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Introduccion: los inhibidores del factor de necrosis tumoral alfa (anti-TNF) son farmacos eficaces en el tratamiento de la colitis ulcerosa (CU) moderada-grave. Sin embargo, muchos pacientes no responden o tienen una perdida de respuesta terapeutica durante el seguimiento. Objetivo: analizar los factores que determinan la respuesta clinica a los anti-TNF en la CU. Metodos: estudio multicentrico retrospectivo en 79 pacientes con CU que iniciaron tratamiento con anti-TNF entre 2009 y 2015. El criterio de valoracion principal fue la remision clinica (indice pMayo ≤ 1) a los 12 meses. Asimismo, se analizaron la remision y respuesta clinica (indice pMayo final ≤ 3) y la retirada de corticoides a los tres, seis y 12 meses. Se realizo analisis para identificar las variables predictoras de respuesta clinica. Resultados: a los 12 meses, presento remision y respuesta clinica el 59,2 % y el 77,8 % de los pacientes, respectivamente. Se consiguio retirar los corticoides en el 82,4 % de los pacientes. A los 12 meses, la retirada de corticoides (< 3 meses) (OR 0,06; IC 95 %: 0,01-0,24) y la respuesta clinica a los seis meses (OR 0,008; IC 95 %: 0,001-0,053) fueron factores predictivos independientes de remision clinica. Conclusion: en pacientes con CU activa tratados con anti-TNF, la retirada de los corticoides en los primeros tres meses y la respuesta clinica a los seis meses de iniciado el tratamiento predicen la remision clinica de la enfermedad.

Bile duct brush cytology, intraductal biopsy and EUS-FNA are all used to characterize biliary strictures, with suboptimal sensitivity. Surgical resection without confirmed malignancy is undesirable. Cholangioscopy with targeted biopsies appears to increase the diagnostic yield in indeterminate biliary strictures, but it is still considered optional.

A 72-year-old man presented with acute cholangitis. He underwent endoscopic retrograde cholangiography (ERCP), which revealed a type IIIb Klatskin tumor. An 8.5-Fr, 12-cm plastic biliary stent was placed. Cholangiocarcinoma was confirmed cytologically and this was deemed unresectable. One month later, the patient presented with abdominal pain and cholestasis without peritoneal signs, fever, or leukocytosis. A computed tomography (CT) scan revealed that the stent had migrated and caused a duodenocolic fistulawithout any associated collection (●" Fig.1). Broadspectrum antibiotics were commenced and a repeat ERCP confirmed that the 8.5-Fr stent had perforated the duodenal wall (●" Fig.2a). The stent was retrieved with a foreign-body forceps. A punctate perforation was evident following removal of the stent (●" Fig.2b) and this was closed with a through-the-scope clip (●" Fig.2c). Cholangiography demonstrated left intrahepatic biliary dilatation and an uncovered biliary metal stent was implanted (●" Video1). The patient was discharged 3 days after the procedure. There are only three reported cases of duodenocolic fistula due to biliary stent migration [1–3]. The most common mechanism of perforation after biliary stent migration is direct contact [4]. Gastrointestinal perforations can be treated endoscopically with clip placement in acute or deferred presentation in patients where there are no signs of peritonitis [4, 5]. The over-the-scope clip has also been used to close duodenocolic fistulas secondary to a migrated biliary stent [6–8], though this is probably not required in chronic cases with small fistulas or perforations. Clinicians should be aware of the endoscopic management options in such cases, thereby avoiding the need for surgical intervention, even in the setting of colonic involvement. This is the first report of a patient who underwent endoscopic removal of the migrated biliary stent and closure of the fistula with a clip.