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Background and study aims: The introduction of new sedative agents and a desire for improved patient care have encouraged the use of sedation for gastrointestinal (GI) endoscopy over the last decade. This survey aims to provide, within Spain, national and regional data on gastroenterologists’ endoscopic sedation and monitoring practices, and on their attitudes concerning these practices. Methods: A 19-item survey covering the current practices of sedation and monitoring in GI endoscopy was electronically mailed to all members of the three nationwide scientific societies. Results: Of 2476 e-mailed questionnaires, a total of 569 (23 %) were returned, proportionally representing the structure of the Spanish health care system. Monitoring and resuscitation resources were universally available, as well as post-endoscopy recovery rooms. Endoscopy teams usually included a registered nurse (98.5 %), an auxiliary nurse (80.5 %), and other physicians (25.7 %), generally anesthesiologists. More than half of esophagogastroduodenoscopies (EGDs) are performed with the patient under sedation; in 25 % of centers, more than 95 % colonoscopies are performed with the patient sedated, but a wide variation was observed. Pre-endoscopic risk is assessed in the vast majority of procedures. Propofol is the most commonly used sedative, either alone (in 70 % of EGDs and 80 % of colonoscopies) or in combination with other drugs. Private funding of a clinic was the only predictor of a significant increase in the use of sedation; 57.7 % of the respondents stated having difficulties in implementing sedation, with the limited availability of anesthesiologists and resuscitation training for the auxiliary staff the most common complaints. Conclusions: The use of sedation during GI endoscopy in Spain varies widely but is on the increase and is more common in private practice. Propofol is the preferred sedative in all procedures.

Background: Bacteria might play a role in the pathogenesis of Crohn_s disease (CD), and patients harbor a different type and density of gut microbiota compared with normal healthy subjects. Thus, the aim of this study was to compare the microbiota adhered to the mucosa of CD patients with that of healthy subjects. Methods: Polymerase chain reactionYdenaturing gradient gel electrophoresis (PCR-DGGE) of 16S rRNA gene fragments was used to identify the dominant bacterial species present in fresh biopsy samples obtained from the mucosa of 15 healthy and 19 CD subjects. Two patients suffering from ulcerative colitis and 1 suffering from ischemic colitis also were included. Results: Individuals were clustered in 2 groups according to their molecular fingerprint, which differentiated the majority of CD specimens (88.2%) from the majority of healthy/ulcerative colitis/ ischemic colitis specimens (82.3%). In addition, the patient-topatient variability in microbiota was greater within the CD cluster than in the healthy/ulcerative colitis cluster (P = 0.000). One hundred forty-one sequences were obtained from the PCR-DGGE bands that were grouped into 58 different phylotypes, 8 of which were novel. BLAST analysis revealed that 74.5% of the sequences were similar to those of bacteria that have never been cultivated. In CD samples, prevalence values for Clostridium spp Ruminococcus torques and Escherichia coli were significantly higher, whereas Faecalibacterium was more frequently found in healthy specimens. Opportunistic pathogenic g-proteobacteria were found occasionally, only in CD mucosal microbiota. Conclusions: Microbiota attached to the ileocolonic mucosa of CD patients is distinguishable from that of healthy subjects. We postulate that individuals who are predisposed to CD are less able to regulate the microbial makeup of their intestines, which leads to an unstable microbial population.

Resumen Introduccion El polipo fibroide inflamatorio (PFI) es una lesion protuberante que se localiza cerca de la muscularis mucosae y esta constituida por una proliferacion de celulas fusiformes y fibras conjuntivas alrededor de los capilares y un infiltrado inflamatorio variable. Se considera una reaccion inflamatoria reparadora mal controlada. El objetivo de este trabajo ha sido estudiar las caracteristicas clinicas, anatomopatologicas y de seguimiento de una serie de pacientes con PFI. Pacientes y metodo Se han estudiado 26 PFI (25 pacientes: 16 mujeres y 9 varones) recogidos entre los anos 1985 y 2001 en un registro especifico de 3 centros de la ciudad de Girona. Las variables analizadas fueron la edad, el sexo y la presentacion clinica, la localizacion y el tamano del PFI, las caracteristicas de la mucosa y las enfermedades asociadas, asi como informacion del seguimiento. Se realizaron las pruebas estadisticas habituales. Resultados El PFI fue antral en 16 casos, ileal en 7, yeyunal en 2 y colonico en el restante. Su tamano condiciono su caracter sintomatico (35 ± 13,6 mm) o asintomatico (8,4 ± 6,3 mm). Los polipos gastricos fueron significativamente mas pequenos que los intestinales. Los polipos sintomaticos (5 de 16 gastricos y 9 de 10 intestinales) predominaron en mujeres y en edades significativamente inferiores que los asintomaticos (59,2 frente a 74,1 anos). La mayoria de los PFI gastricos se asociaron a gastritis cronica atrofica, mientras que solo un PFI ileal lo hizo a diverticulo de Meckel. El seguimiento medio fue de 60,6 meses y, salvo en un caso de reseccion incompleta, no se constato recidiva del PFI. Conclusion El PFI es una entidad heterogenea segun la edad de presentacion, el sexo de los pacientes, su tamano y la localizacion en el tubo digestivo. Tras la reseccion, el PFI no recidiva. La asociacion de los PFI gastricos a gastritis cronica atrofica podria apuntar a un efecto modulador de la mucosa sobre el crecimiento del PFI.

