Hemosuccus Pancreaticus: A Mysterious Cause of Gastrointestinal Bleeding.

Hemosuccus pancreaticus (bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater) is a rare, potentially life-threatening and obscure cause of upper gastrointestinal bleeding. It is caused by rupture of the psuedoaneurysm of a peripancreatic vessel into pancreatic duct or pancreatic psuedocyst in the context of pancreatitis or pancreatic tumors. It can pose a significant diagnostic and therapeutic dilemma due to its anatomical location and that bleeding into the duodenum is intermittent and cannot be easily diagnosed by endoscopy. A 61-year-old female with HIV and alcoholism presented with 3 weeks of intermittent abdominal pain and melena. Examination revealed hypotension with pallor and mild epigastric tenderness. She was found to have severe anemia and a high serum lipase. It was decided to perform a contrast-enhanced computed tomography (CT) scan that demonstrated a hemorrhagic pancreatic pseudocyst with possible active bleeding into the cyst. An emergent angiogram showed a large pseudoaneurysm of the pancreaticoduodenal artery that was successfully embolized. Subsequent endoscopy showed blood near ampulla of Vater confirming the diagnosis of hemosuccus pancreaticus. Thus the bleeding pseudocyst was communicating with pancreatic duct. The patient had no further episodes of gastrointestinal bleeding. Hemosuccus pancreaticus should be considered in patients with intermittent crescendo-decrescendo abdominal pain, gastrointestinal bleeding and a high serum lipase. Contrast-enhanced CT scan can be an excellent initial diagnostic modality and can lead to prompt angiography for embolization of the bleeding pseudoaneurysm and can eliminate the need for surgery.

Increased Barrett's esophagus for the decade between 1991 and 2000 at a single university medical center.

Barrett's esophagus is being diagnosed increasingly in the United States. The aim of this study was to determine whether the increased diagnosis of Barrett's esophagus is due to endoscopic reporting and/or a truly increasing rate. This retrospective study reviewed 18,183 endoscopy reports at Temple University Hospital from January 1991 through December 2000. Annual rates of new cases of endoscopically suspected Barrett's esophagus were determined. Biopsy results were reviewed for the diagnosis of Barrett's esophagus (i.e., specialized intestinal metaplasia). Rates of Barrett's esophagus increased from 3.22 to 8.28 per 100 endoscopies (257%; P < 0.01) on endoscopy and from 0.67 to 2.76 per 100 endoscopies (412%; P < 0.01) on histology from 1991 to 2000. Twenty-four and seven-tenths percent (252/1020) of patients suspected at endoscopy to have Barrett's esophagus were confirmed by histology. This study demonstrates an increasing rate of new cases of suspected Barrett's esophagus on endoscopy and confirmed Barrett's esophagus on histology over the last decade. The endoscopic impression of Barrett's esophagus was about four times higher than the confirmed diagnosis of Barrett's esophagus (intestinal metaplasia) on histology.

Predictors of recurrent specialized intestinal metaplasia after complete laser ablation.

OBJECTIVES: The aim of this study was to determine whether specialized intestinal metaplasia recurs after complete laser ablation and to evaluate the persistence of colon epithelial protein in esophageal mucosa after laser ablation as a predictor of recurrence. METHODS: A total of 31 patients with specialized intestinal metaplasia (Barrett's esophagus) underwent laser photoablation. Investigators without knowledge of treatment status evaluated serial hematoxylin and eosin-stained slides, Alcian blue-stained slides, and immunohistochemistry for the detection of colon epithelial protein (mAb Das-1). RESULTS: Endoscopic ablation of specialized intestinal epithelium was accomplished in 21 patients after 6.5 +/- 1.2 laser sessions. Complications included one perforation, one UGI bleed and one stricture. Of eight post-laser recurrences, seven were successfully re-ablated; one developed adenocarcinoma requiring esophageal resection. Cardia-type mucosa was present by biopsy at the time of complete ablation in all eight recurrent cases despite a normal endoscopic appearance. Colon epithelial protein was detected in all 31 patients before ablation, six of 21 completely ablated patients before they recurred and all eight recurrences. Only two of 15 patients, colon epithelial protein negative at the time of complete ablation, developed recurrent Barrett's esophagus. Thus, cardia-type mucosa and persistent colon epithelial protein staining after complete ablation of specialized intestinal epithelium were predictors of future recurrence (p < 0.001). CONCLUSIONS: Specialized intestinal epithelium was ablated by neodymium:yttrium-aluminum-garnet laser but recurred in eight of 21 (38%) of patients. Colon epithelial protein was present in all primary (31 of 31) and all recurrent (eight of eight) Barrett's esophagus. Recurrent specialized intestinal metaplasia may be deep to squamous epithelium. Replacement of specialized intestinal mucosa by cardia-type mucosa and persistence of colonic epithelial protein are predictors of recurrent specialized intestinal mucosa before its endoscopic or histological detection. Laser ablation of Barrett's epithelium is an investigational intervention that should be restricted to research protocols.

Abdominal computed tomography prolongs length of stay and is frequently unnecessary in the evaluation of acute pancreatitis.

BACKGROUND: Computed tomography (CT) can play a vital role in the diagnosis and staging of patients with acute pancreatitis. However, according to current guidelines, a CT examination should not be performed in all patients. We assessed the use of CT scanning in the evaluation of patients with acute pancreatitis at an urban teaching hospital. METHODS: Retrospective review of patients admitted with the diagnosis of acute pancreatitis from October 1999 to October 2001. We recorded demographics, laboratory values, severity of illness, length of stay, indication for CT, ordering physician, and outcome. RESULTS: Overall, 108 patients met our inclusion criteria. Of these, 58 (54%) underwent CT examination. There was no difference (all P > 0.60) in markers of severity of illness in patients undergoing CT versus no CT. The only significant difference was length of stay (P = 0.003). Patients not undergoing CT were discharged a mean of 3 days sooner. Most appropriate CTs were ordered by the gastroenterology consultants as opposed to the emergency room and medical groups; however, this group's length of stay was longest (P = 0.035). CONCLUSIONS: In 1 teaching institution, physicians ordering CT for the evaluation of acute pancreatitis frequently do so without regard to the severity of patient illness. These examinations may prolong the length of hospitalization. Continued refinement and dissemination of guidelines for the diagnostic evaluation of acute pancreatitis is needed.

La diarrea en los adultos: algunas notas prácticas

La diarrea es uno de los motivos de consulta médica más frecuentes en todo el mundo. Sin embargo, no se trata de un cuadro clinico unico ni sus causas son las mismas en todas las personas o paises. La historia clinica enfocada de manera adecuada, junto con cuidadoso examen fisico y algunos examenes complementarios bien elegidos, permiten llegar al diagnostico y realizar el tratamiento mas adecuado, lo que se traduce en pronta recuperacion del enfermo o en la identificacion de algun problema mas grave -por ejemplo, infeccion por el VIH- que sea la verdadera amenaza para el enfermo.