Search

Resumen Introduccion En la endoscopia digestiva alta de pacientes con cirrosis hepatica a menudo se observan lesiones inespecificas, que se suelen orientar como gastropatia por hipertension portal (GHP). Sin embargo, el diagnostico de GHP puede ser dificil, tanto endoscopica como histologicamente. El estudio de expresion de CD34, que realza las celulas endoteliales de la microvasculatura podria ayudar al diagnostico diferencial. Los objetivos del estudio fueron evaluar la correlacion entre la endoscopia y la histologia en el diagnostico de la GHP y valorar la utilidad del CD34 en el diagnostico de la misma. Material y metodos Se analizaron biopsias fundicas de 100 pacientes cirroticos y 20 controles, y se realizo inmunotincion para CD34. Se compararon con las imagenes endoscopicas. Resultados Se observo una correlacion muy baja entre la histologia con el diagnostico endoscopico de GHP (kappa = 0,15). Ademas, la medicion del diametro de los vasos gastricos realzados mediante el uso de la tincion inmunohistoquimica (CD34) no mostro buena correlacion con el diagnostico endoscopico (p = 0,26) y tampoco parece aportar informacion relevante para el diagnostico histologico de GHP. Discusion Existe una baja correlacion entre la histologia y la endoscopia para el diagnostico de GHP. El uso de la inmunotincion para CD34 no mejora la rentabilidad diagnostica del estudio histologico.

Portal hypertensive gastropathy (GHP) is a complication of portal hypertension usually associated with liver cirrhosis. The pathogenesis is unclear but the presence of portal hypertension is an essential factor for its development. GHP may be asymptomatic or present as gastrointestinal bleeding or iron deficiency anemia. Endoscopic lesions vary from a mosaic pattern to diffuse red spots; the most common location is the fundus. Treatment is indicated when there is acute or chronic bleeding, as secondary prophylaxis. There is insufficient evidence to recommend primary prophylaxis in patients who have never bled. Drugs that decrease portal pressure, such as non-cardioselective beta-blockers, and/or endoscopic ablative treatments, such as argon-beam coagulation, may be used. The role of transarterial intrahepatic portosystemic shunt) or bypass surgery has been insufficiently analyzed. Antral vascular ectasia (EVA) is a rare entity in liver cirrhosis, whose pathophysiology is still unknown. Clinical presentation is similar to that of GHP and endoscopy usually shows red spots in the antrum. Biopsy is often required to differentiate EVA from GHP. There is no effective medical therapy, so endoscopic ablative therapy and, in severe cases, antrectomy are recommended.

Perforations of the gastrointestinal tract are a significant source of morbidity in clinical practice. Surgery has been the standard of care. However, endoscopic treatment with clips can be used when perforations are small. The development of natural orifice transluminal endoscopic surgery (NOTES) has substantially contributed to research in this field, such as the over the scope clip (OVESCO or OTSC). This system is one of the most promising technologies for closure of perforations of the gastrointestinal tract because of its efficacy, safety and rapidity. Other indications include severe gastrointestinal bleeding, fistulae, anastomotic leaks, and bariatric surgery anastomosis remodelling. This article describes the OVESCO system from its initial design to its introduction in clinical practice.

Resumen La unidad de atencion continuada y hospital de dia permite el manejo ambulatorio de los pacientes con una enfermedad digestiva. Objetivo Disminuir los ingresos hospitalarios y el numero de pacientes con una enfermedad digestiva que acude a urgencias. Material y metodos Los pacientes se atienden segun dos niveles asistenciales: a) atencion continuada, en que se visitan de forma urgente los pacientes con una descompensacion aguda de su enfermedad digestiva, y b) atencion programada, en que se realizan procedimientos que por su complejidad requieren personal de enfermeria, sin ser necesario el ingreso hospitalario. Resultados En el periodo comprendido entre 1995 y 2005 se ha pasado de realizar 118 visitas en atencion continuada en 1995 a 784 en 2005. En atencion programada las paracentesis han aumentado de 237 en 1995 a 687 en 2006 y las infusiones de hierro intravenoso de 111 en 2004 a 519 en 2006. El numero de ingresos hospitalarios paso inicialmente de 605 en 1995 a 430 en 2000, para posteriormente aumentar. El numero de pacientes con una enfermedad digestiva que acudio a urgencias disminuyo un 75% estos anos. Conclusiones La unidad de atencion continuada y hospital de dia permite una disminucion inicial del numero de ingresos en el area de hospitalizacion convencional y en el porcentaje de pacientes con patologia digestiva que acuden a urgencias.

