No abstract

Endoscopic retrograde access to the biliary tree is not always possible and endoscopic ultrasound (EUA)-guided biliary drainage is increasingly used. EUS-guided hepaticogastrostomy has been proved to be feasible, although safety issues still need to be evaluated. There are few reports [1-5] with 90 %-100 % technical and 75 %-100 % clinical success rates. Major complications included stent migration, bile leaks, and cholangitis [4, 5]. An 81-year-old man with obstructive jaundice secondary to gallbladder adenocarcinoma and duodenal stricture was referred for endoscopic drainage. Magnetic resonance imaging (MRI) showed an infiltrative mass and biliary stenosis with dilated intrahepatic ducts (• " Fig. 1). The duodenal stricture was dilated with a balloon. Following failure of several attempts at transpapillary deep cannulation of the bile duct, a decision was taken to carry out transgastric EUS-guided drainage. A linear EUS scope positioned in the gastric lesser curvature disclosed a dilated intrahepatic biliary system (• " Fig. 2 a), and a 19-gauge needle was inserted inside a left intrahepatic branch (• " Fig. 2 b). After stylet removal, a cholangiogram was obtained (• " Fig. 3) and a 0.035-inch guide wire was introduced through the needle (• " Video 1). The guide wire was then positioned into an intrahepatic biliary branch. The transmural tract was enlarged by using a needle-knife. A partially covered self-expandable metal stent (SEMS), 10 × 60 mm in size (Wallstent, Boston Scientific International, La Garenne Colombes, France), was inserted (• " Fig. 4). At the end of the procedure, an enteral SEMS, 30 × 90 mm in size (Wallflex, Boston Scientific), was placed across the duodenal stenosis (• " Fig. 5 and• " Video 1).

Multiple plastic stents are currently the first treatment option for AS in patients with duct-to-duct anastomosis. cSEMS was associated with increased pancreatitis risk and higher recurrence rate.

The jararacuçu, one of the most dreaded snakes of Brazil, southern Bolivia, Paraguay and northeastern Argentina, is a heavily-built pit viper which may grow to a length of 2.2 m. Up to 1000 mg (dry weight) of highly-lethal venom may be milked from its venom glands on a single occasion. It has accounted for 0.8% to 10% of series of snake bites in São Paulo State, Brazil. We examined 29 cases of proven jararacuçu bites recruited over a 20-year period in two São Paulo hospitals. Severe signs of local and systemic envenoming, (local necrosis, shock, spontaneous systemic bleeding, renal failure) were seen only in patients bitten by snakes longer than 50 cm; bites by shorter specimens were more likely to cause incoagulable blood. Fourteen patients developed coagulopathy, six local necrosis (requiring amputation in one) and five local abscesses. Two became shocked and four developed renal failure. Three patients, aged 3, 11 and 65 years, died 18.75, 27.75 and 83 h after being bitten, with respiratory and circulatory failure despite large doses of specific antivenom and intensive-care-unit management. In two patients, autopsies revealed acute renal tubular necrosis, cerebral oedema, haemorrhagic rhabdomyolysis at the site of the bite and disseminated intravascular coagulation. In one survivor with chronic renal failure, renal biopsy showed bilateral cortical necrosis; the patient remains dependent on haemodialysis. Effects of polyspecific Bothrops antivenom were not impressive, and it has been suggested that anti-Bothrops and anti-Crotalus antivenoms should be given in combination.

High values on MELD are associated with EV and thrombocytopenia, with varices which need prophylactic therapy. As a result of their low sensitivity and specificity, it is suggested to maintain the recommendation of upper gastrointestinal endoscopy for all patients with cirhosis.

No abstract

Introduction: Adequate sedation is one of the cornerstones of good quality gastrointestinal endoscopy (GIE). Propofol sedation has increased significantly but there has been much debate over whether it can be administered by endoscopists. The aim of this prospective trial was to compare nonanesthesiologist-administered propofol (NAAP) and monitored anesthesia care (MAC). Methods: A total of 2000 outpatients undergoing GIE at Hospital Albert Einstein (São Paulo, Brazil), a tertiary-care private hospital, were divided into two matched groups: NAAP (n = 1000) and MAC (n = 1000). In NAAP, propofol doses were determined by the endoscopist. A second physician stayed in the room during the entire procedure, according to local regulations. In MAC, the anesthesiologist administered propofol. Results: In total, 1427 patients (71.3 %) were ASA (American Society of Anesthesiologists) class I and 573 were ASA class II. In NAAP, patients received more propofol + fentanyl (61.1 % vs. 50.5 %; P < 0.05) and there were fewer cases of deep sedation (44.7 % vs. 66.1 %; P < 0.05). Hypoxemia rates were similar (12.8 % for NAAP and 11.2 % for MAC; P = 0.3) but these reverted more rapidly in MAC (4.22 seconds vs. 7.26 seconds; P < 0.05). Agitation was more frequent in MAC (14.0 % vs. 5.6 %; P < 0.05). No later complications were observed. Patient satisfaction was very high and similar in both groups. Conclusion: In this setting, NAAP was as safe and effective as MAC for healthy patients undergoing GIE.Clinical trial ref. no.: U1111-1134-4430

Bleeding from gastric varices is a life-threatening condition. We report our experience with cyanoacrylate injection. Twenty three patients with portal hypertension and gastric varices underwent intra-variceal injection of a cyanoacrylate/lipiodol solution (1:1). Study endpoint was variceal obliteration. Mean follow-up was 25.3 months. Variceal obliteration was achieved in 87% of patients. Recurrence occurred in one patient (4.3%) and rebleeding in another case (4.3%). Mild abdominal pain was described in 13% of patients. Overall mortality was 21.7% and rebleeding related mortality rate was 4.3%. Our results confirm that cyanoacrylate injection is effective and safe to eradicate gastric varices.