Resumen El sindrome de Bouveret es una enfermedad poco frecuente que afecta a mujeres ancianas con antecedentes de sintomatologia biliar. La clinica es de obstruccion al vaciamiento gastrico como consecuencia de uno o varios calculos biliares impactados en el duodeno, debido a una fistula bilioenterica. El diagnostico se efectua mediante endoscopia, transito esofagogastroduodenal baritado o en el acto operatorio. Es importante efectuar un diagnostico y tratamiento precoz para mejorar su pronostico. Se presentan 5 casos de sindrome de Bouveret y se realiza una revision de la bibliografia.

Item does not contain fulltext BACKGROUND AND STUDY AIMS: A novel large-diameter, lumen-apposing, self-expanding metal stent with bilateral flanges was recently developed for endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic pancreatic fluid collections (PFCs). The aim of this study was to evaluate the efficacy and safety of this stent in a large cohort. PATIENTS AND METHODS: Patients with a PFC undergoing EUS-guided drainage with this novel stent were prospectively enrolled in this multicenter cohort study. RESULTS: There were 61 patients: 46 patients (75 %) with walled-off necrosis (WON) and 15 (25 %) with a pancreatic pseudocyst. Stent placement was technically successful in 60 patients (98 %, 95 %CI 95 % - 100 %). Clinical success, defined as resolution of clinical symptoms in combination with a decrease in the PFC size to

Two recent genome-wide association studies in Asians have reported the association between the PSCA (prostate stem cell antigen) rs2294008CT gene polymorphism and two Helicobacter pylori infection-related diseases such as gastric cancer (GC) and duodenal ulcer (DU). Since rs2294008 allele frequencies differ notably among ethnicities, we aimed to assess the role of rs2294008 on the susceptibility to GC and DU in a Caucasian population in Spain. Moreover, the relevance of rs2294008 on GC prognosis was evaluated. Genomic DNA from 603 Spanish patients with primary GC, 139 with DU and 675 healthy controls was typed for the PSCA rs2294008CT polymorphism by PCR-TaqMan assays. H. pylori infection [odds ratio (OR): 8.27; 95% confidence interval (CI): 3.45-15.33] and nonsteroidal anti-inflammatory drugs (OR: 6.54; 95% CI: 3.19-12.43) were identified as independent risk factors for DU whereas the rs2294008T allele was associated with reduced risk of developing the disease (OR: 0.52; 95% CI: 0.33-0.82). Infection with CagA strains (OR: 2.10; 95% CI: 1.63-2.34), smoking (OR: 1.93; 95% CI: 1.54-2.61), family history of GC (OR: 2.83; 95% CI: 2.01-3.83), and the rs2294008T allele (OR: 1.46; 95% CI: 1.07-1.99) were associated with increased risk of GC. Interestingly, the association with the rs2294008T allele was restricted to noncardia GC (OR: 1.43; 95% CI: 1.12-1.82), particularly of the diffuse histotype (OR: 1.59; 95% CI: 1.16-1.92). Finally, Cox regression analysis identified the rs2294008T variant as a prognosis factor associated with worse overall survival in patients with diffuse-type GC (hazard ratio: 1.85; 95% CI: 1.12-3.06). From these results we conclude that the PSCA rs2294008 polymorphism is involved in the susceptibility to GC and DU, as well as in the prognosis of the diffuse-type of GC in Caucasians.

Objective:Butyrate enemas may be effective in the treatment of active distal ulcerative colitis. Because colonic fermentation ofPlantago ovataseeds (dietary fiber) yields butyrate, the aim of this study was to assess the efficacy and safety ofPlantago ovataseeds as compared with mesalamine in mainta

Few studies have assessed the IgA antineutrophil cytoplasmic antibody (ANCA) positivity in ulcerative colitis patients and there is no information about factors related to its synthesis and its status after colectomy. The aims of the study were to assess the serum IgA ANCA prevalence in ulcerative colitis patients, both nonoperated and operated, and to determine the clinical factors related to this positivity.Fifty-four ulcerative colitis patients, 63 ulcerative colitis colectomized patients (32 with Brooke's ileostomy and 31 with ileal pouch anal anastomosis), and 24 controls were studied. Antineutrophil cytoplasmic antibodies were detected by specific indirect immunofluorescent assays.The percentage of IgA ANCA was significantly higher in patients with ileal pouch anal anastomosis (45%) than in patients with Brooke's ileostomy (22%). There were no differences related to the presence of pouchitis in ileal pouch anal anastomosis patients. Patients with nonoperated extensive colitis (47%) had a significantly higher percentage of IgA ANCA than patients with proctitis (19%). Total percentage of ANCA (IgA and/or IgG) tended to be higher in ulcerative colitis and in patients with ileal pouch anal anastomosis than in patients with Brooke's ileostomy. However, in ileal pouch anal anastomosis patients, ANCA positivity was mainly due to exclusive IgA production.A substantial percentage of ulcerative colitis patients, and especially colectomized patients with ileal pouch anal anastomosis, had IgA ANCA, suggesting that ANCA production in ulcerative colitis might be stimulated by an immune reaction in the intestinal mucosa.

