient to reduce the burden of chronic liver disease secondary to MAFLD. Endoscopic bariatric interventions (EBI) appear to be safe and effective therapies for obesity and chronic liver disease secondary to MAFLD. Gastric EBI include endoscopic sleeve gastroplasty (ESG) and intragastric balloons (IGB). Small bowel EBI are also evolving in the field of bariatric endoscopy.

Human footprints provide snapshot of last interglacial ecology in the Arabian interior.

The nature of human dispersals out of Africa has remained elusive because of the poor resolution of paleoecological data in direct association with remains of the earliest non-African people. Here, we report hominin and non-hominin mammalian tracks from an ancient lake deposit in the Arabian Peninsula, dated within the last interglacial. The findings, it is argued, likely represent the oldest securely dated evidence for Homo sapiens in Arabia. The paleoecological evidence indicates a well-watered semi-arid grassland setting during human movements into the Nefud Desert of Saudi Arabia. We conclude that visitation to the lake was transient, likely serving as a place to drink and to forage, and that late Pleistocene human and mammalian migrations and landscape use patterns in Arabia were inexorably linked.

Eculizumab in refractory catastrophic antiphospholipid syndrome: a case report and systematic review of the literature.

Catastrophic antiphospholipid syndrome (CAPS) is a rare disorder, characterized by the development of multiple vascular thrombosis over a short period of time, in patients with persistently detectable antiphospholipid antibodies (aPLs). The vascular occlusions predominantly affect small vessels. The overall mortality is 36.9%, despite the recent progress in the therapeutic approach. It has been shown that aPLs are able to induce a hypercoagulability state through different mechanisms of action, including complement activation, which in turn plays a key role in the pathogenesis of some thrombotic microangiopathies. Consequently, complement inhibition may be proposed as a targeted intervention to effectively prevent the progression of the microthrombotic storm. The employment of the complement inhibitor eculizumab has been proposed in CAPS on the basis of occasional reports and expert opinion. We report the case of a 54-year-old woman with a CAPS refractory to conventional therapies, who was successfully treated with eculizumab. The administration of this anti-C5 monoclonal antibody aborted the acute progressive thrombotic events and prevented further clinical episodes of thrombosis in the following year. We also faced our case to a systematic literature review, by analyzing all reported cases of CAPS in which eculizumab was added to conventional therapy. Even if further investigation is needed, our results suggest that the inhibition of one mechanism of aPL-induced organ damage may be an add-on treatment for this condition.

Recurrent Pleural Effusion Secondary to a Pancreatic-Pleural Fistula Treated Endoscopically.

BACKGROUND Pancreatic-pleural fistula (PPF) is an uncommon complication of pancreatitis. Pleural effusions secondary to PPF are caused by fistulization of pancreatic secretions to the thorax derived from the rupture or leakage of a pseudocyst. CASE REPORT We describe the case of a 44-year-old male with recurrent right-sided pleural effusions and alcoholic pancreatitis who presented with epigastric pain and shortness of breath. Pleural fluid analysis revealed an amylase of 7002 U/lt. MRCP showed segmental narrowing and stricture of the proximal main pancreatic duct and an area of walled-off necrosis. The fistula was managed endoscopically with ERCP and placement of a plastic stent into the pancreatic duct. The pleural effusion resolved and subsequent examinations showed no evidence of recurrence. CONCLUSIONS The diagnosis of PPF is challenging. Endoscopic treatment of PPF can be a safe and effective approach.

Burkitt's Lymphoma of the Rectosigmoid and Stomach Presenting as Hematochezia.

BACKGROUND: Burkitt's lymphoma (BL) is an uncommon cause of non-Hodgkin lymphoma in adults and accounts for only 0.1-0.5% of all malignant tumors of the colon and rectum. Very few cases of rectosigmoid and stomach BL have been reported in adults. CASE REPORT: A 51-year-old Hispanic woman presented with a 1-month history of hematochezia, associated with a foreign-body sensation in the rectum and 7 kg weight loss. Initial laboratory workup showed normocytic anemia and positive fecal occult blood. Computed tomography of the abdomen revealed an asymmetric appearance of the stomach and pylorus with nodularity of the mucosa and thickening of the posterior wall, and a 10.8-cm rectal mass. Esophagogastroduodenoscopy and colonoscopy were performed and biopsies of the stomach and rectum were obtained; histopathology demonstrated involvement by Burkitt's lymphoma in the gastric body nodule and rectal mass. After 4 cycles of chemotherapy, a follow-up abdominal CT demonstrated complete resolution of the mural thickening of the rectum and no intra-abdominal lymphadenopathy. CONCLUSIONS: Our case illustrates the importance of considering BL in the extensive differential diagnosis of rectal bleeding, change in bowel habits, and other lower and upper GI symptoms, since the rapidly growing nature of this rare malignancy requires a prompt diagnosis and initiation of appropriate therapy.