Preliminary studies suggested that octreotide may be therapeutic in bleeding angiodysplasia. Our aim was to investigate the efficacy of long-term octreotide therapy in the prevention of rebleeding from gastrointestinal angiodysplasia.A cohort of 32 patients diagnosed with bleeding from angiodysplasia was treated with octreotide 50 mu 12 h subcutaneously for a 1-2 yr period. This cohort was compared with an external control group (38 patients who had received placebo [1 tablet/day] in a concurrent randomized clinical trial for the same period.Two patients of the octreotide group were lost to follow-up. Treatment failure occurred in seven of 30 (23%) patients in the octreotide group and in 17 of 35 (48%) in the placebo group (three dropouts before first visit) (P= 0.043). The actuarial probability of remaining free of rebleeding at 1 and 2 yr of follow-up was 77% and 68%, respectively, for the octreotide group and 55% and 36%, respectively, for the placebo group (log rank P= 0.030). Multivariate proportional hazards-regression analysis showed that octreotide therapy and previous bleeding episodes were positive and negative predictors of efficacy, respectively. No significant differences between the groups were observed according to number of bleeding episodes (0.4 +/- 0.7 vs 0.9 +/- 1.5, P= 0.070) and transfusion requirements (1.1 +/- 2.6 vs 0.7 +/- 1.5 units); however, iron requirements were lower in the octreotide than in the placebo group (22 +/- 62 vs 166 +/- 267 units; P0.001). Likewise, major adverse events (1 vs 1) and mortality (0 vs 1) were similar between groups.This study suggests that octreotide treatment may be beneficial in preventing rebleeding from gastrointestinal angiodysplasia.

Summary Aim To evaluate (i) the diagnostic usefulness of a delayed test in initially negative patients; and (ii) the reliability of the rapid urease test, histology or a combination of the two to diagnose Helicobacter pylori during emergency endoscopy in a large clinical practice series. Patients and methods Records of patients with ulcer bleeding from 1995 to 2000 were reviewed. Patients with initially negative tests were retested 4–8 weeks after the bleeding episode. Sensitivity of urease, histology or a combination of the two to detect H. pylori at initial endoscopy and the efficacy of delayed Urea Breath Test in detecting missed infection was determined. Results The study included 429 patients. A delayed second test detected H. pylori infection in 57 out of 72 (79%) of initially negative patients. The sensitivity for detecting H. pylori was 76%, 78% and 86% for urease, histology and their combination, respectively. The prevalence of H. pylori was 95% in duodenal and 88% in gastric ulcer. In addition, only one test was performed in 17 of the 32 patients who were considered negative. Conclusion Not even the combination of a negative urease and histology in the initial endoscopy is able to rule out infection in bleeding ulcer patients. A delayed test should be performed to rule out Helicobacter pylori infection completely.

INTRODUCTION: The need for sedation is increasing in digestive endoscopy units (DEU). There are no data on the use of sedation in DEU in Catalonia (Spain). OBJECTIVE: To evaluate the use of sedation in DEU in Catalonia. MATERIAL AND METHOD: A questionnaire on the practice of sedation was designed and sent to the heads of medical and nursing staff of the DEU of 63 public and private hospitals in Catalonia. Two mailings were sent with an interval of three months between each. The questionnaire included 62 items on the characteristics of the hospital and the DEU, number of explorations, frequency of sedation use, drugs employed, participation of an anesthesiologist, use of monitoring, and complications. RESULTS: Forty-four DEU (70%) corresponding to 31 public hospitals and 13 private hospitals completed the questionnaire. Evaluation of sedation patterns was based on 105,904 explorations performed in the various DEU (56,453 gastroscopies, 47,278 colonoscopies and 2,173 endoscopic retrograde cholangiopancreatographies (ERCP) in 2001. Sedation, sedation-analgesia or anesthesia was used in 17% of gastroscopies, 61% of colonoscopies and 100% of ERCP. Sedation was administered by an anesthesiologist in 7% of gastroscopies, 25% of colonoscopies and 38% of ERCP. Anesthesiologist administration was more frequent in private than in public centers (gastroscopies: 25% vs. 2%; colonoscopies: 57% vs. 9%, p < 0.001). No deaths associated with the use of sedation were reported. Eighty-nine percent of the DEU complied with standard recommendations for the practice of sedation. CONCLUSIONS: In Catalonia, the use of sedation is highly variable, depending on the endoscopic procedure and the DEU. Use of sedation in infrequent in gastroscopy, fairly widespread in colonoscopy and routine in ERCP. Anesthesiologist administration is significantly more frequent in private hospitals. Most DEU follow standard sedation practices.