Patients with inflammatory bowel disease (IBD) have increased plasma n3 polyunsaturated fatty acids (PUFAs), which in ulcerative colitis (UC) patients persists six months after colectomy, suggesting a primary abnormality in fatty acid (FA) metabolism in IBD. This finding needed to be confirmed in a larger series of UC long-term colectomized patients. We aimed to assess the plasma FA pattern in UC colectomized patients with either Brooke's ileostomy (UC-BI) or ileal pouch anal anastomosis (UC-IPAA) and the mucosal FA pattern in the ileal reservoir of the UC-IPAA patients. Plasma FAs were assessed in 63 UC colectomized patients (31 with BI and 32 with IPAA) and 30 controls. In 26 UC-IPAA (8 with pouchitis and 18 without pouchitis) and in 13 healthy controls gut mucosal FAs were also investigated. FAs were detected by capillary column gas-liquid chromatography. Increased levels of saturated fatty acids (SFAs) and decreased percentages of monounsaturated fatty acids (MUFAs) were observed in both groups of patients. There were no changes in plasma n3 and n6 PUFAs. The mucosal FA pattern of the ileal reservoir consisted of increased long-chain PUFAs, specially n6 PUFA, and a decrease of their essential precursors. High percentages of SFAs and low percentages of MUFAs were also seen. The plasma FA profile previously described in IBD is not observed long-term after colectomy in UC, suggesting that it is related with the presence of inflamed intestine. High concentrations of SFAs and decreased percentages of MUFAs might represent early events in disturbed FA metabolism in IBD. The changes in FAs of the ileal reservoir, which closely resemble those found in human and experimental IBD, probably represent a common pattern of intestinal inflammation.

Background: There is little information about the effect of infliximab on the clinical course of liver disease in Crohn’s disease patients with concomitant hepatitis B virus (HBV) infection. Theoretically, immunosuppression induced by infliximab will facilitate viral replication which could be followed by a flare or exacerbation of disease when therapy is discontinued. There are no specific recommendations on surveillance and treatment of HBV before infliximab infusion. Two cases of severe hepatic failure related to infliximab infusions have been described in patients with rheumatic diseases. Patients and methods: Hepatitis markers (C and B) and liver function tests were prospectively determined to 80 Crohn’s disease patients requiring infliximab infusion in three hospitals in Spain. Results: Three Crohn’s disease patients with chronic HBV infection were identified. Two of the three patients with chronic HBV infection suffered severe reactivation of chronic hepatitis B after withdrawal of infliximab therapy and one died. A third patient, who was treated with lamivudine at the time of infliximab therapy, had no clinical or biochemical worsening of liver disease during or after therapy. From the remaining 80 patients, six received the hepatitis B vaccine. Three patients had antibodies to both hepatitis B surface antigen (anti-HBs) and hepatitis B core protein (anti-HBc) with normal aminotransferase levels, and one patient had positive anti-hepatitis C virus (HCV) antibodies, negative HCV RNA, and normal aminotransferase levels. Except for the patients with chronic HBV infection, no significant changes in hepatic function were detected. Conclusions: Patients with Crohn’s disease who are candidates for infliximab therapy should be tested for hepatitis B serological markers before treatment and considered for prophylaxis of reactivation using antiviral therapy if positive.

Patients with active inflammatory bowel disease (IBD) have increased levels of n3 and decreased levels of n6 plasma long-chain polyunsaturated fatty acids (LC-PUFA). Using multivariate statistical techniques, this study assessed the influence of the potentially important factors of diagnosis (ulcerative colitis versus Crohn's disease), disease activity, malnutrition, location of disease, therapy, age, and sex on these plasma fatty acid abnormalities. Plasma fatty acids were analyzed by semicapillary column gas-liquid chromatography in 73 patients with IBD and 107 healthy controls. The effect of each confounder upon either "low" (below the first quartile of the control group) or "high" (above the third quartile of the control group) levels of each fatty acid (FA) was assessed by means of stepwise logistic regression analyses. After controlling for these factors, disease activity remained the primary factor associated with changes in the plasma FA profile. Moderate/severe activity was significantly associated with low n6 LC-PUFA and was inversely related to high n3 LC-PUFA. Corticosteroid therapy was independently associated with high C16:0 and C18:2n6 plasma values and low C20:3n6 values and unsaturation index. Sulfasalazine therapy was inversely associated with low percentages of both C18:0 and C20:3n6. Hypoalbuminemia was significantly related only to low values of C18:0. No relationship between any confounder and high levels of n3 LC-PUFA was found. The observed relationships may be of importance in the pathogenesis and treatment of IBD.

Background: Genetic factors influencing the prognosis of gastric adenocarcinoma (GAC) are not well known. Given the relevance of cytokines and other pro-inflammatory mediators in cancer progression and invasiveness, we aimed to assess the prognostic role of several functional cytokine and cyclooxygenase gene polymorphisms in patients with GAC. Methodology: Genomic DNA from 380 Spanish Caucasian patients with primary GAC was genotyped for 23 polymorphisms in pro-inflammatory (IL1B, TNFA, LTA, IL6, IL12p40), anti-inflammatory (IL4, IL1RN, IL10, TGFB1) cytokine, and cyclooxygenase (PTGS1 and PTGS2) genes by PCR, RFLP and TaqMan assays. Clinical and histological information was collected prospectively. Survival curves were estimated by the Kaplan-Meier method and compared using the log rank test. Outcome was determined by analysis of Cox proportional hazards, adjusting for confounding factors. Results: The median follow-up period and median overall survival (OS) time were 9.9 months (range 0.4-120.3) and 10.9 months (95% CI: 8.9-14.1), respectively. Multivariate analysis identified tumor stages III (HR, 3.23; 95% CI:2-5.22) and IV (HR, 5.5; 95% CI: 3.51-8.63) as independent factors associated with a significantly reduced OS, whereas surgical treatment (HR: 0.44; 95%CI: 0.3-0.6) was related to a better prognosis of the disease. Concerning genetic factors, none of the 23 polymorphisms evaluated in the current study did influence survival. Moreover, no gene-environment interactions on GAC prognosis were observed. Conclusions: Our results show that, in our population, the panel of selected pro- and anti-inflammatory cytokine, and cyclooxygenase gene polymorphisms are not relevant in determining the prognosis of gastric adenocarcinoma. © 2012 García-González et al., This study was supported by the Spanish >Fondo de Investigaciones Sanitarias> (grants PI05/0405 and PS09/00213), and Instituto de Salud Carlos III (CIBER de enfermedades hepaticas y digestivas).