A rock engraving made by Neanderthals in Gibraltar.

The production of purposely made painted or engraved designs on cave walls--a means of recording and transmitting symbolic codes in a durable manner--is recognized as a major cognitive step in human evolution. Considered exclusive to modern humans, this behavior has been used to argue in favor of significant cognitive differences between our direct ancestors and contemporary archaic hominins, including the Neanderthals. Here we present the first known example of an abstract pattern engraved by Neanderthals, from Gorham's Cave in Gibraltar. It consists of a deeply impressed cross-hatching carved into the bedrock of the cave that has remained covered by an undisturbed archaeological level containing Mousterian artifacts made by Neanderthals and is older than 39 cal kyr BP. Geochemical analysis of the epigenetic coating over the engravings and experimental replication show that the engraving was made before accumulation of the archaeological layers, and that most of the lines composing the design were made by repeatedly and carefully passing a pointed lithic tool into the grooves, excluding the possibility of an unintentional or utilitarian origin (e.g., food or fur processing). This discovery demonstrates the capacity of the Neanderthals for abstract thought and expression through the use of geometric forms.

Variation in lithic technological strategies among the Neanderthals of Gibraltar.

THE EVIDENCE FOR NEANDERTHAL LITHIC TECHNOLOGY IS REVIEWED AND SUMMARIZED FOR FOUR CAVES ON THE ROCK OF GIBRALTAR: Vanguard, Beefsteak, Ibex and Gorham's. Some of the observed patterns in technology are statistically tested including raw material selection, platform preparation, and the use of formal and expedient technological schemas. The main parameters of technological variation are examined through detailed analysis of the Gibraltar cores and comparison with samples from the classic Mousterian sites of Le Moustier and Tabun C. The Gibraltar Mousterian, including the youngest assemblage from Layer IV of Gorham's Cave, spans the typical Middle Palaeolithic range of variation from radial Levallois to unidirectional and multi-platform flaking schemas, with characteristic emphasis on the former. A diachronic pattern of change in the Gorham's Cave sequence is documented, with the younger assemblages utilising more localized raw material and less formal flaking procedures. We attribute this change to a reduction in residential mobility as the climate deteriorated during Marine Isotope Stage 3 and the Neanderthal population contracted into a refugium.

The changing face of prosthetic valve endocarditis at a tertiary-care hospital: 1986-2005.

INTRODUCTION AND OBJECTIVES: To investigate changes in the clinical characteristics, etiology and prognosis of prosthetic valve endocarditis at a tertiary-care hospital. METHODS: Retrospective cohort study of all patients diagnosed with prosthetic valve endocarditis using modified Duke criteria between 1986 and 2005. The analysis covered two time periods: January 1986 to December 1995 (P1) and January 1996 to December 2005 (P2). RESULTS: In total, 133 episodes of endocarditis occurred in 122 patients. Of these, 73 (54.9%) were diagnosed in P1 and 60 (45.1%) in P2, with incidences of 2.19% and 2.18%, respectively. The patients' mean age (SD) was 52.6+/-16.6 years in P1 and 66.2+/-11.5 years in P2 (P=.0001). Clinical characteristics were similar in the two study periods. The increase in Enterococcus infection was remarkable (12.5% in P2 vs. 4.9% in P1; relative risk [RR]=2.5; 95% confidence interval [CI], 0.7-9.6), as was the decrease in viridans group Streptococcus infection (12.5% in P2 vs. 31.1% in P1; RR=0.4; 95% CI, 0.2-0.9). Some 90.4% of patients (63/73) underwent surgery in P1, while 68.3% (41/60) underwent surgery in P2. The difference was significant (RR=0.8; 95% CI, 0.6-0.9). The in-hospital mortality rate was 28.8% in P1 and 30% in P2 (RR=1; 95% CI, 0.6-1.7). CONCLUSIONS: Changes in the epidemiology and microbiological etiology of prosthetic valve endocarditis were observed over the 20-year study period. Diagnostic and therapeutic approaches also changed, but mortality remained high.

