A 58 years old male consulted to his practitioner due to long evolution and continuous abdominal pain with non constant diarrhea. His medical history includes chronic ischemic cardiopathy, atrial flutter, hypertension, bilateral hip prosthesis. A colonoscopy was performed finding no abnormalities. The scanner showed an infiltrative mesenteric mass of 7 x 14 cm with undefined margins which contacted with pancreatic cephalic portion and uncinate process (Fig. 1). A MRI dismissed local and linfovascular infiltration. The study was completed with a FNA cytology guided by EUS being positive for neoplastic cells, suggesting pancreatic adenocarcinoma moderately differentiated. After this diagnosis cephalic pancreaticoduodenectomy was performed.Postoperative evolution was good with a pancreatic leak solved with medical measures. Further anatomical pathology analysis demonstrated pancreatic ascariasis with fibrocaseous nodules and abscess affecting cephalic pancreas and transverse mesocolon (Fig. 2). There were no tumor cells founded in the surgical specimen. The patient was treated with albendazole 400 mg. DISCUSSIONAscariasis is frequent helminthic infection which is suffered by a quarter of the human population. Its condition is endemic in developing countries, Asia and Latin America. In developed countries it is unusual (1). The biliopancreatic affection is unlikely, being in our environment extremely rare, but it can be responsible for potentially serious complications (2).Their eggs (Fig. 3) are swallowed, the larvae emerge, they invade intestinal mucosa and get through the portal and systemic circulation to lungs where they maturate and move to pharynx getting the digestive tract again. They colonize the small intestine and they remain causing no symptoms in most of cases (1,2).Inbetween abdominal manifestations we focus on biliopancreatic sphere. Toxins excreted by the nematodes (neurotoxins, anafilotoxins, hemolysins,...) produce a spam at Oddi's sphincter (3), and plus detritus from the intestinal tract, bile and pancreas canalicules may get occluded and infect organic fluids (2). The most common form is the biliary colic. Less frequent but more transcendental are other conditions such as acute cholecystic, cholangitis, liver abscess, obstructive jaundice, choledocolithiasis and acute and chronic pancreatitis (4,5).The elective method of diagnosis is microscopic identification of the eggs in the feces, the fresh exam is able to detect moderate to high infections. The US may be diagnostic in case worms are directly seen.The treatment for biliary ascariasis is bases in digestive repose, analgesia, extended spectrum antibiotherapy (if there REV ESP ENFERM DIG (Madrid) Vol. 103. N.° 11, pp. 592-593, 2011 Fig. 1. Inflammatory process over pancreas cephalic portion. PICTURES IN DIGESTIVE PATHOLOGY
A 49-year-old man presented at the emergency department for severe epigastric pain and a 48-hour episode of vomiting with a greatly affected general state. This is a patient diagnosed with Behçet's disease and ankylosing spondylitis, operated for a hiatal hernia two months before his admission, where a laparoscopic Nissen fundoplication and pillars closure were performed. During the immediate postoperative period, he manifested a picture of vomiting and dysphagia after waking up from the anesthetic procedure. Both disappeared with corticosteroid administration.At the admission to the hospital, the patient showed clear signs of difficulty breathing, paleness, sweating, tachypnea, and tachycardia. On examination, we found no breath sounds in the right hemithorax, and the abdominal exploration revealed signs of rigidity of abdominal wall. Chest X-ray (Fig. 1).Our differential diagnosis stated hiatal hernia recurrence vs. secondary acute esophageal perforation for abdominal overpressure due to persistent nausea (Boerhaave syndrome). A thoraco-abdominal CT scan was requested (Fig. 2).An urgent surgery was performed, where we found a complete transhiatal migration from stomach to chest and an associated organoaxial volvulus, as well as a partially disrupted fundoplication. Once the herniated viscera were reintroduced in the abdominal cavity, a proper vascularisation was showed. The fundoplication was rebuilt and the pillars were approached. An abdominal drainage was inserted and removed 4 days after the postoperative period. DISCUSSIONThe Nissen fundoplication is considered as the "gold standard" procedure in patients which are affected by a gastroesophageal reflux disease resistant to conservative management. Thanks to it, efficient clinical and histological results with a low operative morbidity and mortality rates are achieved (1).Long-term antireflux surgery re-operations are close to 3%, as published in the broadest series shown in the bibliography. Fundoplication intrathoracic migration which determines a persistent clinical outcome is the most frequent cause (27.9%) of re-operation in the late postoperative antireflux surgery. In descending order of frequency are described: disruption of the fundoplication (22.7%), telescoping (14.1%), paraesophageal hernia (6.1%), disruption of hiatus (5.3%), tight fundoplication (5.3%) and stenosis (1.9%) (2,3).The need for urgent reoperation (excluding those cases of bleeding during the immediate postoperative period or injury to nearby organs) is anecdotal. Vol. 104. N.° 10, pp. 546-547, 2012 Fig. 1. It reveals the presence of a right hydropneumothorax with compressive atelectasis of the lung and contralateral mediastinal shift. Fundoplication intrathoracic migration associated with gastric organoaxial volvulus PICTURES IN DIGESTIVE PATHOLOGY
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