Human glutathione S-transferases (GSTs) are phase II metabolizing enzymes that play a key role in protecting against cancer by detoxifying numerous potentially cytotoxic/genotoxic compounds. The genes encoding the human GST isoenzymes GSTM(mu)1, GSTT(theta)1 and GSTP(pi)1 harbour polymorphisms, which have been considered important modifiers of the individual risk for environmentally induced cancers such as gastric cancer (GC). However, results are inconsistent among studies from different geographic areas and ethnic groups. Our goal was to perform a nationwide, case-control study in Spain to evaluate the relevance of several functional GST gene polymorphisms and environmental factors to GC risk and phenotype. DNA from 557 GC patients and 557 sex- and age-matched healthy controls (HC) was typed for two deletions in the GSTM1 and GSTT1 genes and two SNPs in the GSTP1 gene (rs1695 and rs1138272) using polymerase chain reaction-restriction fragment length polymorphism methods. Logistic regression analysis identified Helicobacter pylori infection with CagA strains [odds ratio (OR): 2.36; 95% confidence interval (CI): 1.78-3.15], smoking habit (OR: 2.10; 95% CI: 1.48-2.97) and family history of GC (OR: 3.2; 95% CI: 2.02-5.16) as independent risk factors for GC. No differences in the frequencies of GSTM1 or GSTT1 null genotypes were observed between cases and controls (GSTM1: 50.8% vs. 48%; GSTT1: 21.5% vs. 21%). Moreover, simultaneous carriage of both, the GSTM1 and the GSTT1 null genotypes, was almost identical in both groups (10.7% in GC vs. 10.6% in HC). In addition, no significant differences in GSTP1 Ile105Val (rs1695) and GSTP1 Val114Ala (rs1138272) genotype distribution were observed between GC patients and controls. Subgroup analysis for age, gender, Helicobacter pylori status, smoking habits, family history of GC, anatomic location and histological subtype revealed no significant association between GST variants and GC risk. Our results show that the GST polymorphisms evaluated in this study are not relevant when determining the individual susceptibility to GC or phenotype in a South-European population. © The Author 2012. Published by Oxford University Press on behalf of the UK Environmental Mutagen Society. All rights reserved.

The developments in enteral feeding for Crohn's disease in the past decade are critically reviewed. The advent of amino acid based chemically defined elemental diets signalled the end of 'total bowel rest' in the management of these patients. Subsequently, controlled clinical trials showed that elemental diets were as effective as corticosteroids in inducing clinical remission in patients with acute exacerbations of Crohn's disease. The later use of peptide based elemental diets, in Crohn's disease produced somewhat conflicting results. The initial uncontrolled studies suggest that polymeric whole protein diets might also be effective in the management of acute exacerbations of the disease, casting in turn doubts concerning the role of dietary antigens in the pathogenesis of Crohn's disease. Results of controlled studies comparing the use of elemental and polymeric diets as primary therapy in Crohn's disease have, however, also produced conflicting results. The results of one recent controlled trial in which the use of polymeric diet was compared with that of corticosteroids does, however, suggest that these diets may have a primary therapeutic effect in Crohn's disease. An analysis of the composition of some of the enteral diets used in different trials suggest that the effectiveness of enteral diets in treating active Crohn's disease might relate more to their fat than nitrogen composition. A hypothesis is proposed that the effectiveness of enteral nutrition in the primary therapy of acute exacerbations of Crohn's disease occurs because the successful diets used contain insufficient precursors for arachidonate derived eicosanoid synthesis.

Introduccion: La dehiscencia de sutura esofagica (DSE) se asocia a una elevada morbimortalidad. Las protesis auto-expandibles (PE) son una alternativa en su tratamiento. Objetivo: Evaluar la eficacia y seguridad de las PE en el tratamiento de DSE post cirugia esofago-gastrica neoplasica. Metodos: Revisamos los pacientes intervenidos desde el 2005, analizando retrospectivamente aquellos con diagnostico de DSE tratados endoscopicamente. Demostramos el cierre de la fuga por tolerancia oral, radiologia o cese del drenaje pleural. La curacion se comprobo tras la extraccion de la protesis. Resultados: Entre 194 intervenciones (90 esofaguectomias, 104 gastrectomias), hubo 18 fallos de sutura (9,27%): 7 cervicales, 7 toracicas y 4 abdominales. Seis mujeres, edad media 66 anos. Todas las DSE cervicales fueron tratadas con endoscopia: 6 dilataciones y 1 PE; las 7 toracicas fueron tratadas con protesis y de las abdominales: 2 protesis, 1 reintervenida y otra resuelta conservadoramente. En total 10 pacientes (55,6%) fueron tratados con PE. El intervalo diagnostico-colocacion de la PE fue 17,3dias; mayor en los 4 pacientes que requirieron un recambio del stent (32,6 vs. 9,6dias). Con una sola protesis se consiguio el cierre en una media de 5dias en 5 casos (50%) y en 19dias en uno (10%). En este caso el cierre no se comprobo antes por su condicion de gravedad. Tres (30%) requirieron un recambio del stent por persistir drenaje o por migracion y a uno (10%) se le adiciono otra protesis. Se curaron todos los pacientes (100%) en una media de 79dias. Conclusiones: El empleo de PE para el tratamiento de DSE post cirugia esofago-gastrica neoplasica es eficaz y seguro, consiguio la curacion en todos los pacientes tratados. El retraso en la colocacion del stent parece relacionarse con el fallo del cierre y la necesidad de insertar nuevos stents.

