Search

INTRODUCTION: To compare Engerix-B and Fendrix hepatitisBvirus for primo vaccination in inflammatory bowel disease (IBD). METHODS: Patients with IBD were randomized 1:1 to receive Engerix-B double dose or Fendrix single dose at months 0, 1, 2, and 6. Anti-HBs titers were measured 2 months after the third and fourth doses. Response to vaccination was defined as anti-HBs >= 100 UI/L. Anti-HBs titers were measured 2 months after the third and fourth doses and again at 6 and 12 months after the fourth dose. RESULTS: A total of 173 patients were randomized (54% received Engerix-B and 46% Fendrix). Overall, 45% of patients responded (anti-HBs >= 100 IU/L) after 3 doses and 71% after the fourth dose. The response rate after the fourth dose was 75% with Fendrix vs 68% with Engerix-B (P 5 0.3). Older age and treatment with steroids, immunomodulators, or anti-tumor necrosis factor were associated with a lower probability of response. However, the type of vaccine was not associated with the response. Anti-HBs titer negativization occurred in13% of patients after 6months and 20% after12months. Anti-HBs 100 IU/L after vaccination was the only factor associated with maintaining anti-HBs titers during follow-up. DISCUSSION: We could not demonstrate a higher response rate of Fendrix (single dose) over Engerix-B (double dose). A 4-dose schedule is more effective than a 3-dose regimen. Older age and treatment with immunomodulators or anti-tumor necrosis factors impaired the success. A high proportion of IBD patients with protective anti-HBs titers after vaccination loose them over time. The risk of losing protective anti-HBs titers is increased in patients achieving anti-HBs

Immunosuppressant therapies (IMTs; thiopurines, anti-tumor necrosis factor agents) may influence the immunologic control of cancer and might facilitate the spread and recurrence of cancer. This study assesses the impact of the use of IMTs on the development of incident cancers (recurrent or new) in patients with inflammatory bowel disease (IBD) and a history of malignancy.Patients with IBD included in the ENEIDA registry with a history of cancer without being exposed to IMTs were identified and retrospectively reviewed and compared regarding further treatment with IMTs or not by means of a log-rank test.Overall, 520 patients with previous extracolonic cancer naive to IMTs before the diagnosis of cancer were identified. Of these, 146 were subsequently treated with IMTs (exposed), whereas 374 were not (nonexposed). The proportion of patients with incident cancers was similar in both exposed (16%) and nonexposed (18%) patients (P = 0.53); however, there was more than a 10-year difference in the age at index cancer between these 2 groups. Cancer-free survival was 99%, 98%, and 97% at 1, 2, and 5 years in exposed patients, and 97%, 96%, and 92% at 1, 2, and 5 years in non-exposed patients, respectively (P = 0.03). No differences in incident cancer rates were observed between exposed and nonexposed patients when including only those who were exposed within the first 5 years after cancer diagnosis.In patients with IBD and a history of cancer not related to immunosuppression, the use of IMTs is not associated with an increased risk of new or recurrent cancers even when IMTs are started early after cancer diagnosis.

OBJECTIVES: The long-term safety of exposure to anti-tumor necrosis factor (anti-TNFα) drugs during pregnancy has received little attention. We aimed to compare the relative risk of severe infections in children of mothers with inflammatory bowel disease (IBD) who were exposed to anti-TNFα drugs in utero with that of children who were not exposed to the drugs.METHODS: Retrospective multicenter cohort study. Exposed cohort: children from mothers with IBD receiving anti-TNFα medication (with or without thiopurines) at any time during pregnancy or during the 3 months before conception. Non-exposed cohort: children from mothers with IBD not treated with anti-TNFα agents or thiopurines at any time during pregnancy or the 3 months before conception. The cumulative incidence of severe infections after birth was estimated using Kaplan-Meier curves, which were compared using the log-rank test. Cox-regression analysis was performed to identify potential predictive factors for severe infections in the offspring.RESULTS: The study population comprised 841 children, of whom 388 (46%) had been exposed to anti-TNFα agents. Median follow-up after delivery was 47 months in the exposed group and 68 months in the non-exposed group. Both univariate and multivariate analysis showed the incidence rate of severe infections to be similar in non-exposed and exposed children (1.6% vs. 2.8% per person-year, hazard ratio 1.2 (95% confidence interval 0.8-1.8)). In the multivariate analysis, preterm delivery was the only variable associated with a higher risk of severe infection (2.5% (1.5-4.3)).CONCLUSIONS: In utero exposure to anti-TNFα drugs does not seem to be associated with increased short-term or long-term risk of severe infections in children.Am J Gastroenterol advance online publication, 20 February 2018; doi:10.1038/ajg.2017.501.

