Fecha de publicación: 25 Octubre 2011
Cano-medel, C.; Ampuero, J.; Rojas-feria, M.; Millán-lorenzo, M.; Castro-fernández, M.; Romero-gómez, M.
VALME HOSPITAL, DIGESTIVE DISEASES SERVICE. SEVILLE.
To evaluate the prevalence of non perianal or entero-enteric fistulas in inflammatory bowel disease (IBD), the effectiveness of biological treatment and the need for surgical treatment.
A single-center, observational and retrospective study was carried out. It included information about 331 consecutive patients with IBD, 247 (74.8%) with Crohn's disease (CD) and 84 (25.2%) with ulcerative colitis (UC), collected from 2003. The average age at diagnosis was 31.7 ± 13.8 and follow-up lasted 10 ± 6.4 years. The percentage of patients were: 52% men and 48% female. The variables analyzed were: activity, size, pattern, smoking and drinking habit, family history, previous surgery, extraintestinal manifestations and previous treatment with biologic and immunomodulators therapies. Statistical methods: chi-square distribution and Kaplan-Meier.
35 patients (10.6%) developed non perianal or entero-enteric fistulas: 12 (3.6%) of them were enterocutaneous, 13 (3.9%) enterovesical, 8 (2.4%) rectovaginal and 1 (0.3%) cutaneous-vaginal. 23 patients (65.7%) received biological treatment (5 with adalimumab and 18 with infliximab), between 3 and 84 sessions. Complete response was obtained in 14 cases (60.9%), and 5 of them showed recurrence. 21 patients (60%) needed surgery, 4 of them after recurrence after treatment. A relationship was observed with the administration of biologic (p = 0.020) and immunomodulator (p = 0.044) therapies before the onset of the fistula. This association is corroborated by the survival analysis: biological (log rank 3.75, p = 0.05) and immunomodulator (log rank 3.73, p = 0.05) therapies.
The biological and immunomodulatory treatment prevents the development of enterocutaneous rectovaginal and enterovesical fistulas. The biological treatment achieved fistula closure in 61% of cases, although with a high recurrence rate. Larger cohorts are needed to establish a relationship with epidemiological variables.
Benítez Cantero, J.1; Jurado García, J.1; Hervás Molina, A.1; Pleguezuelo Navarro, M.1; Gómez Barbadillo, J.2; Villar Pastor, C.3; Rodríguez Perálvarez, M.1; Soto Escribano, P.1
1REINA SOFIA HOSPITAL, CLINICAL MANAGEMENT UNIT, GASTROENTEROLOGY SERVICE. CORDOVA 2REINA SOFIA HOSPITAL, GENERAL SURGERY SERVICE. CORDOVA 3REINA SOFIA HOSPITAL, ANATOMIC PATHOLOGY SERVICE. CORDOVA.
Analyzing patients from our hospital diagnosed with colorectal cancer as well as their epidemiology, diagnosis and approach.
A descriptive, observational, ambispective study was carried out including all patients diagnosed with colorectal adenocarcinoma (2007-2010). We collected demographic, clinical and therapeutic variables.
1048 patients were analyzed; their average age was 69.41 ± 11 and 64.2% of them were men. 33.1% came from primary care, 28.1% from the emergency service and 11.1% from the gastroenterology service. 69.9% of the cases were investigated by the gastroentergology service and 20.5% of them in the digestive surgery service; outpatient patients (58.5%), admitted patients (28.7%) and emergency patients (10.1%). The most frequent symptoms were: rectal bleeding in 32.5% of cases, change in bowel habits in 12.5% of cases, obstruction in 11.2% of cases and anemia in 10.4% of cases. Tumor location: colon (71.3%) and rectum (28.7%); greater sigma involvement (33.3%) and lower rectum (13.5%). 85.3% patients underwent an endoscopy and 3.1% had stents placed. Surgery was performed in 81.3% patients, 13.7% of them requiring it urgently. Postoperative histology: adenocarcinoma (94.9%), severe dysplasia (2.6%), no dysplasia (1.4%). Neoadjuvant therapy was performed in 14% patients, with an average duration of 51.88 days. 63.5% underwent postoperative chemotherapy, starting 31.6 ± 21 days after surgery. After the study, 66.5% patients were referred for surgery, 24.6% for oncology services and 4.3% for palliative care. Mean time from consultation until endoscopy was performed: 23.07 ± 20 days; anatomopathological result obtained 8.43 days later. Mean time from initial consultation until patients were referred to a service: 29.91 days.