To date, this is the largest prospective series in patients with malignant colorectal obstruction to evaluate the effectiveness and safety of colonic self-expanding metal stents (SEMSs) as an alternative to emergency surgery. SEMSs allow restoration of bowel transit and careful tumor staging in preparation for elective surgery, hence avoiding the high morbidity and mortality associated with emergency surgery and stoma creation.This report is on the SEMS bridge-to-surgery subset enrolled in two multicenter international registries. Patients were treated per standard of practice, with documentation of clinical and procedural success, safety, and surgical outcomes.A total of 182 patients were enrolled with obstructive tumor in the left colon (85%), rectum (11%), or splenic flexure (4%). Of these patients, 86% had localized colorectal cancer without metastasis. Procedural success was 98% (177/181). Clinical success was 94% (141/150). Elective surgery was performed in 150 patients (9 stomas) and emergency surgery in 7 patients for treatment of a complication (3 stomas). The overall complication rate was 7.8% (13/167), including perforation in 3% (5/167), stent migration in 1.2% (2/167), bleeding in 0.6% (1/167), persistent colonic obstruction in 1.8% (3/167), and stent occlusion due to fecal impaction in 1.2% (2/167). One patient died from complications related to surgical management of a perforation.SEMSs provide an effective bridge to surgery treatment with an acceptable complication rate in patients with acute malignant colonic obstruction, restoring luminal patency and allowing elective surgery with primary anastomosis in most patients.

Fatty acid levels (from C14:0 to C22:6n3) in plasma lipid fractions were prospectively studied in 11 cirrhotic patients with chronic hepatic encephalopathy and compared with those in 23 cirrhotic patients without chronic hepatic encephalopathy with similar age, sex distribution, and liver and nutritional status, and in 11 age- and sex-matched, healthy subjects. Plasma lipid fractions were separated by thin-layer chromatography and fatty acids were identified by capillary column gas-liquid chromatography. Total n6 polyunsaturated fatty acid plasma levels were lower in cirrhotic patients--with and without chronic hepatic encephalopathy--than in control subjects. In addition, arachidonic acid levels, both in total lipids and fractions, were lower in patients with than in those without chronic encephalopathy. On the other hand, a selective decrease of plasma docosahexaenoic acid (a major component of neuronal membranes) was observed in those patients with chronic encephalopathy as compared with both control and cirrhotic subjects without chronic encephalopathy. These findings may be due to various mechanisms. Differences in long-chain polyunsaturated fatty acid content in fish- and meat-restricted diets partly may account for these findings. However, it could be speculated that polyunsaturated fatty acid biosynthesis may be reduced further in patients with chronic hepatic encephalopathy because of either a decrease in portal essential fatty acid extraction in the postabsorptive phase due to portal-systemic shunting or to the effect of protein-restricted diets. Furthermore, the finding of low plasma docosahexaenoic acid in these patients raises the possibility that this deficiency might be an additional pathogenic factor in chronic hepatic encephalopathy.

Background:Escherichia coli, particularly the adherent-invasive E. coli (AIEC) pathovar, has been increasingly implicated in the ethiopathogenesis of Crohn's disease (CD). We describe the richness, abundance, diversity, and pathogenic features of E. coli and AIEC strains that colonize the intestinal mucosa. Methods: Approximately 100 E. coli colonies per biopsy from 20 CD patients (18 biopsies from colon and 23 from ileum) and 28 healthy controls (C) (25, colon; 27, ileum) were isolated. Repetitive extragenic palindrome-polymerase chain reaction (Rep-PCR) and pulsed field gel electrophoresis (PFGE) were used to analyze the clonality of isolates. For AIEC identification, adhesion and invasion assays were performed over Intestine-407 cells, and the capacity to survive and replicate intracellularly was determined over macrophages J774. The serotypes, phylotypes, and genotypes (19 virulence genes) of strains were also investigated. Results: Mucosa-associated E. coli richness (E. coli subtypes/patient: C = 2.0 ± 1.0; CD = 2.1 ± 1.3) and diversity (Shannon Index: H'C: 2.1 ± 0.6; H'CD: 2.5 ± 0.8) were similar between CD and C, but higher E. coli counts were characteristic of CD patients (P = 0.010), particularly those with Crohn's ileitis (P = 0.001). Host-specific pulsotypes shared virulence features of ExPEC at similar frequencies between CD and C, except for iucD, which was more prevalent in E. coli from controls (C: 75%, CD: 40%, P = 0.027). In contrast, greater AIEC prevalence (% subjects with AIEC: CD = 51.9%; C = 16.7%; P = 0.003), abundance (% AIEC/E. coli: CD = 3.8 ± 5.0%; C = 1.5 ± 3.8%; P = 0.039), and richness (number of AIEC subtypes: CD = 0.8 ± 1.4; C = 0.2 ± 0.4; P = 0.015) of E. coli strains belonging to the AIEC pathovar was observed for CD patients. AIEC subtypes showed a high variability of seropathotypes and pulsotypes, although the B2 phylogroup was the most prevalent (AIEC: 64%, non-AIEC: 38%, P = 0.044). Conclusions: New data about ecological parameters of AIEC reinforces the implication of AIEC in CD. (Inflamm Bowel Dis 2009)