The most important novel findings presented on oesophageal disease in DDW 2015 were the following: 1) GERD: a) hypervigilance seems to be a key pathogenic factor in reflux symptoms refractory to PPI; b) post-reflux swallowing-induced peristaltic waves could be an excellent diagnostic criterion for GERD; c) laryngeal pH-metry is not useful in the diagnosis of extra-oesophageal symptoms; d) the recommendation of weight loss adequately recorded in the clinical reports of patients with GERD and obesity or overweight is an excellent quality indicator and is associated with better outcomes. 2) Barrett's oesophagus: a) persistent low-grade dysplasia in more than one endoscopy and a diagnosis of “indefinite for dysplasia” are associated with a high risk of neoplastic progression; b) narrow-band imaging allows areas of dysplasia on Barrett's oesophagus to be identified with high sensitivity and specificity; c) initial endoscopy fails to identify a high percentage of advanced neoplasms in Barrett's oesophagus. Early re-endoscopy should be considered; d) endoscopists specialized in Barret's oesophagus obtain a much higher yield in the diagnosis of advanced lesions. Patients at high risk–men, older patients, smokers and those with long-segment Barrett's oesophagus–could benefit from follow-up in a referral center. 3) Achalasia: POEM seems safe and effective, independently from patient characteristics (age, comorbidity) and the technical variations used. 4) Eosinophilic esophagitis: topical budesonide and exclusion diets are reasonably effective in PPI non-responders.

SUMMARYBackgroundDetermining the risk of rebleeding after endoscopic therapy for peptic ulcerbleeding (PUB) may be useful for establishing additional haemostatic mea-sures in very high-risk patients.AimTo identify predictors of rebleeding after endoscopic therapy.MethodsBibliographic database searches were performed to identify studies assessingrebleeding after endoscopic therapy for PUB. All searches and data abstrac-tion were performed in duplicate. A parameter was considered to be anindependent predictor of rebleeding when it was detected as prognostic bymultivariate analyses in ‡2 studies. Pooled odds ratios (pOR) were calcu-lated for prognostic variables.ResultsFourteen studies met the prespecified inclusion criteria. Pre-endoscopic pre-dictors of rebleeding were: (i) Haemodynamic instability: significant in 9 of13 studies evaluating the variable (pOR: 3.30, 95% CI: 2.57–4.24); (ii) Hae-moglobin value: significant in 2 of 10 (pOR: 1.73, 95% CI: 1.14–2.62) and(iii) Transfusion: significant in two of six (pOR not calculable). Endoscopicpredictors of rebleeding were: (i) Active bleeding: significant in 6 of 12studies (pOR: 1.70, 95% CI: 1.31–2.22); (ii) Large ulcer size: significant in 8of 12 studies (pOR: 2.81, 95% CI: 1.98–4.00); (iii) Posterior duodenal ulcerlocation: significant in four of eight studies (pOR: 3.83, 95% CI: 1.38–10.66)and (iv) High lesser gastric curvature ulcer location: significant in three ofeight studies (pOR: 2.86; 95% CI: 1.69–4.86).ConclusionsMajor predictors for rebleeding in patients receiving endoscopic therapy arehaemodynamic instability, active bleeding at endoscopy, large ulcer size, ulcerlocation, haemoglobin value and the need for transfusion. These risk factorsmay be useful for guiding clinical management in patients with PUB.Aliment Pharmacol Ther 2011; 34: 888–900

The abdomen normally accommodates intra-abdominal volume increments. Patients complaining of abdominal distension exhibit abnormal accommodation of colonic gas loads (defective contraction and excessive protrusion of the anterior wall). However, abdominal imaging demonstrated diaphragmatic descent during spontaneous episodes of bloating in patients with functional gut disorders. We aimed to establish the role of the diaphragm in abdominal distension.In 20 patients complaining of abdominal bloating and 15 healthy subjects, we increased the volume of the abdominal cavity with a colonic gas load, while measuring abdominal girth and electromyographic activity of the anterior abdominal muscles and of the diaphragm.In healthy subjects, the colonic gas load increased girth, relaxed the diaphragm, and increased anterior wall tone. With the same gas load, patients developed significantly more abdominal distension; this was associated with paradoxical contraction of the diaphragm and relaxation of the internal oblique muscle.In this experimental provocation model, abnormal accommodation of the diaphragm is involved in abdominal distension.