Hospital records let you know the reality of colon adenocarcinoma in a tertiary hospital, as well as they let you know the degree of compliance with the multidisciplinary protocol and the periodic analysis of indicators.
Pérez-gisbert, J.1; Castro-fernández, M.2; Pérez-aisa, A.3; Cosme, A.4; Cabriada, J.5; Rodrigo, L.6; Gisbert, J.1; Lamas, E.2; Pabon, M.2; Marcos, S.1
1PRINCESA HOSPITAL. MADRID. 2VALME HOSPITAL. SEVILLE. 3COSTA DEL SOL HOSPITAL. MARBELLA.. 4DONOSTIA HOSPITAL. SAN SEBASTIAN. 5GALDAKAO HOSPITAL. BISCAY. 6ASTURIAS CENTRAL HOSPITAL.
Sometimes, infection with H. pylori persists despite 3 consecutive eradication treatments have been administered. It is unknown whether it is worth in terms of efficacy and safety to try a 4th line eradication therapy in these refractory cases.
To evaluate the efficacy and safety of a 4th rifabutin-based rescue treatment in patients who have previously suffered 3 eradication failures.
Design of the study: prospective multicenter study. Patients: consecutive patients who had failed initial treatment with a proton pump inhibitor (PPI) + clarithromycin + amoxicillin, a second treatment with a quadruple therapy (PPI + bismuth + tetracycline + metronidazole) and a third one with PPI + amoxicillin + levofloxacin. Exclusion criteria: patients who had previously underwent gastric surgery and allergy to any of the antibiotics listed. Approach: a fourth eradication treatment was administered consisting of rifabutin (150 mg/12 h), amoxicillin (1 g/12 h) and PPI (standard dose/12 h) for 10 days. All medicines were administered together after breakfast and dinner. Compliance was assessed by questioning. Outcome variable: H. pylori eradication was defined as obtaining a negative result in the 13C-urea breath test two months after treatment had finished.
The study included 87 patients (average age 51; 35% male, 37% with a peptic ulcer and 63% with functional dyspepsia). Seven patients did not take the medication correctly (6 due to adverse effects): fever, myalgia, abdominal pain and diarrhea (2 patients), vomiting (3 patients) and abdominal pain (1 patient). "Per protocol" and "intent to treat" eradication rates were 53% (95% CI = 41-64%) and 52% (95% CI = 41-62%), respectively. Adverse effects were described in 29 patients (34%), although none of them were considered severe ones: nausea/vomiting (12), abdominal pain (5), fever (5), diarrhea (4), myalgia (3), hypertransaminasemia (2), leukopenia (<1,500 neutrophils) (2), and thrombocytopenia (<150,000 platelets) (2). Myelotoxicity disappeared spontaneously after completion of treatment.
Even after the failure of the 3 previous eradication treatments, a fourth empirical rescue therapy with rifabutin may be effective to eradicate the H. pylori infection in about half of cases. The rifabutin-based "rescue" treatment is a good alternative after eradication therapy containing multiple key antibiotics such as amoxicillin, clarithromycin, metronidazole, tetracycline and levofloxacin have failed.
Rojas-feria, M.; Cano-medel, C.; Eslam, M.; Millán-lorenzo, M.; Ampuero, J.; Castro-fernández, M.; Romero-gómez, M.
To study the efficacy and safety of the treatment with infliximab (IFX) as monotherapy or in combination with thiopurines in inflammatory bowel disease (IBD).