Thirty-five severely malnourished cirrhotic patients were randomized to receive either enteral-tube feeding as the sole nutritional support (n = 16) or an isocaloric, isonitrogenous, low-sodium standard oral diet (n = 19). Both groups were homogeneous regarding age, sex distribution, etiology of liver cirrhosis, history of previous complications, clinical status, liver and renal function, modified Child's score, and nutritional status at admission. The enteral formula diet was energy dense, containing 40 mmol Na/day, whole protein plus branched-chain amino acids, medium- and long-chain triglycerides, and maltodextrin. It supplied 2115 kcal/day. The amount of vitamins and trace elements was at the upper limit of the recommended dietary allowances. The orally fed patients were encouraged to eat all meals served. Total enteral nutrition was well tolerated without major complications. Serum albumin and Child's score improved in the enterally fed patients but not in controls. Mortality rate while in the hospital was lower in patients on enteral feeding than in controls (12% vs 47%). These results show that total enteral nutrition is safe and effective in improving the short-term clinical outcome in severely malnourished cirrhotics.

Background Self-expanding metal stents (SEMS) are being increasingly used to solve malignant colorectal obstruction (MCRO). Patients can then either undergo scheduled surgery or have the stent left in place as a definitive palliative treatment. The majority of reports on the use of SEMS in MCRO come from single centers; therefore, its use in general endoscopic practice is not clearly known. Objective To study the use of SEMS for MCRO in a wide endoscopic practice. Design Retrospective study. Setting A survey was carried out among endoscopists in 13 hospitals in Spain (6 tertiary referral centers and 7 community hospitals). Patients Those who presented with MCRO. Interventions A total of 175 attempts to insert colorectal SEMS were made during a 12-month period (October 2003 to September 2004). Main Outcome Measures Technical and clinical success and possible differences according to the type of hospital. Results There was a mean of 1.2 attempts/mo per center (range, 2-0.5 attempts/mo per center). Insertion success was achieved in 162 (92.6%) and acceptable colonic decompression in 138 of 175 (78.8%) attempts and in 138 of 162 (85.1%) of successfully inserted stents. SEMS served as a bridge to scheduled surgery in 72 of 175 (41%) and as a palliative definitive treatment in 66 of 175 (37.7%). The major complication was perforation, which occurred in 7 of 175 occasions (4%) and led to death in 2 patients (1%). There were other less severe complications (25 [14%]). No significant differences in outcome of stent placement procedures were found between both categories of centers. Limitations Retrospective study involving many centers and the possibility of bias for different assessments of outcomes. Conclusions In this study, success rates for SEMS placement and colonic decompression in MCRO were acceptable, without substantial differences according to the type of hospital. This procedure appeared to be feasible in general endoscopic practice.

Background: Dietary fat has been suggested to determine the therapeutic effect of enteral diets in Crohn's disease. Aim: To assess the efficacy of two whole protein based diets with different fat compositions (n6 polyunsaturated fatty acids v monounsaturated fatty acids) in inducing clinical remission in active Crohn's disease compared with steroids. Methods: Sixty two patients with active Crohn's disease were randomised to receive, for not more than 4 weeks: (a) a polymeric enteral diet containing 35 g of lipids per 1000 kcal, high in oleate (79%) and low in linoleate (6.5%) (PEN1), (b) an identical enteral diet except for the type of fat which was high in linoleate (45%) and low in oleate (28%) (PEN2), or (c) oral prednisone (1 mg/kg/day). Diets were double blindly administered. The steroid group received a conventional ward diet. Treatment failure was considered when remission was not achieved at week 4. Clinical activity and biological and nutritional parameters were monitored. Independent predictors of remission were identified by stepwise logistic regression analysis. Results: Overall remission rates (by intention to treat) were 20% (4/20) for PEN1, 52% (12/23) for PEN2, and 79% (15/19) for steroids (overall p=0.001; p

