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Esophageal lichen planus (ELP) is a rare condition with unknown prevalence that can sometimes be underestimated due to the subtle and nonspecific findings of diagnostic workup. Oral lesions rarely extend to the esophageal mucosa, but when they do, the most frequent symptoms are dysphagia and odynophagia. There is often a significant delay in diagnosis and inadequate treatment. We report the case of a 59-year-old woman diagnosed with ELP, successfully treated with rituximab, a chimeric monoclonal antibody that depletes CD20+B cells. To our knowledge, this is only the second report of this treatment in ELP.

Celiac disease (CD) presents a wide clinical spectrum. There are asymptomatic or oligosymptomatic forms, which are difficult to diagnose. Since patients with untreated CD can develop severe complications, early diagnosis of these forms is important. Consequently, in groups at risk for CD, such as patients with type 1 diabetes (DM1), screening through determination of antigliadin (AGA), anti-tissue transglutaminase (ATG) and antiendomysial antibodies (EMA) is recommended. In the present study, 463 DM1 patients were screened for these antibodies. Patients who were positive for one or more were offered an upper endoscopy to obtain distal duodenum biopsies. Histological lesions, when present, were classified using Marsh's classification. Of the 463 patients, 62 (13.4%) were positive for at least one of the three antibodies, and 42 accepted to undergo an endoscopy. Fourteen patients (3% of the DM1 patients) were histologically diagnosed with CD. Most of these patients had no symptoms of CD, although some showed laboratory findings frequent in CD. The presence of clinical or analytical data compatible with CD was independent of the grade of histological lesions. Finally, we calculated the sensitivity and positive predictive value for each antibody. The most sensitive were ATG and EMA. Because of the technical simplicity of determining ATG with ELISA, in our opinion, this test should be the option of choice for screening.

Resumen Introduccion se discute la necesidad de efectuar sistematicamente una segunda gastroscopia de control tras el diagnostico inicial de una ulcera gastrica benigna. Metodo revisamos 226 casos consecutivos de ulcera gastrica. Analizamos la sensibilidad (S), la especificidad (E), el valor predictivo positivo y negativo (VPP, VPN) y la precision de la primera exploracion: gastroscopia con biopsias, de modo global y segun la experiencia del primer explorador (medico de plantilla o MIR). Comparamos la precision diagnostica entre la primera y la segunda endoscopia. Calculamos el numero necesario de segundas exploraciones (NNE) para diagnosticar un nuevo caso de ulcera maligna y su coste, tanto global como segun la experiencia del explorador. Resultados registramos 178 (79%) ulceras benignas y 48 (21%) malignas. La primera exploracion fue efectuada por un medico de plantilla (74%) y MIR (26%): S 87,2%, E 100%, VPP 100%, VPN 96,7% y precision 96,7%. La precision del medico de plantilla fue superior (98,2%) a la del MIR (94,8%) (p=0,18). La segunda exploracion de control tuvo una precision del 100%, mejorando significativamente a la primera (p=0,035) y diagnosticando 3 nuevos linfomas MALT y 3 carcinomas tratados con intencion curativa. El NNE y el coste de un nuevo diagnostico de lesion maligna fueron los siguientes: global, 37,3 (4.675 euros); medico de plantilla, 55,2 (6.845 euros), y MIR, 19,3 (2.393 euros). Conclusiones la primera exploracion obtuvo una elevada precision diagnostica, ligeramente menor para los MIR. La segunda endoscopia de control mejora significativamente los resultados, confirmando su beneficio clinico al diagnosticar lesiones malignas potencialmente curables. El coste medio de cada nuevo diagnostico de malignidad ascendio a 4.675 euros, siendo 3 veces inferior si la primera exploracion la efectua un medico con menos experiencia.

