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Resumen Introduccion La infeccion cronica por el virus de la hepatitis C (VHC) se ha asociado a enfermedad glomerular, que se manifiesta mediante proteinuria con o sin disfuncion renal. Metodo Estudio observacional analitico transversal con 120 pacientes infectados por el VHC y 145 controles VHC-negativos para determinar la prevalencia de dano renal asociada al VHC y su relacion con factores de riesgo. Se recogieron datos de la historia clinica y anamnesis y se realizaron al menos 3 analisis de sangre y orina en un ano. La insuficiencia renal se definio por un filtrado glomerular estimado inferior a 60 ml/min/1,73 m 2 y/o una microalbuminuria superior a 20 mg/l o un indice microalbuminuria/creatinina mayor de 30 μg/mg. Resultados La prevalencia de microalbuminuria e insuficiencia renal se estimo en el 19,3 y 11,7% en los VHC-positivos vs el 10,5 y 0,7% en los VHC-negativos (p = 0,04), respectivamente. El 26,1% de los pacientes VHC-positivos tenia algun signos de dano renal vs el 11,8% de los VHC-negativos (p = 0,003). La infeccion por el VHC se asocio de forma independiente y significativa con la probabilidad de deterioro de la funcion renal. La prevalencia de microalbuminuria e insuficiencia renal se incremento progresivamente con el aumento de edad. Conclusion Los pacientes VHC-positivos presentan una alta prevalencia de microalbuminuria e insuficiencia renal en comparacion con sujetos VHC-negativos. El riesgo de insuficiencia renal asociado al VHC es independiente en presencia de otros factores predisponentes como hipertension arterial y diabetes.

One of the problems affecting metallic biliary stents is the difficulty of removing them, especially after a period of months or if they have migrated. Several approaches have been used to remove both covered and uncovered stents, although with different degrees of effectiveness. We report two new approaches to removing partially covered stents that migrated proximally and that impacted in the papillary area and distal common bile duct. One stent was removed by papillectomy and the other by using duodenoscopy-guided controlled radial expansion balloon dilation. In both cases, the stents were removed without severe complications for the patient, leaving a good caliber in the stenosis.

Resumen Introduccion se discute la necesidad de efectuar sistematicamente una segunda gastroscopia de control tras el diagnostico inicial de una ulcera gastrica benigna. Metodo revisamos 226 casos consecutivos de ulcera gastrica. Analizamos la sensibilidad (S), la especificidad (E), el valor predictivo positivo y negativo (VPP, VPN) y la precision de la primera exploracion: gastroscopia con biopsias, de modo global y segun la experiencia del primer explorador (medico de plantilla o MIR). Comparamos la precision diagnostica entre la primera y la segunda endoscopia. Calculamos el numero necesario de segundas exploraciones (NNE) para diagnosticar un nuevo caso de ulcera maligna y su coste, tanto global como segun la experiencia del explorador. Resultados registramos 178 (79%) ulceras benignas y 48 (21%) malignas. La primera exploracion fue efectuada por un medico de plantilla (74%) y MIR (26%): S 87,2%, E 100%, VPP 100%, VPN 96,7% y precision 96,7%. La precision del medico de plantilla fue superior (98,2%) a la del MIR (94,8%) (p=0,18). La segunda exploracion de control tuvo una precision del 100%, mejorando significativamente a la primera (p=0,035) y diagnosticando 3 nuevos linfomas MALT y 3 carcinomas tratados con intencion curativa. El NNE y el coste de un nuevo diagnostico de lesion maligna fueron los siguientes: global, 37,3 (4.675 euros); medico de plantilla, 55,2 (6.845 euros), y MIR, 19,3 (2.393 euros). Conclusiones la primera exploracion obtuvo una elevada precision diagnostica, ligeramente menor para los MIR. La segunda endoscopia de control mejora significativamente los resultados, confirmando su beneficio clinico al diagnosticar lesiones malignas potencialmente curables. El coste medio de cada nuevo diagnostico de malignidad ascendio a 4.675 euros, siendo 3 veces inferior si la primera exploracion la efectua un medico con menos experiencia.