Introduccion Los inmunosupresores pueden aumentar la replicacion viral con exacerbacion de la hepatitis B (VHB) y C (VHC). Existe escasa informacion con respecto a la influencia del tratamiento inmunosupresor en pacientes con enfermedad inflamatoria intestinal (EII) e infeccion viral simultanea. En pacientes hematologicos sometidos a terapia antineoplasica, se demuestra reactivacion por el VHB que oscila del 14–78%, con un alto porcentaje de hepatitis fulminante (50% mortalidad), siendo la reactivacion por el VHC menos frecuente. Objetivo Evaluar la influencia del tratamiento inmunosupresor en la evolucion de la infeccion por el VHB y C en pacientes con EII. Metodos Estudio multicentrico retrospectivo que incluye todos los pacientes con EII e infeccion por el VHB y/o VHC actual o pasada y que hayan recibido tratamiento inmunosupresor en 18 hospitales espanoles. Se recopila informacion sobre el tipo y periodo de uso de los inmunosupresores utilizados y se evalua la funcion hepatica y marcadores virales pre, durante y postratamiento. Los datos se introducen en una base electronica ( www.repentina.com ), finalizando el reclutamiento el 31 marzo 2009. Resultados En el momento del envio del resumen, disponemos de datos de los marcadores virales de 77 pacientes; 43 de los cuales con serologia positiva para el VHB y 39 para el VHC. Cinco de estos tenian marcadores de ambas infecciones (antiHBc+AcVHC). En la tabla se muestra la evolucion de la infeccion de los pacientes HBsAg y RNA-VHC positivos, en relacion con la inmunosupresion. Casos Reactivacion No reactivacion Datos incompletos VHB (HBsAg) 13 53,8% (7/13) 46,1% (6/13) 0% (0/13) VHC (RNA) 23 8,7% (2/23) 52,2% (12/23) 39,1% (9/23) La reactivacion del VHB se observo en la mayoria de los casos con la utilizacion simultanea de 2 inmunosupresores (azatioprina+infliximab o esteroides), y se acompano de insuficiencia hepatica grave en 5 de 7 casos (71%). En 1 paciente con marcadores de infeccion pasada por VHB (antiHBc+antiHBs) y tratado con infliximab+azatioprina se detecto DNAVHB en dos ocasiones sin evidencia de reactivacion. Conclusiones 1) Igual como se ha descrito en otras situaciones de inmunosupresion, la reactivacion del VHB (HBsAg positivo) es mucho mas frecuente y grave que con el VHC. 2) La mayoria de las reactivaciones del VHB se producen con la administracion de 2 inmunosupresores simultaneos. 3) Los pacientes con marcadores de infeccion pasada por VHB deben ser controlados de forma estricta por la posibilidad de infeccion oculta.

Las glutation S-transferasas son una familia de enzimas involucradas en mecanismos de detoxificacion celular, eliminando xenobioticos y substancias nocivas para las celulas. Los genes que codifican la sintesis de las isoformas GSTM(mu)1, GSTT(theta)1 y GSTP(pi) son altamente polimorficos. Existen 2 polimorfismos caracterizados por una delecion de los genes GSTM1 y GST1 que conllevan un perdida total de la activad enzimatica correspondiente y cuya presencia se ha asociado con un mayor riesgo de desarrollar ciertos tipos de cancer. Ademas, el gen GSTP1 presenta dos polimorfismos relativamente frecuentes (Ile105Val y Val114Ala) relacionados con una disminucion de la actividad enzimatica. Puesto que el status GST de un individuo podria ser determinante en el proceso de carcinogenesis, el objetivo de nuestro estudio fue analizar el papel de dichos polimorfismos en el desarrollo del cancer gastrico (CG). Metodos ADN genomico procedente de 515 pacientes con CG y 515 individuos sanos fue tipado mediante RFL-PCR para el analisis de los polimorfismos GSTP1 Val105Ile (rs1695) y GSTP1 Val114Ala (rs1138272) y mediante PCR multiple para el estudio de las deleciones de los genes GSTM1 y GSTT1. El estatus de infeccion por H. pylori y de anticuerpos CagA/VacA se realizo mediante Western blot. Resultados La infeccion por cepas cagA de H. pylori (OR: 2,33; 95% IC: 1,78–3,06), el tabaco (OR: 2,26; 95% IC: 1,39–3,08) y la existencia de antecedentes familiares de CG (OR: 3,1; 95% IC: 1,83–5,14) fueron factores de riesgo asociados al desarrollo de CG. El porcentaje de individuos homozigotos para la delecion de los genes GSTM1 y GSTT1 fue similar en pacientes y controles (52% vs 49%, OR: 1,57; 95% IC: 0,89–1,49 para GSTM1 y 22% vs 21%, OR: 1,07; 95% IC: 0,78–1,46 para GSTT1). Igualmente, el porcentaje de individuos homozigotos para ambas deleciones fue casi identico en ambos grupos (10,8% en CG vs 10,7% en controles; OR: 1,14; 95% IC: 0,73–1,78). Tampoco se observaron diferencias significativas en la distribucion de genotipos y frecuencias alelicas de los polimorfismos GSTP1 Val105Ile y GSTP1 Val114Ala entre pacientes y controles. Por ultimo, no se encontraron diferencias significativas en los genotipos cuando los pacientes fueron clasificados en funcion del sexo, edad, tabaquismo, status de infeccion por H. pylori, presencia de anticuerpos anti CagA/VacA, tipo histologico tumoral, localizaron del tumor o antecedentes familiares de cancer gastrico. Conclusion Nuestros resultados sugieren que los polimorfismos geneticos de GTSM1, GTST1 y GTSP1 analizados en nuestro estudio no estan implicados en la susceptibilidad al desarrollo de CG.