Resumen Objetivo Analizar la presencia de posibles rasgos diferenciales de la hemorragia digestiva alta (HDA) por lesion de Dieulafoy (LD), comparandola con el sangrado por ulcera gastroduodenal. Material y metodos Evaluamos los parametros referentes a las caracteristicas de los pacientes, de la hemorragia y de la gravedad clinica en 31 casos de hemorragia por LD y 31 por ulcera gastroduodenal. Se efectuo un analisis comparativo univarinate y multivariante entre ambos grupos. Resultados El indice de comorbilidad fue del 80% en LD y del 42% en la ulcera ( odds ratio [OR] = 5,54; intervalo de confianza del 95%, 1,5-20,7; p Conclusiones En la LD, la localizacion gastrica y el sangrado activo son hallazgos mas frecuentes que en el grupo ulceroso. El diagnostico de LD es mas dificil, ya que requiere un mayor numero de gastroscopias. La gravedad inicial de la hemorragia y el exito del tratamiento endoscopico sonsimilares en ambos grupos. La mayor mortalidad encontrada en las LD podria explicarse por la mayor comorbilidad de estos pacientes, con una peor tolerancia al sangrado.

A 90-year-old man was admitted to our hospital because of recurrent upper gastrointestinal bleeding due to a 5-cm gastrointestinal stromal tumor (GIST) in the lesser curve of the stomach (●" Fig.1). After conventional endoscopic sclerotherapy failed to achieve a response, and because of the patient’s condition, it was decided to perform endoscopic ultrasound (EUS)-guided therapy. The lesion was located at the lesser curve of the stomach; therefore, it was easily approached with the echoendoscope and punctured with a 20-gauge needle (Cook Ireland Ltd., Limerick, Ireland). This needle is specifically designed for celiac plexus neurolysis, and the multiple perforations at the tip allow better diffusion of the injected agent. The needle was placed in the middle of the lesion, and 1.5mL of 99% alcohol was injected (●" Fig.2). The original plan had been to inject the alcohol first in the middle of the lesion and then in the distal and proximal areas to ensure adequate therapeutic coverage. However, because excellent diffusion of the alcohol was observed along the entire lesion during the first injection, it was not placed in other areas. During a second-look endoscopy 1 week later, partial necrosis of the lesion was noted (●" Fig.3), and3months later, the tumor had practically disappeared (●" Fig.4). Only a slight, isolated thickening of the gastric folds was seen. During a follow-up of 3 years, no episodes of rebleeding occurred. Although the first-line treatment of GISTs is surgery, EUS-guided therapy can be considered because it has been demonstrated to be feasible and effective in selected cases. Complications resulting from the injection of alcohol in luminal and extraluminal gastrointestinal lesions, such as ulcerations in gastric lesions [1] and intratumoral hemorrhage and pancreatitis in hepatic and pancreatic lesions, have been described [2–5]. However, all reported cases were mild and responded to conservative therapy.

Esophageal lichen planus (ELP) is a rare condition with unknown prevalence that can sometimes be underestimated due to the subtle and nonspecific findings of diagnostic workup. Oral lesions rarely extend to the esophageal mucosa, but when they do, the most frequent symptoms are dysphagia and odynophagia. There is often a significant delay in diagnosis and inadequate treatment. We report the case of a 59-year-old woman diagnosed with ELP, successfully treated with rituximab, a chimeric monoclonal antibody that depletes CD20+B cells. To our knowledge, this is only the second report of this treatment in ELP.

Celiac disease (CD) presents a wide clinical spectrum. There are asymptomatic or oligosymptomatic forms, which are difficult to diagnose. Since patients with untreated CD can develop severe complications, early diagnosis of these forms is important. Consequently, in groups at risk for CD, such as patients with type 1 diabetes (DM1), screening through determination of antigliadin (AGA), anti-tissue transglutaminase (ATG) and antiendomysial antibodies (EMA) is recommended. In the present study, 463 DM1 patients were screened for these antibodies. Patients who were positive for one or more were offered an upper endoscopy to obtain distal duodenum biopsies. Histological lesions, when present, were classified using Marsh's classification. Of the 463 patients, 62 (13.4%) were positive for at least one of the three antibodies, and 42 accepted to undergo an endoscopy. Fourteen patients (3% of the DM1 patients) were histologically diagnosed with CD. Most of these patients had no symptoms of CD, although some showed laboratory findings frequent in CD. The presence of clinical or analytical data compatible with CD was independent of the grade of histological lesions. Finally, we calculated the sensitivity and positive predictive value for each antibody. The most sensitive were ATG and EMA. Because of the technical simplicity of determining ATG with ELISA, in our opinion, this test should be the option of choice for screening.