Resumen No hay datos en la literatura medica respecto del uso del hierro (Fe) intravenoso en los hospitales de dia de aparato digestivo. Objetivo Determinar las indicaciones, la dosificacion y la tolerancia del Fe intravenoso en los pacientes ambulatorios atendidos en un hospital de dia de digestivo. Material y metodos Se revisaron retrospectivamente las historias clinicas de los pacientes que habian recibido Fe intravenoso en el periodo comprendido entre agosto de 2007 y julio de 2008. Se recogieron las indicaciones, la dosificacion, los requerimientos de transfusion, los efectos adversos y la evolucion clinicoanalitica de los pacientes. Resultados Durante el periodo de estudio 111 pacientes (el 41% eran mujeres, con edad media de 63,8±18 anos) recibieron Fe intravenoso. Las principales causas de anemia para la administracion de Fe intravenoso fueron gastropatia por hipertension portal (n=55), enfermedad inflamatoria intestinal (n=22) y angiodisplasia intestinal (n=12). Los pacientes recibieron un total de 557 infusiones de Fe, con una dosis media de 1.033 mg de Fe por paciente. La infusion de Fe no presento efectos secundarios. A pesar del tratamiento, 46 pacientes necesitaron transfusion. Los pacientes con cirrosis hepatica presentaron un requerimiento de Fe, transfusion y una mortalidad significativamente mayores que el resto del grupo de estudio. Conclusion El Fe intravenoso se utiliza muy a menudo en el hospital de dia de digestivo. La mayor parte de las infusiones se realizan a pacientes con perdidas cronicas y los pacientes con cirrosis hepatica son los que presentan una anemia mas marcada, una enfermedad de base mas grave y una mayor mortalidad.

Patients complaining of abdominal bloating have impaired tolerance and clearance of intestinal gas loads. Mild exercise enhances intestinal clearance and prevents retention of intestinal gas loads in healthy subjects. Our aim was to evaluate the putative beneficial effects of physical activity in patients with abdominal bloating.In eight patients complaining of bloating, seven with irritable bowel syndrome, and one with functional bloating, according to Rome II criteria, a gas mixture was continuously infused (12 mL/min) into the jejunum for 120 min with simultaneous duodenal lipid perfusion (1 kcal/min). Gas evacuation, perception (0-6 scale), and abdominal girth were measured at 15-min intervals. Paired studies were randomly performed in the supine position during intermittent pedaling (5 min with 3-min rest intervals at 40 rpm and 0.15 kp load) versus rest (as control).During rest, a significant proportion of the gas infused was retained in the gut (45 +/- 9%, P0.01 vs basal), but retention was significantly lower during exercise (24 +/- 7%, P0.05 vs rest). Gas retention during rest was associated with significant abdominal symptoms (3.6 score; P0.01 vs basal), and symptoms also improved during exercise (2.8 score, P0.05 vs rest). During the test, patients developed abdominal distension, which was related to the volume of gas retained (r = 0.68, P0.05).Mild physical activity enhances intestinal gas clearance and reduces symptoms in patients complaining of abdominal bloating.

We sought to evaluate colonic gas accommodation, ileocecal competence, and colonic clearance in subgroups patients with abdominal bloating.Thirty-six patients complaining of abdominal bloating (12 constipation-predominant irritable bowel syndrome (IBS-C), 12 diarrhea-predominant irritable bowel syndrome (IBS-D), and 12 functional bloating) and 18 healthy controls were studied. Abdominal perception and girth were measured during: (i) 1 h continuous infusion of gas at 24 ml/min into the rectum (accommodation period) and (ii) 30 min free rectal gas evacuation (clearance period). In eight patients and eight healthy subjects, the gas infused was labeled with radioactive xenon (74 MBq (133)Xe), and gas distribution was determined by scintigraphy.Colonic gas accommodation produced significantly more abdominal symptoms and distension in patients than in healthy subjects (3.8+/-0.2 vs. 2.4+/-0.3 perception score; P0.001; 10.9+/-0.6 vs. 8.3+/-0.5 mm girth increment; P=0.009). Scintigraphy showed no differences in colonic gas distribution and no ileal gas reflux, but patients exhibited impaired gas clearance from the proximal colon (63%+/-10% clearance in 30 min vs. 80%+/-2% in health; P=0.042), resulting in more residual gas (506+/-46 vs. 174+/-47 ml; P0.001), perception (1.9+/-0.2 vs. 1.0+/-0.2 score; P=0.015), and girth increment (4.2+/-0.7 vs. 2.2+/-0.5 mm; P=0.024); IBS-C patients exhibited increased sensation and objective distension, as opposed to sensation only in IBS-D and distension only in functional bloating.Patients with abdominal bloating have normal colonic accommodation and ileocecal competence but impaired gas clearance from the proximal colon after retrograde infusion, and the consequences of this dysfunction are related to bowel habit.