Design of the study: a single-center, observational and retrospective study was carried out. Study Period: 2000-2010. Patients: 124 consecutive patients with IBD treated with IFX, 98 patients with Crohn's disease and 26 patients with ulcerative colitis. Average age: 31.3 ± 13.8. 71 (57%) men. They were classified according to the initial treatment received: IFX as monotherapy vs. IFX combined with azathioprine or mercaptopurine. All patients received three doses of induction therapy (0.2 and 6 weeks). Clinical response to treatment was evaluated during follow-up, being defined as significant improvement in symptoms and clinical remission defined by the absence of symptoms without requiring corticosteroids and/or surgery. We collected data related to the serious adverse effects to treatment. Results 102 patients received a combined treatment (IFX and thiopurines) and 22 patients were treated with IFX monotherapy. The treatment duration ranged between 3 and 89 months. Clinical response was observed in 75.4% of patients (77 cases) and clinical remission in 54.9% of patients (56 cases) with combined treatment and clinical response was observed in 59% of patients (13 cases) and clinical remission in 36.3% (8 cases) of patients treated with monotherapy (P = 0.001). Significant adverse effects were observed in 11% of patients. Infections were detected in 3.9% of patients with combined treatment and in 4.5% of those treated with IFX monotherapy (p = NS).
IBD patients treated with IFX and thiopurines had a higher rate of clinical response and clinical remission than patients treated with IFX monotherapy, without increasing the risk of side effects.
Peinado Caño, A.1; Fatela Cantillo, D.1; Domínguez Jiménez, J.2; Marín Moreno, M.2; Puente Gutiérrez, J.2; Díaz Iglesias, J.1; Fernández Suárez, A.1
1ALTO GUADALQUIVIR HOSPITAL, ANDUJAR, BIOTECHNOLOGY UNIT. JAEN. 2ALTO GUADALQUIVIR HOSPITAL, ANDUJAR, GASTROENTEROLOGY SERVICE. JAEN.
Determine the concentrations of fecal occult blood (FOB) in samples from patients with suspected colorectal cancer (CRC) in terms of diagnostic efficacy and comparison with a qualitative method.
Stool samples were collected in a consecutive way (from 2008 to 2010) from a cohort of patients who had clinical suspicion of CRC. The FOB was always quantified before diagnostic colonoscopies by the automated clinical analyzer OC-SENSOR μ (EIKEN CHEMICAL, Tokyo, Japan) and compared with the RAPID TEST qualitative method (BIMCLINIC, Barcelona, Spain).
169 patients were included in the study [average age 61.7 (range, 20-93), 52.7% women]. The CRC diagnosis was confirmed by the anatomic pathology in 42 cases. The rest of patients had polyps (29), benign digestive diseases (45), non-CRC neoplasms (5), non digestive diseases or diseases not related to tumors (4), or diseases that did not reveal any relevant pathology (44). The area under the ROC curve (95% confidence interval) was 0.898 (0.840 to 0.955); a cutoff of 102.00 ng/mL of FOB had a 78.6% sensitivity with a 89.8 % specificity. The FOB median (percentile 25-percentile 75) for the group with CRC, 1072.00 ng/mL (175.00 to 1436.00), was significantly higher (p <0.001) than in the other groups, except in the case of patients with ulcerative proctitis. The quantitative FOB improved in a 32.64% the positive predictive value (71.74% vs. 32.10% qualitative), the negative predictive value being similar in both methods (92.68% vs. 96.25%).
Specificity in the detection of CRC with respect to the qualitative method was significantly improved by the quantitative FOB.
García Caparrós, C.1; Rodríguez Perálvarez, M.1; García Sánchez, V.1; Gónzalez Ojeda, R.2; Benítez Cantero, J.1; Marín Pedrosa, S.1; Iglesias Flores, E.1; Muntane Relat, J.2; Gómez Camacho, F.1
1REINA SOFIA HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA 2REINA SOFIA HOSPITAL, EXPERIMENTAL LABORATORY. CORDOVA
To identify those plasma cytokines with independent prognostic value in patients with ulcerative colitis (UC).
