Search

Intraductal papillary neoplasm of the bile duct (IPNB) is a premalignant disease characterized by a low incidence, a high risk of malignant transformation, and an uncertain prognosis. We hereby present the case of an 8-mm IPNB in the left liver lobe detected by endosonography in a 76-year-old woman followed for a dissociated asymptomatic cholestasis who was treated with a left hepatectomy. The resected IPNB had low-grade dysplasia and no nodal involvement in the surgical piece; however, signs of recurrence of the disease were observed in the right liver lobe a year and a half later. Therefore, given that it can be multifocal and recurrent, IPNB is a disease that requires close follow-up.

Accessory spleen is a frequent congenital abnormality (10-20%) resulting in the fusion failure of splenunculi. We present a case report of a 74 year-old man with a nodule identified in the tail of the pancreas of 1.8 cm x 1.5 cm in size. The CT scan showed soft tissue attenuation and arterial hyperenhancement with a lower uptake in the central area, low 18-FDG affinity and no evidence of 111-In-octretide uptake. A solid, round and well-circumscribed nodule was defined as an intrapancreatic accessory spleen (IPAS) by endoscopic ultrasound (EUS), due to shared ultrasonographic characteristics and a pattern of contrast enhancement with the spleen. The material obtained by EUS guided puncture was consistent with a lymph node. A distal pancreatectomy confirmed the presence of an IPAS.

A 60-year-old male was operated upon in 2002 for liver hydatidosis, which included partial right hepatectomy with cholecystectomy and bilioduodenal anastomosis. He then developed liver cirrhosis secondary to left hepatic duct stricture. He presents at the emergency room with dry cough, which he had for a month and then became associated with yellowish, bitter-tasting "fluid" expectoration. A chest-abdominal CT scan revealed a 6 x 5-cm collection roughly located somewhere between the middle pulmonary lobe and subphrenic area . A fistula was suspected, which prompted a sputum biochemistry test that was positive for bilirubin. Given the patient's impaired liver function because of his liver disease conservative treatment was initiated with an inner-outer drain under transparietal hepatic cholangiography (TPHC) to promote bile outflow via the duodenum. Subsequently, TPHC was used to locate the point where contrast leaked from the biliary tree into a pleural cavity, and the fistula was sealed using cyanoacrylate glue, which resulted in improved symptomatology.

Isolated polycystic liver disease (IPLD) is a rare genetic condition characterized by the presence of multiple liver cysts with no association with polycystic kidney disease. Most patients are asymptomatic and acute complications (cyst torsion, bleeding, infection) are uncommon. Imaging techniques, including abdominal ultrasounds, computerized axial tomography, and magnetic resonance imaging, represent a vital diagnostic modality. They are also useful for therapy support in this disease. Below we report a peculiar case of a female patient recently diagnosed with IPLD who, having received treatment with ultrasound-guided percutaneous drainage and sclerotherapy for a giant liver cyst, showed symptom and laboratory improvement. La enfermedad hepática poliquística aislada (EHPA), es una rara entidad genética que se caracteriza por la presencia de múltiples quistes hepáticos, sin estar asociada a la poliquistosis renal. La mayoría de los pacientes son asintomáticos, y son infrecuentes las complicaciones agudas (torsión quística, hemorragia e infecciones). Las técnicas de imagen, como la ecografía abdominal, tomografía axial computarizada y resonancia magnética, son un método diagnóstico fundamental. Además, son útiles como apoyo terapéutico en esta enfermedad. A continuación les presentamos un caso clínico peculiar de una paciente recientemente diagnosticada de enfermedad hepática poliquística aislada, quien tras recibir un tratamiento con drenaje percutáneo de un quiste hepático gigante y escleroterapia guiada por ecografía, presentó mejoría sintomática y analítica.

Isolated polycystic liver disease (IPLD) is a rare genetic condition characterized by the presence of multiple liver cysts with no association with polycystic kidney disease. Most patients are asymptomatic and acute complications (cyst torsion, bleeding, infection) are uncommon. Imaging techniques, including abdominal ultrasounds, computerized axial tomography, and magnetic resonance imaging, represent a vital diagnostic modality. They are also useful for therapy support in this disease. Below we report a peculiar case of a female patient recently diagnosed with IPLD who, having received treatment with ultrasound-guided percutaneous drainage and sclerotherapy for a giant liver cyst, showed symptom and laboratory improvement.

Fifty-four cases of Achromobacter xylosoxidans bacteremia diagnosed over a 10-year period in patients from 2 months to 87 years of age were reviewed. Fifty-two episodes were nosocomial. The most frequent underlying condition was neoplasm (solid or hematological). The source of infection was a contaminated intravenous catheter in 35 patients (60%) and pneumonia in 6 patients. Eight (15%) patients died. The only risk factors significantly associated with mortality were age over 65 years and neutropenia. The results of in vitro susceptibility studies of the isolates showed that antibiotic therapy with antipseudomonal penicillins or carbapenems would be a reasonable choice. An epidemiological study conducted in the hemodialysis unit showed Achromobacter xylosoxidans in tap water and on the hands of two healthcare workers but not in the hemodialysis systems. Patients were probably contaminated when healthcare workers manipulated the intravenous catheters without wearing gloves.