BACKGROUND AND AIM We previously showed that colonic gas infusion increases the girth and modifies the muscular activity of the anterior abdominal wall. We hypothesized that abdominal accommodation to volume loads is an active process instrumented by the coordinated activity of the anterior wall and the diaphragm. METHODS To increase intraabdominal volume in healthy subjects, a gas was infused into the colon (1.44 L in 1 h) while measuring girth (by tape measure) and electromyography (EMG) activity of the anterior wall (via four pairs of surface electrodes) and the diaphragm (via six ring electrodes over an esophageal tube in the hiatus). After preliminary feasibility studies (N = 12), postural activity (N = 6) and responses to colonic gas loads, both with the trunk erect (N = 8) and in supine position (N = 8), were studied. A morphometric analysis was performed by computed tomography, image analysis (N = 8). RESULTS In the erect position, anterior wall tone was higher and diaphragmatic tone was lower than in the supine position. With the trunk erect, gas infusion induced diaphragmatic relaxation (by 21 +/- 3%; P < 0.05) and anterior wall contraction (16 +/- 4% EMG increment; P < 0.05). By contrast, in the supine position, it induced diaphragmatic contraction (15 +/- 6%, P < 0.05), while the anterior wall, in the absence of postural tone, showed no change (3 +/- 2%, NS). Gas infusion was associated with girth increase (7.3 +/- 1.0 mm with the trunk erect and 8.6 +/- 1.4 mm in the supine position) and diaphragmatic ascent (17.6 +/- 5.2 mm; P < 0.05). CONCLUSION The degree of abdominal distension produced by intraabdominal volume increments results from posture-related abdomino-phrenic muscular responses.

Summary Background The evidence on whether high-dose proton pump inhibitors (PPIs) increase cure rates of Helicobacter pylori treatment has not been previously assessed. Aim To evaluate the evidence on the usefulness of high-dose PPI in standard triple therapy by performing a systematic review and a meta-analysis. Methods A systematic search was performed in multiple databases and in the abstracts submitted to the Digestive Diseases Week, the European Helicobacter Study Group congress and the United European Gastroenterology Week. Randomized trials comparing a standard dose of a PPI with high-dose PPI both twice a day in triple therapy combining a PPI plus clarithromycin and either amoxicillin or metronidazole were selected. Relative risk (RR) and 95% confidence intervals (95% CIs) for all comparisons were calculated using Review Manager. Results Six studies fulfilled the inclusion criteria. All used triple therapy for 7 days. A mean intention-to-treat cure rate of 82% was achieved with high-dose PPI and one of 74% with standard dose (RR: 1.09; 95% CI: 1.01–1.17). Subgroup analysis showed that the maximum increase was observed when the PPI compared were omeprazole 20 mg or pantoprazole 40 mg vs. esomeprazole 40 mg. Conclusion High-dose PPI seems more effective than standard-dose for curing H. pylori infection in 7-day triple therapy.

Abdominal bloating is a frequent complaint in irritable bowel syndrome (IBS), but its underlying mechanism remains uncertain. Our aim was to determine whether the abdominal wall, specifically its adaptation to intra-abdominal volumes, plays a role.In 12 patients complaining of abdominal bloating (8 IBS and 4 functional bloating) and in 12 healthy controls, the effect of colonic gas load (24 mL/min rectal gas infusion for 1 hour) on perception (measured by a 0-6 scale), abdominal girth, and muscular activity was tested. With the participants sitting on an ergonomic chair and the trunk erect, multichannel electromyography was measured via bipolar surface electrodes located over the upper and lower rectus abdominis, and the external and internal oblique bilaterally.In healthy controls, colonic gas loads produced subjective symptoms (score, 3.0 +/- 0.3), objective abdominal distention (girth increment, 6 +/- 1 mm), and increased the activity of the abdominal muscles (external oblique activity, 11% +/- 3% in; P.05 vs basal). At the same infused gas volumes, the patients developed significantly more symptoms (score, 4.5 +/- 0.4) and abdominal distention (11 +/- 1 mm; P.05 vs healthy for both). These abnormal responses were associated with failed tonic contraction of the abdominal wall (external oblique activity change, -1% +/- 4%; P value not significant vs basal) and paradoxic relaxation of the internal oblique (activity reduction, 26% +/- 7%; P.01 vs basal).In patients with bloating, abdominal perception and distention in response to intra-abdominal volume increments are exaggerated markedly and associated with muscular dystony of the abdominal wall.

