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Background Carriers of the human leucocyte antigen variant HLADQA1*05 (rs2097432) are at risk of developing antibodies against infliximab and adalimumab with reduced tumor necrosis factor (TNF) antagonist persistence. The impact of proactive therapeutic drug monitoring (PTDM) on this association has been barely assessed. Methods We conducted a retrospective single-center cohort study including patients with inflammatory bowel disease starting anti-TNF therapy between January 2017 and March 2021. Proactive therapeutic drug monitoring was defined as periodic drug level measurement (≥2 determinations during the first year of treatment and ≥1/annual determination during the following years), regardless of clinical condition, followed by dose optimization. Variables associated with treatment persistence were assessed with multivariable Cox regression analysis. Results A total of 112 patients were included, 52 (46.4%) HLA-DQA1*05 carriers, with a median follow-up of 73.9 (interquartile range, 35.4-133.1) weeks. Combination therapy with thiopurines was more frequent among HLA-DQA1*05 noncarriers (28 [46.7%] vs 12 [23.1%]; P = .01). Clinical remission rates at week 14 (77.9% vs 73.9%; P = .69) and 56 (73.2% vs 68.4%; P = .64) were similar between HLA-DQA1*05 noncarriers and carriers. Drug persistence was higher among HLA-DQA1*05 carriers (hazard ratio [HR], 0.32; 95% confidence interval, 0.14-0.71; P = .01). Multivariable Cox regression analysis identified systemic steroids at anti-TNF initiation (HR, 4; 95% confidence interval, 1.7-9.7) as a risk factor and HLA-DQA1*05 carriers (HR, 0.31; 95% confidence interval, 0.12–0.81) as a protective factor of treatment cessation. Conclusion In adult patients with PTDM, a positive HLA-DQA1*05 genotype does not associate a higher risk of treatment cessation nor worse clinical outcomes.

Background and aims Transjugular intrahepatic portosystemic shunts (TIPS) are successfully used in the management of portal hypertension (PH)-related complications. Debate surrounds the diameter of the dilation. The aim was to analyse the outcomes of and complications deriving from TIPS in patients with cirrhosis and identify predictors of survival. Methods This was a retrospective single-centre study, which included patients with cirrhosis who had a TIPS procedure for PH from 2009 to October 2018. Demographic, clinical and radiological data were collected. The Kaplan–Meier method was used to measure survival and predictors of survival were identified with the Cox regression model. Results A total of 98 patients were included (78.6% male), mean age was 58.5 (SD±/−9.9) and the median MELD was 13.3 (IQR 9.5–16). The indications were refractory ascites (RA), variceal bleeding (VB) and hepatic hydrothorax (HH). Median survival was 72 months (RA 46.4, VB 68.5 and HH 64.7) and transplant-free survival was 26 months. Clinical and technical success rates were 70.5% and 92.9% respectively. Age (HR 1.05), clinical success (HR 0.33), sodium (HR 0.92), renal failure (HR 2.46) and albumin (HR 0.35) were predictors of survival. Hepatic encephalopathy occurred in 28.6% of patients and TIPS dysfunction occurred in 16.3%. Conclusions TIPS with 10-mm PTFE-covered stent is an effective and safe treatment for PH-related complications in patients with cirrhosis. Age, renal failure, sodium, albumin and clinical success are independent predictors of long-term survival.

Renal squamous cell carcinoma is a rare neoplasm in adults, but with an aggressive behavior. It is diagnosed in most cases in advanced stages. The invasion of the digestive tract by this type of tumor is rare, due to the anatomical arrangement of the colon, however, when it occurs, it carries a poor prognosis for the patient. Digestive endoscopy allows us to reach a definitive diagnosis since these patients usually present digestive manifestations, such as diarrhoea, digestive bleeding or abdominal pain.

