Papilla of Vater morphology as an influencing factor in successful cannulation during resident training in advanced endoscopy. A prospective clinical study

INTRODUCTION AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training.

MATERIAL AND METHODS

Patients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods.

RESULTS

Of the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%).

CONCLUSION

Papilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

The Mexican consensus on nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) affects nearly one third of the population worldwide. Mexico is one of the countries whose population has several risk factors for the disease and its prevalence could surpass 50%. If immediate action is not taken to counteract what is now considered a national health problem, the medium-term panorama will be very bleak. This serious situation prompted the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología to produce the Mexican Consensus on Fatty Liver Disease. It is an up-to-date and detailed review of the epidemiology, pathophysiology, clinical forms, diagnosis, and treatment of the disease, whose aim is to provide the Mexican physician with a useful tool for the prevention and management of nonalcoholic fatty liver disease.

Eosinophilic esophagitis. The North against the South? A bio-economic-social mechanistic approach and clinical implications

Eosinophilic esophagitis is a chronic antigen-mediated disease characterized by esophageal symptoms, esophageal eosinophilia, and the absence of response to proton pump inhibitors. It is the most frequent cause of dysphagia and food impaction in adults. Its incidence and prevalence is very high in the developed countries (USA, Europe, Australia), where its connotation is that of an emerging epidemic. While studies have been published with large case series in the developed countries, those published in Latin America are small or consist of isolated case reports. The differences in the prevalence of the disease between the developed and developing regions are unknown. Genetic or racial causes have been cited. Nevertheless, the epidemic nature of the disease suggests that environmental causes are the most powerful. Based on the published hypotheses, as well as on epidemiologic studies, the present review discusses some of the possible causes of the disparity in the prevalence of eosinophilic esophagitis between the two types of countries. The 'hygiene hypothesis' is reviewed, together with the possible relation of Helicobacter pylori, intestinal parasites, and modifications of the esophageal microbiota in patients with eosinophilic esophagitis. In reference to studies conducted in the United States, the clinical behavior and progression of eosinophilic esophagitis in Hispanics is reviewed and a possible predominant phenotype in Mexican and other Latin American patients is discussed. Finally, based on the above, an algorithm for studying the disease in the Latin American countries is proposed.

[Obscure gastrointestinal bleeding due to duodenal infiltration of a non-functioning pancreatic neuroendocrine tumor diagnosed by capsule endoscopy: a case report]

Non-functioning pancreatic neuroendocrine tumors (PNETs) are infrequent slow-growing, clinically-silent tumors. They are incidentally detected and some of them may present in advanced stages with local involvement of surrounding structures. The diagnostic accuracy of endoscopio ultrasound (EUS) and fine needle aspiration (FNA) biopsy is significantly lower in neuroendocrine tumors (46.7%) compared with adenocarcinoma (81.4%) and other histologies (75%). Therefore, preoperative diagnosis is very difficult. Exceptionally, hey present with gastrointestinal bleeding. We present a case of a non-functioning PNET initially diagnosed as cystic serous tumor of pancreas with EUS and FNA biopsy. Two years later patient presented obscure gastrointestinal bleeding due to duodenal infiltration. Diagnosis was made by capsule endoscopy.

Prevalence of gastroesophageal reflux disease in patients with extraesophageal symptoms referred from otolaryngology, allergy, and cardiology practices: a prospective study

AIM

To investigate the prevalence of gastroesophageal reflux disease (GERD) as well as the clinical, endoscopic, and manometric characteristics in 57 adult patients with otolaryngeal symptoms, asthma, or noncardiac chest pain referred from specialized services.

METHODS

The following evaluations were performed: (1) upper endoscopy, (2) 24-hour ambulatory esophageal pH monitoring, and (3) esophageal manometry. The prevalence of GERD was determined, and demographic, clinical, endoscopic, and manometric characteristics of patients with or without GERD were evaluated.

RESULTS

Thirty-four out of 57 patients (60%) had GERD. The 95% confidence interval ranged from 48 to 72%. There was no statistical difference between patients with or without GERD regarding gender, age, or time of evolution of symptoms. Cough was more frequent in the subjects with GERD (75 vs. 25%, p<0.05). Nevertheless, cough was observed in only 53% of the patients with GERD. Patients suffering from laryngitis had a greater proximal and distal esophageal acid exposure time than those without.

CONCLUSIONS

The prevalence of GERD was 60%. There is not a definite demographic or clinical profile that permits us to distinguish between patients with and without GERD among those with ear, nose, and throat and pulmonary symptoms or chest pain.

[Achalasia, alacrima without adrenal insufficiency with peripheral and autonomic neurological dysfunction (Allgrove's syndrome)]

OBJECTIVE

To present a patient with Allgrove's syndrome and peripheral and autonomic neurological dysfunction. This pathological entity has not been previously reported in national medical literature.