To analyze the possible differential features of upper gastrointestinal (GI) bleeding due to Dieulafoy's lesion (DL) compared with bleeding due to gastroduodenal ulcer.We evaluated variables associated with patient characteristics, hemorrhagic characteristics and clinical severity in 31 cases of bleeding secondary to DL and 31 cases of gastroduodenal ulcer bleeding. Univariate and multivariate statistical analysis were performed.The comorbidity rate was 80% in the DL group and 42% in the ulcer group (OR = 5.54; 95%CI, 1.5-20.7; p0.0004). Lesion location was gastric in 87% of DL versus 39% of ulcers (OR = 10.7; 95%CI, 2.6-47.6; p0.0003). More than one gastroscopy was required for diagnosis in 30% of DL vs. 3.2% of ulcers (OR = 12.9; 95%CI, 1.4-291; p0.01). Endoscopic treatment was required in 97% of DL and 39% of ulcers (OR = 47.5; 95%CI, 5.5-106.1; p0.0001). Active bleeding during endoscopy was registered in 81% of DL and in 29% of ulcers (OR = 10.2; 95%CI, 2.7-40.3; p0.0005). The remaining variables analyzed showed no significant differences. The mortality rate was 9.7% in the DL group and 3.2% in the ulcer group (p = NS). Multivariate analysis showed that gastric location (p0.01), active bleeding (p0.01), and comorbidity (p0.02) were more frequent in DL.Active bleeding and gastric location of the lesion were more frequent in the DL group than in the ulcer group. Diagnosis of DL is difficult, requiring a greater number of gastroscopies. Initial hemorrhage severity and the success rate of endoscopic treatment were similar in the two groups. The higher mortality found in DL can be explained by the greater comorbidity in these patients, with a worse bleeding tolerance.

We analyzed the need to routinely perform a second gastroscopy after an initial diagnosis of benign gastric ulcer.A total of 226 consecutive cases of gastric ulcer were reviewed. Sensitivity (S), specificity (Sp), positive and negative predictive value (PPV and NPV) and the accuracy of the initial gastroscopy plus biopsy were analyzed, both overall and according to the initial endoscopist's experience (attending or resident physician). The diagnostic accuracy of the initial and second-look gastroscopies was compared. The number of second endoscopies required to diagnose a new case of malignant gastric ulcer and their cost was calculated, both overall and according to the endoscopist's experience.There were 178 benign ulcers (79%) and 48 malignant ulcers (21%). The initial gastroscopy (S: 87.2%; Sp: 100%; PPV: 100%; PNV: 96.7%; accuracy: 96.7%) was performed by an attending physician in 74% of the patients and by a resident physician in the remaining 26%. Diagnostic accuracy was higher for attending physicians than for residents (98.2% vs. 94.8%; p=0.18). The accuracy of second-look endoscopy was 100%, with a significant improvement when compared with the initial procedure (p=0.035). Three new cases of MALT lymphoma and three new cases of gastric adenocarcinoma were diagnosed and could be treated with curative intent. The number of second gastroscopies required to diagnose a new case of malignant gastric ulcer and their economic cost was: 37.3 (4,675 Euros) for the whole group, 55.2 (6,845 Euros) for attending physicians and 19.3 (2,393 Euros) for residents.Initial gastroscopy showed high diagnostic accuracy, which was slightly lower when performed by resident physicians. Second-look gastroscopy significantly improved the results, confirming the clinical benefit of this procedure in diagnosing potentially curable malignant lesions. The mean cost of each new diagnosis of malignancy was 4,675 Euros, which was three times lower if the initial gastroscopy was performed by a less experienced endoscopist.