The use of premedication for upper gastrointestinal endoscopy (UGE) is not widely established in western countries. The primary aim was to compare gastric visibility according to the total visibility score (TVS). As secondary aim to assess complications, diagnostic yield, endoscopic procedure time, sedation dose and patient' satisfaction.Single center prospective cohort study including consecutive adults undergoing an UGE in the afternoon working shift. After completing enrolment in the control group, patients were administered 200 mg simethicone and 500 mg N-acetylcysteine diluted in 100 ml of water15 minutes before the procedure. All procedures were recorded and a single, blinded endoscopist evaluated the TVS after recruitment of both cohorts. Patient' satisfaction was evaluated using the Spanish translation of the American Society of Gastrointestinal Endoscopy satisfaction questionnaire.205 patients were included, 103 females (50.2%) with a median age of 54.8-years (IQR: 41.2-65.2). 104 were enrolled to the control group and 101 to the intervention group. Patients receiving premedication presented a higher rate of adequate gastric visibility (74.3% vs 45.2; difference 95% CI: 16,3-41,9%, p0.001) and excellent (23.8% vs 7.7%; difference 95% CI: 6,3-25,8%, p=0.002). Propofol dose was similar, although median procedure time was lower in the group of no intervention [5 (IQR: 4-7) vs 6 minutes (IQR: 5-7); p=0.03]. Procedure related adverse events were similar, except that patient without premedication experienced more nausea episodes. Major and minor endoscopic findings and the satisfaction questionnaire showed no differences between both groups.Patients receiving premedication with simethicone and N-acetylcysteine presented a better gastric visibility score, without increase in adverse events or affecting the patients' satisfaction.

Background and Aims Clinical trials and real-life studies with ustekinumab in Crohn’s disease [CD] have revealed a good efficacy and safety profile. However, these data are scarcely available in elderly patients. Therefore, we aim to assess the effectiveness and safety of ustekinumab in elderly patients with CD. Methods Elderly patients [>60 years old] from the prospectively maintained ENEIDA registry treated with ustekinumab due to CD were included. Every patient was matched with two controls under 60 years of age, according to anti-tumour necrosis factor use and smoking habit. Values for the Harvey–Bradshaw Index [HBI], endoscopic activity, C-reactive protein [CRP] and faecal calprotectin [FC] were recorded at baseline and at weeks 16, 32 and 54. Results In total, 648 patients were included, 212 of whom were elderly. Effectiveness was similar between young and elderly patients during the follow-up. Steroid-free remission was similar at week 16 [54.6 vs 51.4%, p = 0.20], 32 [53.0% vs 54.5%, p = 0.26] and 54 [57.8% vs 51.1%, p = 0.21]. Persistence of ustekinumab as maintenance therapy was similar in both age groups [log-rank test; p = 0.91]. There was no difference in the rate of adverse effects [14.2% vs 11.2%, p = 0.350], including severe infections [7.1% vs 7.3%, p = 1.00], except for the occurrence of de novo neoplasms, which was higher in older patients [0.7% vs 4.3%, p = 0.003]. Conclusions Ustekinumab is as effective in elderly patients with CD as it is in non-elderly patients. The safety profile also seems to be similar except for a higher rate of de novo neoplasms, probably related to the age of the elderly patients.

Background A rare but life-threatening cause of pancytopenia after liver transplantation is hemophagocytic syndrome. We present a 48-year-old woman who underwent liver transplantation and developed a hemophagocytic syndrome secondary to Epstein-Barr virus with a fatal course, despite initial treatment with immunosuppressants. The diagnosis was made based on the bone marrow aspiration, in which macrophages with phagocytic activity were observed, and clinical findings. Due to the very poor outcomes and high mortality, in patients with severe pancytopenia hemophagocytic syndrome should be excluded, and a bone marrow aspiration should be considered.