Introduccion La infeccion por Helicobacter pylori afecta a mas de la mitad de la poblacion mundial y esta asociada al desarrollo de la gastritis cronica, ulceras pepticas y adenocarcinoma gastrico. La rifaximina es un nuevo antibiotico no absorbible de amplio espectro del grupo de la rifamicina que alcanza altas concentraciones en el tracto gastrointestinal. Objetivo Determinar in vitro la susceptibilidad de H. pylori frente a la rifaximina. Metodos Se estudiaron 31 cepas de H. pylori por el metodo de dilucion en agar. Como antibiotico control se utilizo la claritromicina. Como cepas control se utilizaron Staphylococcus aureus y Streptococcus pneumoniae . Las placas se leyeron a los 4 y a los 7 dias de incubacion. Se determinaron las CMI50 y las CMI90 para cada antibiotico. Se consideraron resistentes a la claritromicina las cepas con CMI > 1 μg/ml. Resultados Las CMI50 de la claritromicina a los 4 y 7 dias fueron de 0,125 μg/ml y las CMI90 a los 4 y 7 dias fueron de 8 y 16 μg/ml, respectivamente. Las CMI50 de la rifaximina a los 4 y 7 dias fueron de 1 y 2 μg/ml, respectivamente, y las CMI90 a los 4 y 7 dias fueron de 4 μg/ml. El 20% de las cepas de H. pylori fueron resistentes a la claritromicina. En estas cepas, el crecimiento de H. pylori fue inhibido a una concentracion maxima de rifaximina de 4 μg/ml. Conclusion Estos resultados indican que la rifaximina puede ser util en la erradicacion de la infeccion. Este nuevo antibiotico podria tener una mayor actividad en las cepas resistentes a la claritromicina y asi ser util en las combinaciones con este farmaco o en el tratamiento de los fracasos.

Background & Aims: The efficacy of hormonal therapy for recurrent bleeding from gastrointestinal angiodysplasia remains uncertain. We investigated the efficacy of long-term estrogen-progestagen therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. Methods: Seventy-two noncirrhotic patients bleeding from gastrointestinal angiodysplasia confirmed by endoscopy or angiography were randomized to receive in double-blind conditions treatment with ethinylestradiol (0.01 mg) plus norethisterone (2 mg) (1 tablet/d), or placebo (1 tablet/d) for a minimum period of 1 year (range: 1-2 years). Results: Four patients could not be assessed because they did not attend the first follow-up visit. Failure of treatment occurred in 13 of 33 (39%) patients in the treatment group and in 16 of 35 (46%) patients in the placebo group ( P = NS). No significant differences between groups were found according to number of bleeding episodes (0.7 ± 1.0 vs. 0.9 ± 1.5) and transfusional requirements (0.9 ± 1.9 vs. 0.7 ± 1.5 units). Treatment received was not an independent predictor for rebleeding prevention in the multivariate regression analysis. Severe adverse events (2 vs. 1) and mortality (0 vs. 1 patient, respectively) were similar between the treatment and placebo groups. Conclusions: Continuous estrogen-progestagen treatment is not useful in the prevention of rebleeding from gastrointestinal angiodysplasia. GASTROENTEROLOGY 2001;121:1073-1079

The diagnosis of colonic angiodysplasia is often challenging and relies on endoscopy or catheter angiography. We investigated whether computed tomographic angiography (CTA) contributes to the diagnosis of colonic angiodysplasia.Twenty-eight patients with suspected bleeding from colonic angiodysplasia were prospectively evaluated. Gastrointestinal bleeding was investigated by colonoscopy plus visceral angiography and by CTA. The level of agreement between CTA and the former procedures was determined.CTA images of diagnostic quality were obtained in 26 patients. Eighteen patients were diagnosed with colonic angiodysplasia by colonoscopy plus visceral angiography, and 14 by CTA (kappa = 0.68; P0.001). Sensitivity, specificity, and positive predictive values of CTA for detection of colonic angiodysplasia were 70%, 100%, and 100%, respectively. CTA signs including accumulation of vessels in the colonic wall, early filling vein, and supplying enlarged artery were present in 55%, 50%, and 22% of cases, respectively. None of these signs were present in the 8 patients with obscure gastrointestinal bleeding and negative diagnostic investigation of the digestive tract.CTA is a sensitive, specific, well-tolerated, and minimally invasive tool for the diagnosis of colonic angiodysplasia.