Prospective study of 67 patients diagnosed with UC. When a patient was included, his/her disease activity was determined and a plasma sample was extracted and analyzed by Bio Plex Technology (Bio-Rad Laboratories, USA) by measuring IL1β, IL2, IL6, IL8, IL 10, IL13, IL17, IFNγ and TNFa. The median follow up of patients was 57 weeks (range 37-73). We used a multivariate Cox regression analysis to identify predictors of poor prognosis.
The average age was 43.3 ± 12 years and 42 of the patients (62.7%) were men. The extension of the disease was pancolitis in 31 patients (46.3%). During follow-up 15 patients (22.4%) relapsed. Corticosteroid dependence or corticosteroid refractoriness was developed in 15 cases (30%). Sixteen patients (27.1%) required the introduction of biological treatment during follow-up. Multivariate analysis showed that younger patients (RR = 0.93), with high concentrations of IL-1β (RR = 3.08) and low serum concentrations of TNFα (RR = 0.89), relapsed more often (p = 0.026, p = 0.022 and p = 0.027). Those patients included in the study with moderate to severe endoscopic disease, accompanied by high IL-8 and low concentrations of IL-10, had a higher risk of corticosteroid dependence or corticosteroid refractoriness (RR = 26.3/p = 0.01, RR = 1.78/p = 0.002 and RR = 0.92/p = 0.002). Finally, patients with severe histological lesions and elevated levels of IL-1β with low concentrations of IL-13 required biological treatment during follow-up (RR = 16.6/p = 0.007, RR = 3.85/p = 0.03 and RR = 0.72, p = 0.03).
In patients with UC, the combination of the clinical features of the disease and the cytokine serum profile may identify patients with poor prognosis.
Martín Ruiz, J.1; Selfa, A.1; López Segura, R.1; Caballero Morales, T.2; Entrala, C.3; Fernández Rosado, F.4; Alcázar Jaén, L.1; Salmerón, F.1
1SAN CECILIO CLINICAL AND UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE. GRANADA. 2SAN CECILIO CLINICAL AND UNIVERSITY HOSPITAL. ANATOMIC PATHOLOGY. GRANADA. 3LORGEN CENTRE. HEALTH-SCIENCES TECHNOLOGY PARK. GRANADA. 4LORGEN CENTRE. HEALTH-SCIENCES TECHNOLOGY PARK.
Lynch syndrome (LS) is an autosomal dominant hereditary CRC caused by germline mutations in DNA repair genes. It can be found by using personal/family history data (Amsterdam or Bethesda criteria), or using other algorithms such as the PREMM(1,2,6) model which estimates the individual probability of MMR mutation. In other patients, mutations are not detected. (CRC type X).
Assess the clinical utility/applicability.
A retrospective study (January 2009 - June 2011) of consecutive patients with suspected LS according to Bethesda criteria was carried out: the study included 7 patients with CRC and 32 first-degree relatives at risk (FR). The information collected was: personal data, family tree, tumor characteristics with immunohistochemical analysis of MMR protein expression. Amsterdam criteria and PREMM(1,2,6) model were applied in the study. For mutation analysis, DNA was extracted from peripheral blood leukocytes (Applied-Biosystems).
Six out of 7 patients with CRC were at > 5% risk, according to the PREMM model. Mutation was found in 5 of these 6 patients (MLH1 in 4 patients and MSH2 in the other patient). In first-degree relatives at risk, PREMM model ruled out 6 of the 32 patients selected according to Bethesda criteria. None of them showed mutation, found in 10 subjects: 7 in MLH1, one in MSH2 and 2 in MSH6. The Amsterdam criteria would have ruled out one patient suffering from CRC with MLH1 mutation and 7 first-degree relatives at risk (one with MLH1 mutation).
In our series the PREMM(1,2,6) model identifies individuals suffering from CRC or with cancer risk with equal sensitivity/specificity than a contrasted model (Bethesda) for possible MMR mutation, improving the PPV. The Amsterdam criteria have a lower sensitivity and lose patients associated (SL) or not (CRC-X) to identifiable mutations.