To establish the nasogastric enteral nutrition tolerance in patients with severe acute pancreatitis.A total of 12 patients with severe acute pancreatitis (or = 3 Ranson criteria; C-reactive protein210 mg/dl) and adverse clinical course were included during 2006. When we verified the disease severity, nasogastric (10 F) enteral nutrition was initiated. We used a low fat semi-elemental feed (Dietgrif) in a slow infusion rate. We evaluated the enteral nutrition tolerance and the adverse events.The patient (4 women and 8 men) mean age (standard deviation) was 70 (11) years and the mean hospital stay was 86 days (range: 14-405 days). The etiology of pancreatitis was: gallstones 8, alcohol abuse one and unknown 3. All patients had medical and/or pancreatic complications. Seven had significant pancreatic necrosis detected in the abdominal computed tomography. Three patients were admitted in the critical care unit and 2 died. The nasogastric enteral nutrition was well tolerated in 8 out of 12 patients (67%) regardless of their medical or pancreatic complications. Only in 3 patients we had initially to discontinue the feeding because of ileus and total parenteral nutrition was provisionally necessary. Enteral nutrition was impossible in one patient because of duodenal stenosis.Nasogastric enteral nutrition is well tolerated in patients with severe acute pancreatitis and it is an alternative to others nutritional routes.

Tesis doctoral inédita leida en la Universidad Autónoma de Madrid. Facultad de Medicina. Departamento de Medicina. Fecha de lectura: 14 de Mayo de 2004

Objective Because of the low incidence of pancreatic ascites, only case reports and case series have been published, and no randomized controlled trials have been performed to find out which is the best therapeutic approach. The aim of this study was to evaluate the utility of the different treatments for pancreatic ascites by a thorough review of all case reports described in the literature in which an independent analysis of the efficacy of the treatment administered to each patient is possible. Methods We conducted an analysis of all case reports and case series of pancreatic ascites published between 1975 and 2000 in which clinical data of every patient could be identified individually. A total of 139 cases were studied. Clinical characteristics, treatments administered, and response to therapy of every patient were registered. Conservative therapy included drainage of ascitic fluid, total parenteral nutrition and diet, and somatostatin analogues. Interventional therapy was either endoscopic or surgical. Results After multivariate analysis, the only treatments related to success were surgery (adjusted OR = 8.2, 95% CI = 3.0–22.9) and transpapillary stent (adjusted OR = 7.3, 95% CI = 0.8–62.9). No significant relationship was found between failure or death and the use of other treatments, age, sex, year of publication, underlying disease, site of leakage, or serum amylase levels. The apparent lack of effect of somatostatin analogues could be attributed to the small number of cases and the heterogeneity of the dosages. Conclusions Conservative therapy is not advisable for pancreatic ascites because of the high proportion of failures. Interventional therapy with surgery or transpapillary stent has a positive effect in the clinical outcome.

Fever of unknown origin (FUO) associated with HIV infection is different from classic FUO. Relevant etiologies, procedures and time to diagnosis were analyzed. Patients admitted with FUO from 1991 to 1996 were prospectively followed. Thirty with classic FUO (group I) and 46 with FUO and HIV (group II) were included. Data on diagnosis, time to achieve it, and procedures were registered. Diagnosis was obtained in 87% and 93% of cases in groups I and II. Infections were the most frequent cause in group II. Collagen diseases were found in group I and absent in group II. Prevalence of neoplasia was similar. Mean time to diagnosis was near 5 weeks. In HIV the predominant diagnostic method was the Lowenstein culture. Invasive methods were similarly employed. It is concluded that predominance of Mycobacteria and absence of collagen diseases make FUO associated with HIV a different form of FUO. No differences were found in approach and time to diagnosis.

Fundamento y objetivo Valorar la tolerancia a la nutricion por sonda nasogastrica de los pacientes con pancreatitis aguda grave. Pacientes y metodo Incluimos a 12 pacientes con pancreatitis aguda grave (3 o mas criterios de Ranson; proteina C reactiva > 210 mg/dl) y evolucion clinica desfavorable ingresados durante el ano 2006. Una vez establecida la gravedad de la pancreatitis, se inicio alimentacion por sonda nasogastrica (10 F) con dieta polipeptidica pobre en grasas (Dietgrif®) mediante bomba de perfusion continua. Se valoraron la tolerancia a la dieta y las complicaciones. Resultados La edad media (desviacion estandar) de los pacientes (4 mujeres y 8 varones) era de 70 (11) anos y la estancia media fue de 86 dias (intervalo: 14-405 dias). La etiologia de la pancreatitis fue biliar en 8 casos, alcoholica en uno y desconocida en 3. Todos los pacientes desarrollaron complicaciones medicas y/o pancreaticas. Siete presentaban necrosis pancreatica significativa en la tomografia computarizada. Tres ingresaron en la unidad de cuidados intensivos y 2 fallecieron. Ocho de los 12 pacientes (67%) toleraron perfectamente la dieta por sonda nasogastrica independientemente de sus complicaciones. En 3 hubo que interrumpir inicialmente la dieta por ileo paralitico y precisaron nutricion parenteral total de forma transitoria. Solo en un caso fue imposible la nutricion enteral debido a estenosis duodenal. Conclusiones La nutricion por sonda nasogastrica en los pacientes con pancreatitis aguda grave es bien tolerada y podria plantearse como una alternativa a las otras formas de nutricion.