Shortand Long-Term Outcomes of Infliximab Dose Intensification in Patients With Ulcerative Colitis Carlos Taxonera, Manuel Barreiro-de Acosta, Marta Calvo, Cristina Saro, Guillermo Bastida, Maria Dolores Martin Arranz, Javier P. Gisbert, Valle Garcia-Sanchez, Ignacio Marin-Jimenez, Fernando Bermejo, Maria Chaparro, Angel Ponferrada Diaz, Ignacio Fernandez-Blanco, Pilar Martinez-Montiel, R. Pajares, Celia de Gracia, David Olivares, Fermin Estremera Arevalo, Juan L. Mendoza

Introduccion No existen estudios comparativos entre los diferentes modelos matematicos para la prediccion de recidiva y mortalidad en pacientes con hemorragia digestiva alta por ulcera peptica (HDAxUP). Se desconoce tambien si dichos modelos predictivos son superiores al juicio clinico. Objetivo Comparar la precision de los modelos de Rockall, Baylor, Cedars-Sinai y Blatchford frente al juicio clinico del endoscopista en la prediccion de recidiva y mortalidad en pacientes con HDAxUP. Pacientes y metodo Durante un periodo de 2 anos se incluyeron 238 pacientes con HDAxUP en los 3 centros participantes. Todos los pacientes se trataron con IBP i.v, y se realizo endoscopia urgente entre las 12 horas siguientes al ingreso. Se practico tratamiento endoscopico combinado (inyeccion de adrenalina mas polidocanol o clip) en 136 pacientes con ulcera de alto riesgo. Tras ello, el endoscopista clasifico a los pacientes segun su juicio clinico como de riesgo alto-medio-bajo para recidiva y mortalidad, y posteriormente calculo los diferentes modelos matematicos. Se calcularon las curvas ROC, sensibilidad, especificidad, valores predictivos positivo (VPP) y negativo (VPN) para recidiva y mortalidad de cada modelo matematico y del juicio clinico del endoscopista. Resultados Las tasas de recidiva y mortalidad fueron 14% (19/136) y 5,1% (7/136) respectivamente. Las comparaciones entre el juicio clinico del endoscopista y los diferentes modelos matematicos se muestran las tablas. Conclusion Los resultados del presente estudio sugieren que los modelos matematicos disponibles no son mejores que el juicio clinico del endoscopista para la prediccion de recidiva. Ademas, tanto el juicio clinico como dichos modelos no identifican entre un 4% y 10% de pacientes que resangran tras tratamiento endoscopico. Parece adecuado el desarrollo de modelos mas precisos para prediccion de recidiva en pacientes con HDAxUP de alto riesgo. Prediccion Recidiva Juicio clinico Rockall Cedars-Sinai Baylor Blatchford Sensib. (%) 84 79 95 63 79 Especifi. (%) 34 49 21 59 61 VPP (%) 17 20 16 20 25 VPN (%) 93 93 96 91 95 Area bj ROC 0,680 0,665 0,666 0,661 0,695 Prediccion Mortalidad Juicio clinico Rockall Cedars-Sinai Baylor Blatchford Sensi. (%) 100 100 100 71 86 Especifi. (% 71 24 19 57 57 VPP (%) 16 7 6 8 10 VPN (%) 100 100 100 97.5 97 Area ROC 0,866 0,874 0,701 0,735 0,804

peptic ulcers 3(9%) (p=0.02). On histology, 24 (71%) patients with chronic active gastritis had CLR mutations compared to 10 (29%) with chronic inflammation and gastric carcinoma and lymphoma 1(3%) (p= 0.004). Conclusion: Clarithromycin mutations were present in clinical isolates of H. pylori. They were significantly associated with endoscopic gastritis with chronic active gastritis compared to peptic ulcer and gastric carcinoma.