Cambios en el perfil de la endocarditis sobre válvula protésica en un hospital de tercer nivel: 1986-2005 / The changing face of prosthetic valve endocarditis at a tertiary-care hospital: 1986-2005

Introducción y objetivos. Estudiar la evolución de las características clínicas, la etiología y el pronóstico de la endocarditis sobre válvula protésica en un hospital de tercer nivel. Métodos. Estudio de cohortes retrospectivo de todos los pacientes diagnosticados de endocarditis sobre válvula protésica desde 1986 a 2005 según los criterios de Duke modificados. Se analizaron dos periodos temporales: enero de 1986 a diciembre de 1995 (P1) y enero de1996 a diciembre de 2005 (P2).Resultados. Se estudiaron 133 episodios en 122 pacientes. En 73 episodios (54,9%) la endocarditis fue diagnosticada en el P1 y en 60 (45,1%), en el P2 (incidencia del 2,19 y el 2,18% respectivamente). La edad, media ± desviación estándar, fue de 52,6 ± 16,6 años en el P1 y 66,2 ± 11,5 años en el P2 (p = 0,0001). Las características clínicas fueron similares en ambos periodos de estudio. Fue llamativo el incremento de infecciones por enterococo (el 12,5% en el P2 y el 4,9% en elP1; riesgo relativo [RR] = 2,5; intervalo de confianza [IC]del 95%, 0,7-9,6) así como el descenso de las infecciones por estreptococos del grupo viridans (el 12,5% en el P2 y el 31,1% en el P1; RR = 0,4; IC del 95%, 0,2-0,9). Los pacientes intervenidos en el P1 fueron el 90,4%(63/73), mientras que en el P2 fueron el 68,3% (41/60),diferencias que resultaron estadísticamente significativas(RR = 0,8; IC del 95%, 0,6-0,9). La mortalidad intrahospitalaria fue del 28,8% en el P1 y el 30% en el P2 (RR = 1;IC del 95%, 0,6-1,7).Conclusiones. Durante los 20 años de estudio, se ha observado un cambio en la epidemiología y la etiología microbiológica de la endocarditis sobre válvula protésica. El abordaje diagnóstico y terapéutico también se ha modificado, aunque la mortalidad se ha mantenido elevada (AU)

Introduction and objectives. To investigate changes in the clinical characteristics, etiology and prognosis of prosthetic valve endocarditis at a tertiary-care hospital. Methods. Retrospective cohort study of all patients diagnosed with prosthetic valve endocarditis using modified Duke criteria between 1986 and 2005. The analysis covered two time periods: January 1986 to December 1995 (P1) and January 1996 to December 2005 (P2).Results. In total, 133 episodes of endocarditis occurred in 122 patients. Of these, 73 (54.9%) were diagnosed in P1and 60 (45.1%) in P2, with incidences of 2.19% and 2.18%,respectively. The patients’ mean age (SD) was 52.6±16.6years in P1 and 66.2±11.5 years in P2 (P=.0001). Clinical characteristics were similar in the two study periods. The increase in Enterococcus infection was remarkable (12.5%in P2 vs. 4.9% in P1; relative risk [RR]=2.5; 95% confidence interval [CI], 0.7-9.6), as was the decrease in viridans group Streptococcus infection (12.5% in P2 vs. 31.1% in P1;RR=0.4; 95% CI, 0.2-0.9). Some 90.4% of patients (63/73)underwent surgery in P1, while 68.3% (41/60) underwent surgery in P2. The difference was significant (RR=0.8; 95%CI, 0.6-0.9). The in-hospital mortality rate was 28.8% in P1and 30% in P2 (RR=1; 95% CI, 0.6-1.7).Conclusions. Changes in the epidemiology and microbiological etiology of prosthetic valve endocarditis were observed over the 20-year study period. Diagnostic and therapeutic approaches also changed, but mortality remained high (AU)

[Complicated acute apendicitis. Open versus laparoscopic surgery]. / Apendicitis aguda complicada. Abordaje abierto comparado con el laparoscópico.

INTRODUCTION: Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis, especially if it is complicated due reports on the increase in intra-abdominal abscesses. OBJECTIVE: The purpose of this study was to evaluate the morbidity in a group of patients diagnosed with complicated apendicitis (gangrenous or perforated) who had undergone open or laparoscopic appendectomy. MATERIAL AND METHOD: We prospectively studied 107 patients who had undergone appendectomy for complicated appendicitis over a two year period. Mean operation time, mean hospital stay and morbidity, such as wound infection and intra-abdominal abscess were evaluated. RESULTS: In the group with gangrenous appendicitis morbidity was significantly lower in laparoscopic appendectomy group (p = 0.014). Wound infection was significantly higher in the open appendectomy group (p = 0.041), and there were no significant differences in intra-abdominal abscesses (p = 0.471). In the perforated appendicitis group overall morbidity (p = 0.046) and wound infection (p = 0.004) was significantly higher in the open appendectomy group. There were no significant differences in intra-abdominal abscesses (p = 0.612). CONCLUSION: These results suggest that laparoscopic appendectomy for complicated appendicitis is a safe procedure that may prove to have significant clinical advantages over conventional surgery.