Resumen La anemia ferropenica (AF) de origen incierto es una causa frecuente de ferropenia. A pesar de las tecnicas disponibles en la actualidad, no se llega a establecer su diagnostico etiologico. Recientes estudios sugieren que la infeccion por Helicobacter pylori podria ser causa de AF en ausencia de lesions del tracto digestivo, debido a la alteracion que se produce en la absorcion gastrica de hierro. Objetivos Evaluar si la eliminacion de H. pylori consigue la desaparicion de la AF y suprime la necesidad del consumo de hierro oral. Pacientes y metodos Estudio observacional descriptivo, en el que se han incluido pacientes con AF refractaria al tratamiento con hierro oral y sin causas que la justifiquen. Se realizo una gastroscopia, una ileocolonoscopia, un transito intestinal y/o una capsula endoscopica, asi como un estudio ginecologico a las mujeres. Todos los pacientes presentaban H. pylori positivo, por lo que se realizo un tratamiento erradicador estandar hasta su eliminacion. Se hizo un seguimiento minimo de 3 meses tras la eliminacion de H. pylori y se valoraron las necesidades de hierro oral tras la erradicacion. Resultados Se incluyo a 10 pacientes con una media ± desviacion estandar de edad de 53 ± 8,2 anos. La hemoglobina (Hb) antes del tratamiento era de 10,06 ± 0,53 mg/dl, el volumen corpuscular medio (VCM) de 75,43 ± 6,02 fl y la ferritina de 6,1 ± 3,28 ng/ml. Se llevo a cabo un tratamiento erradicador hasta la desaparicion de H. pylori. El tiempo medio hasta la desaparicion de la anemia fue de 4,5 meses. Los parametros analiticos tras el tratamiento fueron: Hb 12,86 ± 0,75 mg/dl, VCM 85,02 ± 4,8 fl y ferritina 28 ± 22,19 ng/dl. Conclusiones La AF de origen incierto, en ausencia de lesions que la justifiquen, puede relacionarse con la infeccion por H. pylori. La eliminacion de esta infeccion se sigue a corto plazo con la desaparicion de la anemia y de la ferropenia.

Large intestine infection due to spirochetes was described in 1967 and is mainly related to two pathogens, Serpulina pilosicoli and Brachyspira aalborgi. Clinically, infection presents as diarrhea and/or rectorrhagia and is more frequent among homosexuals. Its prevalence is difficult to estimate but significant differences have been described according to the socioeconomic level of the area studied. We describe three cases of diarrhea due to spirochetes, which are of interest due to the lack of published cases in Spain. Based on these cases, we describe the main characteristics (morphological, therapeutic, etc.) of this infection.

Chronic hepatitis C virus (HCV) infection is associated with glomerular disease, which is manifested by proteinuria with or without renal dysfunction.To determine the prevalence of HCV-associated renal injury and associated risk factors, we performed an observational, analytic, cross-sectional study of 120 HCV-positive patients and 145 HCV-negative controls. Data were gathered from medical records and history-taking and at least three blood and urine analyses were performed over a 1-year period. Renal insufficiency was defined as an estimated glomerular filtration rate of less than 60ml/min/1.73 m2 and/or microalbuminuria of more than 20mg/l or a microalbumin/creatinine ratio higher than 30 mcg/mg.The prevalence of microalbuminuria and renal insufficiency was 19.3% and 11.7% in HCV-positive patients versus 10.5% and 0.7% in HCV-negative controls (p 0.04), respectively. A total of 26.1% of HCV-positive patients had signs of renal injury compared with 11.8% of HCV-negative controls (p 0.003). HCV infection was independently and significantly associated with the probability of worsening of renal function. The prevalence of microalbuminuria and renal insufficiency progressively increased with greater age.HCV-positive patients show a high prevalence of microalbuminuria and renal insufficiency compared with HCV-negative individuals. The risk of HCV-associated renal insufficiency is independent of the presence of other predisposing factors such hypertension and diabetes.

One of the problems affecting metallic biliary stents is the difficulty of removing them, especially after a period of months or if they have migrated. Several approaches have been used to remove both covered and uncovered stents, although with different degrees of effectiveness. We report two new approaches to removing partially covered stents that migrated proximally and that impacted in the papillary area and distal common bile duct. One stent was removed by papillectomy and the other by using duodenoscopy-guided controlled radial expansion balloon dilation. In both cases, the stents were removed without severe complications for the patient, leaving a good caliber in the stenosis.

Intestinal ischemia is difficult to diagnose and can be caused by several etiologic processes. We report the case of a female patient with recurrent bowel ischemia due to small vessel thrombosis, which is caused by factor VIII, a procoagulant factor.

We analyzed the need to routinely perform a second gastroscopy after an initial diagnosis of benign gastric ulcer.A total of 226 consecutive cases of gastric ulcer were reviewed. Sensitivity (S), specificity (Sp), positive and negative predictive value (PPV and NPV) and the accuracy of the initial gastroscopy plus biopsy were analyzed, both overall and according to the initial endoscopist's experience (attending or resident physician). The diagnostic accuracy of the initial and second-look gastroscopies was compared. The number of second endoscopies required to diagnose a new case of malignant gastric ulcer and their cost was calculated, both overall and according to the endoscopist's experience.There were 178 benign ulcers (79%) and 48 malignant ulcers (21%). The initial gastroscopy (S: 87.2%; Sp: 100%; PPV: 100%; PNV: 96.7%; accuracy: 96.7%) was performed by an attending physician in 74% of the patients and by a resident physician in the remaining 26%. Diagnostic accuracy was higher for attending physicians than for residents (98.2% vs. 94.8%; p=0.18). The accuracy of second-look endoscopy was 100%, with a significant improvement when compared with the initial procedure (p=0.035). Three new cases of MALT lymphoma and three new cases of gastric adenocarcinoma were diagnosed and could be treated with curative intent. The number of second gastroscopies required to diagnose a new case of malignant gastric ulcer and their economic cost was: 37.3 (4,675 Euros) for the whole group, 55.2 (6,845 Euros) for attending physicians and 19.3 (2,393 Euros) for residents.Initial gastroscopy showed high diagnostic accuracy, which was slightly lower when performed by resident physicians. Second-look gastroscopy significantly improved the results, confirming the clinical benefit of this procedure in diagnosing potentially curable malignant lesions. The mean cost of each new diagnosis of malignancy was 4,675 Euros, which was three times lower if the initial gastroscopy was performed by a less experienced endoscopist.