BACKGROUND

Allgrove's syndrome is comprised of achalasia, alacrima and adrenal insufficiency. It is a rare disease. Some isolated cases have been informed in the literature. The most extensive series was published by Grant et al in 1993. In this study, 20 patients from various european countries were analyzed.

METHOD

We describe a patient with diagnosis suggestive of Allgrove's syndrome and expose the results of a review of the medical literature concerning this syndrome. We emphasize in neurological dysfunction of these patients. Such abnormalities are not actually well defined in this syndrome.

RESULTS

A twelve-year-old male patient was admitted to the hospital for dysphagia. A diagnosis of achalasia was performed with endoscopy and esophagogram and confirmed with esophageal manometry. Physical examination showed alacrima and neurological dysfunction. Stimulation of adrenal function with ACTH (Cortosin) was normal. Neurologic examination revealed: peripheral neuropathy, autonomic dysfunction; corticospinal, psychomotor and intellectual impairment.

CONCLUSION

Allgrove's syndrome must be in mind in physicians who see children with achalasia. Nevertheless adrenal insufficiency is not always present in cases when diagnosis is performed. It may appear several years afterwards. Neurological dysfunction seems to be the most prominent feature.

Treatment of active gastroesophageal variceal bleeding with terlipressin or hemostatic balloon in patients with cirrhosis. A randomized controlled trial

Gastroesophageal variceal bleeding due to portal hypertension should be treated by endoscopic sclerotherapy. This procedure, however, has some limitations. It has been established that vasoactive drugs are effective for controlling active variceal bleeding. We report the results of a randomized controlled trial comparing terlipressin to hemostatic tube (Linton-Michel tube) for the treatment of bleeding gastroesophageal varices in cirrhotic patients. Thirty-seven cirrhotic patients with a total of 40 episodes of gastroesophageal variceal bleeding were included in this trial. Patients were randomly assigned to intravenous terlipressin or Linton-Michel tube (LM tube), for 24 h. During this period, hemostasis was defined as obtaining of hemodynamic and hematocrit stabilization and/or absence of hematemesis or melena. Bleeding recurrence was assessed during a 1-month period after treatment. Twenty bleeding episodes were treated with terlipressin (Group I) and 20 with LM tube (Group II). Both groups of patients were similar in age, sex distribution, etiology of cirrhosis and degree of hepatic insufficiency. Bleeding was controlled in 70% of patients from Group I and in 95% from Group II (p < 0.05) during treatment. Bleeding recurred in 14% of patients in Group I vs. 36% in Group II 1 week following the treatment (p > 0.05) and in 16.6% in Group I vs. 83.3% in Group II 1 month after treatment (p < 0.05). Complications were more frequent in Group II than in Group I (65 vs. 15%, p < 0.05). Mortality rate was similar in both groups 1 month after treatment. In conclusion, hemostatic tubes were superior to terlipressin for the control of active gastroesophageal variceal bleeding within the first 24 h. Complications and bleeding recurrence were more frequent in patients treated by hemostatic tube within a period of 1 month after treatment. Mortality rate was similar in both groups of patients.

Total therapeutic paracentesis (TTP) with and without intravenous albumin in the treatment of cirrhotic tense ascites: a randomized controlled trial

We studied 35 cirrhotic patients with tense ascites assigned at random into two groups: Group I consisted of 17 patients treated by total therapeutic paracentesis (TTP) (6-15 l) plus i.v. albumin (5 g/l of fluid) and Group II consisted of 18 patients treated by TTP (5.5-15.5 l) without albumin. On 19 patients we performed a sequential assessment of cardiac output (CO), plasma renin activity (PRA) and plasma aldosterone (PA). Both groups were similar in age, sex, and etiology of cirrhosis. CO, PRA and PA values were expressed as mean changes occurring in relation to their respective baseline values. CO changes after TTP (l/min): Group I: 2.5 after 6 h and 2.2 after 12 h; Group II: 2.2 after 6 h and -0.4 after 12 h, (p < 0.05 comparing values after 12 h between the two groups). PRA changes after TTP (ng/dl/h): Group I: -7.4 after 1 h, -7.8 after 6 h and -3.2 after 24 h; Group II: -2.4 after 1 h, -0.8 after 6 h and 3.9 after 24 h (p < 0.05 comparing values between both groups after 6 and 24 h). PA changes after TTP (ng/dl): Group I: -50.5 after 1 h, -36.7 after 6 h and -34.6 after 24 h; Group II: -18.2 after 1 h, -2.2 after 6 h and 20 after 24 h, (p < 0.05 comparing values between both groups after 1 and 6 h). Complications were minimal in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Granulosa cell tumor with liver metastasis treated with partial hepatectomy and chemotherapy. Report of a case]

A patient with granulosa cell tumor recurrence 14 years after primary resection, was treated with partial hepatectomy and adjuvant chemotherapy (vinblastine, cisplatin and bleomycin). She achieved complete remission and is free of disease 18 months after treatment.