Apendicitis aguda complicada. Abordaje abierto comparado con el laparoscópico / Complicated acute apendicitis. Open versus laparoscopic surgery

Introducción. Aunque el uso de la laparoscopia se ha generalizado en muchas patologías, en el caso de la apendicitis aguda, y sobre todo si es complicada, no ha podido definirse como vía de elección debido al posible aumento de los casos de infección de órgano o espacio. El objetivo es comparar la morbilidad de un grupo de pacientes con apendicitis aguda complicada (gangrenosa o perforada) operados por vía convencional con otro operado por vía laparoscópica. Pacientes y método. Estudio de cohortes prospectivo constituido por 107 pacientes intervenidos por una apendicitis complicada en un período de 2 años. Se analizaron las medias del tiempo de intervención quirúrgica y del tiempo de ingreso y la morbilidad en forma de infección del sitio quirúrgico e infección de órgano o espacio. Resultados. En el grupo con apendicitis aguda gangrenosa, la morbilidad fue significativamente menor en el grupo de laparoscopia (p = 0,014). La infección del sitio quirúrgico fue significativamente mayor en el grupo de cirugía abierta (p = 0,041), y no se encontró diferencias en cuanto a la infección de órgano o espacio (p = 0,471). En el grupo de pacientes con apendicitis aguda perforada (p = 0,026), la morbilidad fue significativamente mayor en el grupo de cirugía abierta (p = 0,046). La infección de sitio quirúrgico fue significativamente mayor en este grupo (p = 0,004), y no hubo diferencias significativas en cuanto a la infección de órgano o espacio (p = 0,612). Conclusiones. Estos resultados indican que la apendicectomía laparoscópica en las apendicitis complicadas es una vía de abordaje segura y ofrece ventajas significativas con respecto a la vía abierta The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Introduction. Although laparoscopy has become the standard approach in other procedures, this technique is not generally accepted for acute appendicitis, especially if it is complicated due reports on the increase in intra-abdominal abscesses. Objective. The purpose of this study was to evaluate the morbidity in a group of patients diagnosed with complicated apendicitis (gangrenous or perforated) who had undergone open or laparoscopic appendectomy. Material and method. We prospectively studied 107 patients who had undergone appendectomy for complicated appendicitis over a two year period. Mean operation time, mean hospital stay and morbidity, such as wound infection and intra-abdominal abscess were evaluated. Results. In the group with gangrenous appendicitis morbidity was significantly lower in laparoscopic appendectomy group (p = 0.014). Wound infection was significantly higher in the open appendectomy group (p = 0.041), and there were no significant differences in intra-abdominal abscesses (p = 0.471). In the perforated appendicitis group overall morbidity (p = 0.046) and wound infection (p = 0.004) was significantly higher in the open appendectomy group. There were no significant differences in intra-abdominal abscesses (p = 0.612). Conclusion. These results suggest that laparoscopic appendectomy for complicated appendicitis is a safe procedure that may prove to have significant clinical advantages over conventional surgery The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Isquemia cólica simulando un carcinoma / Colic ischemia mimicking carcinoma

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Experiencia inicial en el tratamiento de las várices esofágicas mediante ligadura transendoscópica / Band ligation in esophagic variceal portal hypertension. Initial experience

Material y métodos: Se seleccionaron aquellos pacientes que mediante endoscopia se estableció el diagnóstico de várices esofágicas grado II y III de la clasificación de Westaby, de enero de 1997 a julio de 1999, sin datos de sangrado activo del tubo digestivo algo, con tiempos de coagulación alterados y con condiciones generales estables que permitieran la colaboración del paciente con el procedimiento, utilizando un videoendoscopio Olympus GIF-100, un ligador de multibandas de goma tipo MBL-6, y con técnica de inicio a partir del rodete de la unión esofagogástrica, así como del diseño de un recargador cónico de bandas de goma. Resultados: Se obtuvieron un total de 15 pacientes, siendo nueve del sexo femenino y seis del sexo masculino, nueve de ellos con várices grado II, y seis grado III. En ningún caso se presentaron complicaciones durante el procedimiento. En 10 pacientes se presentó estenosis esofágica que cedió con una sola sesión de dilatación del esófago.