Iron deficiency anemia of unknown origin is a frequent cause of anemia in which etiological diagnosis is often not achieved, despite currently available diagnostic techniques. Recent studies suggest that, in the absence of digestive tract lesions, Helicobacter pylori infection could be the cause of iron deficiency anemia, due to the alterations produced in gastric iron absorption.To evaluate whether H. pylori eradication resolves iron deficiency anemia and removes the need for oral iron administration.We performed an observational descriptive study in patients with iron deficiency anemia refractory to treatment with oral iron administration and with out causes that could explain their anemia. Gastroscopy, ileocolonoscopy, intestinal transit study and/or endoscopic capsule were performed. Female patients also underwent gynecological study. All patients were H. pylori-positive and standard eradication therapy was administered until elimination was achieved. The patients were followed-up for a minimum of 3 months after H. pylori eradication and the need for oral iron intake after eradication was evaluated.Ten patients, aged 53+/-8.2 years, were included. Hemoglobin (Hbg) before treatment was 10.06+/-0.53 mg/dl, mean corpuscular volume (MCV) was 75.43+/-6.02 fl and ferritin was 6.1+/-3.28 ng/ml. Eradication therapy was administered until elimination of H. pylori. The mean time before disappearance of anemia was 4.5 months. Laboratory parameters after treatment were as follows: Hgb 12.86+/-0.75 mg/dl, MCV 85.02+/-4.8 fl and ferritin 28+/-22.19 ng/dl.In the absence of lesions that could explain iron deficiency anemia, this disease can be related to H. pylori infection. Eradication of this infection is closely followed by disappearance of anemia and ferropenia.

Large intestine infection due to spirochetes was described in 1967 and is mainly related to two pathogens, Serpulina pilosicoli and Brachyspira aalborgi. Clinically, infection presents as diarrhea and/or rectorrhagia and is more frequent among homosexuals. Its prevalence is difficult to estimate but significant differences have been described according to the socioeconomic level of the area studied. We describe three cases of diarrhea due to spirochetes, which are of interest due to the lack of published cases in Spain. Based on these cases, we describe the main characteristics (morphological, therapeutic, etc.) of this infection.

The use of botulinic toxin has led to new perspectives in the treatment of anal fissures. However, the most effective dose, length of treatment and long term results require further studies to determine the most appropriate place for this therapy.A prospective study was carried out in 40 consecutive patients diagnosed with anal fissure of more than 3 months in duration. Fifteen U of botulinic toxin were injected in the external anal sphincter and the evolution was studied over 6 months. The patients completed a pain scale designed for the study after 1 week, and 1, 3 and 6 months after the injection. The degree of pain, healing and need for surgery were evaluated during the follow up.Healing occurred in 17 patients after 3 months (42.5%) and after 6 months in 3 more patients (50%). Eight patients required surgery during follow up (20%). In the remaining patients, the pain significantly decreased allowing conservative management. Only 2 patients demonstrated incontinence for slight, transitory gases (5%).Injection of botulinic toxin is well tolerated and is relatively effective as an alternative in the treatment of anal fissure. Most patients respond in the first days after treatment and the effect persists for at least 6 months. The use of doses higher than those used in this study merits further studies.

Intestinal ischemia is difficult to diagnose and can be caused by several etiologic processes. We report the case of a female patient with recurrent bowel ischemia due to small vessel thrombosis, which is caused by factor VIII, a procoagulant factor.

The case of a young female diagnosed with an IgG deficit and hepatic granulomas is presented. After 6 years of follow up the patient remains asymptomatic without treatment and with moderate biochemical cholestasis. The tests performed did not lead to a definitive etiologic diagnosis, therefore, according to a review of the literature, we believe that the granulomatous reactions are related with the hypogammaglobulinemia itself.

The case of a patient ulcerative colitis involving an autoimmune base who was treated with recombinant alpha-2 interferon for concomitantly presenting chronic hepatitis B in the replicative phase is reported. With this therapy unreplicative seroconversion of the disease was achieved without modification of the course of the chronic inflammatory intestinal disease (CIID) during treatment or over the posttreatment follow up period. A brief review of the literature was performed concerning the role of autoimmunity in ulcerative colitis, treatment with alpha-interferon in chronic hepatitis B and the exacerbation of autoimmune phenomena which may lead to interferon treatment. According to the evolution of this case and the review of the literature, the authors conclude that the existence of CIID does not contra-indicate the use of recombinant alpha-2 interferon in patients with chronic viral hepatitis, although special control of the disease should be carried out during the treatment period.