We present the case of a 51-year-old female with a 2-month history of intense anal pain and rectal bleeding. A digital rectal exam revealed a possible lower rectal mass. A colonoscopy was then performed that showed a 5 x 6-cm lesion in the middle rectum and a second 3-cm lesion in the lower rectum, without affecting the anal canal. Multiple biopsies were taken and the histopathologic analysis revealed a moderately differentiated squamous-cell proliferation invading beyond the lamina propria. The CT scan confirmed a middle rectum T4N2bM0 and a lower rectum T3N0M0 synchronous neoplasia. These findings were compatible with a synchronous squamous-cell carcinoma (SCC).

We present the case of a 71-years-old male with a history of pulmonary adenocarcinoma with palliative treatment. He was admitted to our hospital with hematochezia and anemia (Hemoglobin 10.6 g/dl).

We appreciate the interest of Sánchez-Luna et al. in our article "Endoscopic internal drainage using transmural double-pigtail stents in leaks following upper gastrointestinal tract surgery", and find their suggestion about using softer urological double pigtail stents (DPS) for endoscopic internal drainage (EID) interesting.

Introduccion: la pandemia mundial por SARS-CoV-2 obligo a paralizar las unidades de endoscopia. Previamente a la reanudacion de la actividad endoscopica disenamos un protocolo de valoracion de gastroscopias y colonoscopias, desprogramadas durante la pandemia, denegando las no indicadas y priorizando las indicadas. Metodos: establecimos dos tipos de denegacion: a) contexto covid-19 en ≤ 50 anos sin sintomas de alarma y baja probabilidad de hallazgos endoscopicos relevantes; y b) contexto inadecuado por no ser acordes con las guias o protocolos clinicos. Las denegaciones se archivaron en la historia clinica del paciente. Clasificamos las adecuadas en preferentes, convencionales y seguimiento. Comparamos las denegadas por especialidad. Valoramos los hallazgos de las preferentes. Resultados: valoramos 1.658 peticiones (44 % gastroscopias, 56 % colonoscopias) entre el 16 marzo y el 30 junio de 2020. Se consideraron adecuadas 1.164 (70 %), de ellas preferentes el 8,5 %, convencionales el 48 %, seguimiento el 43 % y no valorables el 0,5 %. Se denegaron 494 (30 %): 20 % “contexto covid-19” y 80 % “contexto inadecuado”. Los motivos de denegacion en las gastroscopias fueron: seguimiento de lesiones (33 %), sintomas insuficientemente estudiados (20 %) y sintomas recidivantes con gastroscopia previa (18 %). Los motivos de denegacion en las colonoscopias fueron: vigilancia pospolipectomia (25 %), cancer colorrectal intervenido (21 %) y antecedentes familiares de cancer (13 %). Encontramos diferencias significativas en la denegacion segun la especialidad: Cirugia General (52 %), Hematologia (37 %) y Atencion Primaria (29 %). Un 31 % de las preferentes mostraron hallazgos relevantes. Conclusiones: un 24 % de nuestras endoscopias son discordantes con las recomendaciones cientificas. Su denegacion y la priorizacion de las adecuadas optimizan la utilizacion de recursos.

The intestinal spirochaetosis is defined as the presence of spirochetes on the colonic surface. We present the case of a 57-years-old male, with a history of 4-5 months of diffuse abdominal pain, watery diarrhoea due to this infection. The colonoscopy revealed a serpiginous ulcer in the cecum. The biopsy was positive for intestinal spirochaetosis. It is rare infection, more common among immunocompromised patients and HIV, with a faecal-oral transmission. Most cases are incidental findings in the endoscopic screening. In symptomatic patients the watery diarrhoea and non-specific abdominal pain are the most common symptoms. The macroscopic appearance on the colonoscopy is often normal or non-specific lesions can be identified. The diagnosis is based on the biopsy with haematoxylin and eosin and the confirmation can be made with a Warthin-Starry stain. In symptomatic patients the metronidazole is the preferred treatment option. Although it is rare infection, clinicians should be aware of it in patients with common gastrointestinal symptoms.