OBJECTIVE Gastrointestinal angiodysplasia is a major cause of recurrent bleeding. Haemostatic abnormalities have been implicated in the haemorrhage from these common vascular lesions but their precise contribution remains to be established. Our aim was to investigate whether bleeding angiodysplasia is associated with any specific coagulation disorder. METHODS Clinical features and blood samples were prospectively obtained from 21 patients with bleeding gastrointestinal angiodysplasia 3 months after the last episode of haemorrhage. Plasma levels of von Willebrand factor, D-dimer, plasminogen activator inhibitor type 1 (PAI-1), tissue-plasminogen activator activity, tissue factor pathway inhibitor and activated factor VII (FVIIa-rTF) were measured. A group of 14 patients with bleeding duodenal ulcer were similarly studied as controls. RESULTS Mean plasma von Willebrand factor levels were higher in angiodysplasia patients (208+/-12%) than in controls (143+/-11%) (P

El analisis inmunocitoquimico de las muestras obtenidas por USE-PAAF a veces es necesario para llegar a un diagnostico. Sin embargo no existen estudios sistematicos que hayan evaluado el impacto diagnostico de esta tecnica. Objetivo Investigar la utilidad clinica, la frecuencia y el tipo de marcadores inmunocitoquimicos utilizados en las muestras obtenidas mediante USE-PAAF. Pacientes y metodos Estudio unicentrico prospectivo. Se incluyeron en el estudio todos los pacientes a los que se le practico una USE-PAAF utilizando agujas de 22G y 19G. Los especimenes obtenidas fueron evaluados por un citopatologo in situ. Se practico estudio inmunocitoquimico cuando este fue necesario para llegar a un diagnostico. Resultados Se incluyeron 125 pacientes. La USE-PAAF logro el diagnostico las lesiones en 98% de los casos. Se preciso analisis inmunocitoquimica en 29 de 125 pacientes (24%) para llegar a un diagnostico. Se utilizaron diferentes paneles de marcadores inmunocitoquimicos: no-epiteliales (C-kit, CD 34, S-actina, vimentina, desmina, enolasa y proteina S-100), neuroendocrinos (CD 56, sinaptofisina, cromogranina, gastrina, glucagon, insulina), receptores hormonales (estrogenos, progesterona), epiteliales (Citoqueratinas: Cam 5.2, 7 y 20) y TTF-1, y linfoides (CD3, CD5, CD 15, CD 30, CD 20, CD 79a). Tras el analisis inmunocitoquimico el diagnostico final fue: 10 GIST gastricos, 1 leiomioma gastrico, 6 tumores neuroendocrinos (1 MEN tipo I), 2 procesos linfoproliferativos (1 linfoma de Hodgkin y 1 linfoma B difuso), 3 carcinoma pulmonar pobremente diferenciados de celula no pequena, 1 carcinoma escamoso pulmonar, 2 adenocarcinomas pulmonares, 3 linfadenopatias metastasicas (de mama, pulmon y colon) y 1 endometriosis rectosigmoide. Conclusion La inmunocitoquimica es necesaria en el 24% de los pacientes sometidos a USE-PAAF para alcanzar un diagnostico definitivo. Su uso depende de las indicaciones, siendo los marcadores no epiteliales los mas frecuentemente utilizados en nuestra serie para poder diagnosticar las lesiones subepiteliales. Enfermededad inflamatoria intestinal