Objetivo Analizar la influencia de polimorfismos de genes que codifican la sintesis de citocinas pro- y anti-inflamatorias, asi como de las ciclooxigenasas 1 (COX1) y 2 (COX2), en el pronostico del cancer gastrico (CG). Pacientes y metodos Se incluyeron prospectivamente 332 pacientes con CG distal y 65 pacientes con CG cardial desde Mayo de 2002 hasta Diciembre de 2003. El ADN obtenido a partir de sangre periferica fue tipado para el estudio de 24 polimorfismos localizados en genes de citocinas pro-inflamatorias (IL-1B, TNFA, LTA e IL-12p40) y anti-inflamatorias (IL-4, IL-1RN, IL-10 y TGFB1) asi como de COX1 (PTGS1) y COX2 (PTGS2) mediante PCR, RFLP y sondas Taqman. Se excluyeron 107 pacientes por: ausencia de estadio tumoral (n=56), exitus por causa no relacionada con la neoplasia (n=25) y ausencia de seguimiento (n=26). Finalmente se incluyeron 290 pacientes en el analisis. La mediana de seguimiento fue de 282 dias (rango: 5–2221). La supervivencia se analizo mediante los tests de Kaplan-Meier y log-rank. El pronostico de los polimorfismos se realizo mediante analisis de riesgos proporcionales de Cox, ajustando por edad, sexo, indice de comorbilidad de Charlson, tabaquismo, localizacion de la neoplasia y estadio tumoral. Resultados La edad media de los pacientes fue de 69,7±12,2 anos. 194 pacientes (67%) eran varones. En el momento de inclusion, 49 (17%), 27 (9%), 57 (20%) y 157 (54%) pacientes pertenecian a los estadios I–IV, respectivamente. Se realizo gastrectomia con intencion curativa en 123 (42%) pacientes. Durante el seguimiento fallecieron 196 (67%) pacientes: 160 (55%) por progresion de la neoplasia, y el resto por otras causas. La supervivencia media global a los 5 anos fue del 22%. La supervivencia media por estadios I–IV fue de 61%, 42%, 24% y 3%, respectivamente. Los individuos portadores del genotipo TGFB1-869CC presentaron un peor pronostico que los no portadores. Se identificaron como factores de mal pronostico la edad (HR=1,02, IC95%: 1,00–1,34, P=0,03), localizacion cardial de la neoplasia (HR=1,52, IC95%: 0,99–2,33, P=0,05), tabaquismo activo o previo (HR=1,59, IC95%: 1,10–2,29, P=0,01), estadio III (HR=3,35, IC95%: 1,67–6,70, P=0,001), estadio IV (HR=8,55, IC95%: 4,59–15,92, P Conclusion La combinacion de los genotipos PTGS1 644CC/TGFB1 869CC es un factor independiente de mal pronostico en pacientes con adenocarcinoma gastrico.

An abnormal plasma polyunsaturated fatty acid pattern (PUFA) (increased n3 and decreased n6 PUFA) has been reported in active inflammatory bowel disease (IBD). The possibility of a primary defect in the PUFA metabolism in IBD was hypothesised. The aim of this study was to assess plasma PUFA pattern in inactive inflammatory bowel disease and to ascertain whether patients who had had a colectomy and who were suffering from ulcerative colitis have a similar PUFA pattern than those patients with non-active ulcerative colitis and who had not had a colectomy. Plasma fatty acids were analysed by semi-capillary column gas-liquid chromatography in three groups of patients with inactive IBD (24 patients with inactive ulcerative colitis who had not had a colectomy, 15 patients with ulcerative colitis who had had a colectomy, and 27 patients with Crohn's disease). Plasma concentration and percentage of C22:6n3 and unsaturation index were significantly higher in patients with inactive ulcerative colitis without a colectomy and the Crohn's disease group (p < 0.0001) than in controls. Plasma concentration and percentage of C22:6n3 and the unsaturation index remained significantly higher, in both the operated and non-operated ulcerative colitis patients when compared with controls (p < 0.0001). These results suggest that in inactive IBD, an increased PUFA biosynthesis might be the cause of the high values of n3 compounds. These findings although seen in active disease, are more noticeable in remission because of the lack of artefactual factors (malnutrition, steroids, inflammation). In addition, persistence of high values in both groups of ulcerative colitis patients--that is, those who had had a colectomy and those who had not suggests the existence of a primary abnormality in the PUFA metabolism in IBD.

Relevance of GSTM1, GSTT1, and GSTP1 Gene Polymorphisms On Gastric Cancer Susceptibility Maria Asuncion Garcia-Gonzalez, Enrique Quintero, Rafael Benito, Mark Strunk, David Nicolas-Perez, Adolfo Parra-Blanco, Santos Santolaria, Federico Sopena, Elena Piazuelo, Pilar Jimenez, Maria Badia, Jesus Espinel, Rafael Campo, Marisa Manzano, Fernando Geijo, Maria Pellise, Ferran Gonzalez-Huix, Miguel Nieto, Jorge C. Espinos, LLucia Tito, Luis Bujanda, Manuel Zaballa, Maria Angeles Perez-Aisa, Isabel Maria Mendez-Sanchez, Angel Lanas

Liver and biliary abnormalities are well-known complications of inflammatory bowel disease (IBD). It has been suggested that using total parenteral nutrition (TPN) may further impair liver function in these patients; this seems not to be so with total enteral nutrition (TEN). However, prospective trials comparing the incidence of liver function test (LFT) abnormalities with either TPN or TEN have not been carried out. Twenty-nine IBD inpatients with normal LFT, randomized to receive either TEN with a polymeric diet or isocaloric, isonitrogenous "all-in-one" TPN because of protein-energy malnutrition and/or severe disease, were included in the study. Sixteen patients (five with ulcerative colitis and 11 with Crohn's disease) received TEN, and 13 patients (eight ulcerative colitis and five Crohn's disease) were on TPN. All patients were on systemic steroids, and nine of them were on oral metronidazole. Both groups were homogeneous regarding age, sex, diagnosis, disease activity, nutritional status, daily nutrient supply, and days on artificial nutrition. Serum albumin levels significantly increased with TEN (32 +/- 1 to 38.2 +/- 1.6 g/liter, p less than 0.01), but not with TPN (32.1 +/- 2.2 to 33.9 +/- 1.4 g/liter, NS). Clinical improvement occurred in both groups of patients as shown by the change in the disease activity indexes. In all cases, measurements of serum alkaline phosphatase, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltransferase were performed weekly. There were no significant differences in the initial LFT between both groups.(ABSTRACT TRUNCATED AT 250 WORDS)