BACKGROUND AND AIMS Nonalcoholic fatty liver disease (NAFLD) is a long-term complication after liver transplantation. Our aims were to determine de-novo-NAFLD at 5-year post-liver transplantation and identify predictive risk factors. METHODS This was a retrospective analysis of de-novo-NAFLD at 5-year post-liver transplantation. NAFLD was defined as the radiological evidence of steatosis. Data from transplanted patients between November 2001 and May 2014 were collected. Noninvasive fibrosis scores were calculated. Predictors of de-novo NAFLD and survival were assessed by multivariate analyses and Kaplan-Meier method. RESULTS A total of 252 liver transplantations were evaluated after applying exclusion criteria, (78.6% men) with 54.9 years old (SD ± 9.5). Prevalence of de-novo NAFLD at 5-year post-liver transplantation was 36.1%. Cardiovascular events were presented in 19.88% and 23.08% of non-NAFLD and NAFLD patients, (P = 0.58). On multivariate analysis, male sex (OR, 5.40; P = 0.001), obesity (OR, 3.72; P = 0.017), metabolic syndrome (OR, 4.69; P

INTRODUCTION different endoscopic procedures have been proposed for the management of surgical leaks. Endoscopic internal drainage using trans-fistulary double-pigtail plastic stents has emerged as an alternative strategy, especially in fistulae presenting after laparoscopic gastric sleeve. METHODS a retrospective case series was performed at a single tertiary care center including all upper gastrointestinal post-surgical leaks primarily managed with endoscopic trans-fistulary insertion of double-pigtail plastic stents. Clinical success was defined as the absence of extravasation of oral radiographic contrast and radiological resolution of the collection with adequate oral intake Results: nine patients were included, six (66.6 %) females with a median age of 52.6 years (IQR 47-60). Five cases presented after laparoscopic gastric sleeve, two cases after distal esophagectomies, one after a Roux-en-Y gastric bypass and another one after a pancreaticoduodenectomy. Fistulae measured < 10 mm in five patients (55.6 %) and 10-20 mm in four patients (44.4 %). Six were early leaks. Technical and clinical success was achieved in nine (100 %) and seven (77.8 %) cases, respectively. Seven (77.8 %) patients required ≤ 3 endoscopic procedures. The median hospital stay after the first endoscopic procedure was 12 days (IQR 6.5-17.5 days), while the overall median time until leak healing was 118.5 days (IQR 84.5-170). One patient with a post-esophagectomy intrathoracic leak developed an esophageal-tracheal fistula 37 days after stent deployment. CONCLUSIONS our results support the use of endoscopic internal drainage in postsurgical abdominal leaks, regardless of the type of surgery. Although only two patients with intrathoracic dehiscence were included.

El hueso hioides esta colocado transversalmente por encima de la laringe y a la altura de la cuarta vertebra cervical, a nivel del angulo formado por la cara anterior del cuello y el piso de la boca, en forma de herradura o de ipsilon griega, de donde viene su nombre. Este hueso esta aislado del esqueleto, al que solo esta unido por ligamentos y musculos, siendo la division entre musculos suprahioideos e infrahioideos. El cuerpo esta formado por tres partes y de el salen dos prolongaciones: el asta mayor y el asta menor1. Presentamos el caso de una mujer de 28 anos de edad que acude a urgencias de nuestro hospital tras sufrir una caida mientras esquiaba, golpeandose en la region anterior del cuello con uno de los bastones. En la exploracion presenta una erosion superficial en la zona con intenso dolor en region central del cuello. Se solicita una radiografia lateral de partes blandas del cuello (fig. 1) donde se observa fractura del hueso hioides en la zona de union del asta mayor derecha con el cuerpo del hueso. Se trato de forma conservadora con inmovilizacion de la zona con collarin blando, analgesicos y antiinflamatorios. Figura 1. Radiografia lateral de partes blandas del cuello donde se aprecia una fractura del hueso hioides en la zona de union del asta mayor derecha con el cuerpo. La fractura del hioides es un tipo de fractura muy rara, correspondiendo al 0,002% de las fracturas2. En la literatura...