El virus del papiloma humano (VPH) es una agente etiologico implicado en la neoplasia de esofago. Sin embargo su prevalencia es muy variable dependiendo de la localizacion geografica y de los diferentes test utilizados en su deteccion como la hibridacion in situ, southern blot, y reaccion de la polimerasa en cadena (PCR). Objetivo Determinar la prevalencia del VPH en una poblacion seleccionada con neoplasia de esofago de Cataluna. Pacientes y metodos Pacientes consecutivos diagnosticados de neoplasia de esofago fueron seleccionados para el estudio entre Febrero 2007 y Septiembre del 2008. Se realizaron biopsias endoscopicas pareadas de mucosa normal y tumoral, y se recogieron en RNA later. Se extrajo el DNA y fue amplificado utilizando el kit F-VPH typing™ PCR (Molgentix, Espana) Resultados Veinte pacientes (edad media: 62±11, 16V/4M) con neoplasia de esofago participaron en el estudio: 11 diagnosticados de carcinoma escamoso de esofago y 9 con adenocarcinoma. VPH se detecto en 6 de 11 pacientes (54,5%) con carcinoma escamoso de esofago y en 1 de 9 pacientes (11,1%) con adenocarcinoma de esofago. Los VPH del riesgo medio tipos (53, 70, 73) se detectaron en 5 de 7 pacientes tanto en el tumor como en la mucosa normal adyacente. Se detecto multinfeccion con varios VPH del riesgo medio en 4 (57%) de ellos. El VPH de bajo riesgo tipo 42 tambien se detecto en 5/7 (71%) de muestras de pacientes con cancer de esofago, tres en combinacion con varios VPH de riesgo medio, uno aislado y el restante era portador VPH 73 de riesgo medio en la mucosa normal adyacente. Conclusion El VPH esta presente en el 54% de los casos de carcinoma escamoso de nuestra serie. La multinfeccion con varios VPH es comun tanto en el tumor como en la mucosa normal del esofago de estos pacientes.

OBJECTIVE: Angiodysplasia of the colon is a distinct vascular abnormality characterized by focal accumulation of ectatic vessels in the mucosa and submucosa. To investigate whether angiogenesis contributes to the pathogenesis of human colonic angiodysplasia, we examined the expression of basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF), and its endothelial cell receptors flt-1 and KDR. METHODS: Immunohistochemistry was performed in sections of specimens obtained from 18 patients with colonic angiodysplasia and from eight patients with colon cancer and its adjacent, histologically normal margins of resection. We used affinity-purified rabbit polyclonal antibodies and a streptoavidin–biotin peroxidase method. RESULTS: We detected strong immunoreactivity for vascular endothelial growth factor, homogeneously distributed in the endothelial lining of blood vessels of all sizes in 16 (89%) specimens of colonic angiodysplasia and in seven (88%) patients with colon cancer. In contrast, very limited immunoreactivity was found in normal colon. Vascular staining for flt-1 was observed in eight (44%) and one (12.5%) of the colonic angiodysplasia or colon cancer specimens, respectively, but not in normal colon. Vascular immunoreactivity for basic fibroblast growth factor was observed in seven (39%) specimens from patients with colonic angiodysplasia, whereas either very limited or no immunostaining was found in sections from specimens of patients with colon cancer and its normal margins. CONCLUSIONS: In human colonic angiodysplasia, increased expression of angiogenic factors is likely to play a pathogenic role.

Background: Human papillomavirus (HPV) is increasingly recognized as an important etiological factor of esophageal cancer. However, its prevalence is highly variable between different geographic areas, and is also dependent on the different diagnostic tests such as in situ hybridization, southern blot, and polymerase chain reaction (PCR). Aim: To determine the prevalence of HPV in a selected population of esophageal cancer in Catalonia, Spain. Patients and Methods: Consecutive patients diagnosed with esophageal cancer were selected for the study between February 2007 and September 2008. Paired endoscopic biopsy samples were obtained from normal mucosa and tumour and collected in RNA later. Extracted DNA was amplified using F-HPV typingTM kit PCR (Molgentix, Spain) with a set of 24 fluorescently labelled primers recognizing HPV types 6, 11, 16, 18, 26, 31, 33, 35, 39, 42, 43 , 44, 45, 51, 52, 53, 56, 58, 59, 66, 68, 70, 73 and 82. Results: Twenty patients (mean age: 62 ±11, 16 M/ 4 F) diagnosed with 11 squamous cell carcinoma and 9 with esophageal adenocarcinoma participated in the study. HPV was detected in 6 out of 11 patients (54.5 %) with squamous cell carcinoma and in 1 of 9 patients (11.1%) with adenocarcinoma of esophagus. Medium risk HPV types (53, 70, 73) were detected in 5 out of 7 patients in both tumour and the surrounding normal mucosa. Multi-infection with several medium risk HPV types was found in 4 (57%) of them. Low risk VPH 42 was also present in 5/7 (71%) of cancer samples, three in combination with medium risk VPH, one isolated, and the remaining sample had medium risk HPV 73 in the surrounding normal mucosa. Conclusions: HPV is present in 54% of cases of squamous cell carcinoma in our series. The presence of several medium risk HPV is common in both tumor and normal esophageal mucosa samples from these patients.

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