Fernandez-moreno, N.1; Fernandez-sanchez, F.2; Casado Caballero, F.3; Pallarés, H.4; Ramos Lora, M.4; Puente Gutierrez, J.5; Rodriguez Ramos, C.6; Naranjo Rodriguez, A.6; Hervás Molina, A.7; Gonzalez Galilea, Á.8; Montiel Quetzel, N.9; Navarro Jarabo, J.10
1COSTA DEL SOL HEALTH AGENCY. GASTROENTEROLOGY SERVICE. MARBELLA. 2COSTA DEL SOL HEALTH AGENCY. MICROBIOLOGY UNIT. MARBELLA. 3SAN CECILIO CLINICAL HOSPITAL. GASTROENTEROLOGY SERVICE. GRANADA. 4JUAN RAMÓN JIMÉNEZ HOSPITAL. GASTROENTEROLOGY SERVICE. HUELVA 5ALTO GUADALQUIVIR HOSPITAL, ANDUJAR, GASTROENTEROLOGY SERVICE. JAEN. 6PUERTA DEL MAR HOSPITAL. GASTROENTEROLOGY SERVICE. CADIZ.. 7REINA SOFIA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA. 8REINA SOFIA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA. 9COSTA DEL SOL HEALTH AGENCY. MICROBIOLOGY UNIT. MARBELLA. 10COSTA DEL SOL HEALTH AGENCY. GASTROENTEROLOGY SERVICE AND CIBERESP. MARBELLA.
The effective eradication of Helicobacter pylori (HP) infection is conditioned by the HP development of resistance to antibiotics commonly used to remove it. In our region there is very little information available on the prevalence of this phenomenon, as the estimated value (10%) of primary resistance to clarithromycin comes from very old and local studies.
To determine the prevalence of HP primary resistance to clarithromycin and quinolones in our region. This study shows the preliminary results.
Prevalence, multicenter study, covering almost all of the Andalusian territory. The subjects in the study are naïve patients from Andalusia, from whom antrum and body samples were taken. These were processed for determination by CRP of mutations that confer resistance to clarithromycin and quinolones.
From our preliminary results we obtained a rate of primary resistance to clarithromycin of 21%, higher than the previously reported rates in our region. The rate of fluoroquinolone resistance is 14%, similar to that described in other surrounding countries. If these data are confirmed at the end of the study, the eradicating efficacy according to the OCA pattern should be closer monitored as Maastricht III does not advice using clarithromycin in areas with a prevalence of primary resistance higher than 20%.
Soto Escribano, P.1; García Sánchez, V.2; Iglesias Flores, E.2; Jurado García, J.2; González Galilea, Á.2; Gómez Camacho, F.2
1REINA SOFIA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA 2REINA SOFIA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA
Ferric carboxymaltose (FCM) has demonstrated to be effective and safe in the treatment of iron deficiency anemia, but there are few data on its short-term efficacy and on its impact on the quality of life (QOL) in patients with Inflammatory Bowel Disease (IBD).
Describing the response to treatment with FCM, as well as its safety and impact on QoL of patients with IBD and iron deficiency anemia.
The study included 30 patients with IBD and iron deficiency anemia who were indicated to have FCM between May 2010 and May 2011. Their response was evaluated one month after the treatment started and the rise of ≥ 2g/dl baseline hemoglobin (Hb) was taken as a therapeutic response to the treatment. The impact on the patients' QoL was assessed using the IBDQ-9 questionnaire one month before and after the treatment. Side effects were recorded by means of a telephone survey one week after the start of the treatment. Results The average age was 38.6 years (± 14.3), 63.3% (19) of the patients had Crohn's disease, and the rest ulcerative colitis. 80% (24) of the patients responded one month after the start of the treatment with a mean difference in Hb of 2.2 (95% CI 2.7 to 1.8 p <0.05). The IBDQ-9 questionnaires carried out before and after the treatment showed a significant improvement in the patients' QoL with an average difference of 6.1 (95% CI 8.6 to 3.5 p <0.05). Side effects appeared in 13.3% (4) of the patients being mild.
The FCM is effective and safe in the treatment of iron deficiency anemia associated with IBD and an early response is achieved improving the QoL of our patients.
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