Fecha de publicación: 25 Octubre 2011
Benítez Rodríguez, B.; Vazquez Moron, J.; Nuñez Sousa, C.; Pallares Manrique, H.; Ramos Lora, M.
JUAN RAMÓN JIMENEZ GENERAL HOSPITAL, GASTROENTEROLOGY SERVICE. HUELVA
Gastric adenocarcinoma is the most common malignant neoplasm of the digestive tract after colorectal cancer and it is the second leading cause of death from malignant neoplasms in the world after lung cancer.
In severe acute pancreatitis with infected pancreatic necrosis, the therapeutic strategy is controversial. Surgery is the classical indication in these cases, however, there are other less invasive options which have gained importance in recent years. In this series we present the results of using percutaneous drainage in this disease.
A descriptive, observational, retrospective study of 143 patients diagnosed with gastric adenocarcinoma was carried out in our hospital between January 2002 and December 2010 in which we analyzed demographic variables (age, sex, year of diagnosis), histological variables, location, risk factors, symptoms and the stage of neoplasm at diagnosis.
The number of total cases per year was: 6, 8, 23, 8, 18, 19, 18, 15, 28 (the incidence varies from 6-28) from 2002 to 2010 respectively. Gender distribution was: 70% men and 30% women. The average age at diagnosis was 69 (35-92).The main symptoms described were: abdominal pain in 70% of cases, weight loss in 65% of cases, anorexia in 60% of cases, asthenia in 50% of cases, vomiting in 40% of cases, gastrointestinal bleeding in 35% of cases and dysphagia in 15% of cases; Types of injury: tumor in 50% of cases, ulcer in 40% of cases, diffuse lesions in 7% of cases and polyps in 3% of cases. Location of the disease: 25% in the upper third, 28% in the middle third, 40% in the lower third, and 7% diffuse; Histological type: 73% intestinal and 27% diffuse. Risk factors: 70% smoking, 35% drinking, 20% diabetes. Laboratory findings: anemia in 80% of cases, tumor markers (40% high, 28% normal and 32% not determined). TNM stage at diagnosis: 8% IA, 11% IB, 12% II, 18% IIIA, 7% IIIB, 44% IV.
We observed a higher rate of gastric adenocarcinoma in male smokers between the sixth and seventh decades of life, abdominal pain and weight loss being amongst the most common symptoms, both of them found late in order to have been able to make an early diagnosis; anemia was the most commonly observed problem in the laboratory and the one that could have allowed us to make an earlier diagnosis. The lower third (of the antrum and pylorus) was the main location of the disease, primarily present as a tumor or ulcer. The most common histological type for the disease was the intestinal one. There has been a slight increase in cases in recent years and it seems that they are being detected at earlier stages.
López Segura, R.; Selfa Muñoz, A.; Ruiz Escolano, E.; Alcázar Jaén, L.; Barrientos Delgado, A.; García, R.; Salmerón, J.
SAN CECILIO UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE. GRANADA.
Gastroscopy is the gold standard for dyspepsia with no improvement n its symptoms after empirical treatment, but its high prevalence, cost, risk, etc., made ICP for dyspepsia to emerge in order to speed up the diagnostic and therapeutic process.
Assess whether gastroscopy is performed in less than 30 days when there is no response to treatment. Check if patients received information regarding the treatment plan, testing, and consent form.
Self-audit. Criteria/indicators/standards: from the ICP (figure 1). Dimensions: display adequacy, accessibility, safety, continuity of care. Indicator: Process. Population: 43 patients randomly chosen (reference: 220 patients) diagnosed from 1/1/10 to 12/31/10 at the San Cecilio University Hospital. Variables: qualitative-dichotomous. Source: Archinet. Results 55.8% of patients who did not response to treatment underwent a gastroscopy, CI (95%) ± 0.15. 83.3% of patients had the gastroscopy performed in less than 30 days, CI (95%) ± 0.11. 95.8% of patients signed the consent form, CI (95%) ± 0.06. 59.5% had a report written for Primary Care (PC), CI (95%) ± 0.15.
The study showed higher values in the rates of compliance in terms of the short time required to perform the gastroscopy once requested and after the consent form had been signed. However, it showed lower values in the rates related to the request for a gastroscopy and to writing the report. The established standard was only achieved by part of the the issues under discussion.
González Artacho, C.; Matas Cobos, A.; Ojeda Hinojosa, M.; Redondo Cerezo, E.; de Teresa Galván, J.
VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. GRANADA.
Percutaneous endoscopic gastrostomy (PEG) is the method of choice for long-term enteral feeding when dealing with patients with a functioning gastrointestinal tract. Its mainly indicated for patients who, for several reasons, are unable to swallow. It is advisable to make a proper selection of patients, because this is a complicated technique with ethical implications.
Describe the characteristics, progression, complications and mortality of the patients who underwent an endoscopic gastrostomy in our hospital.
Patients undergoing this procedure were examined from February 2009 to July 2011. The following variables were analyzed: age, sex, indications, complications, mortality and duration. We conducted a retrospective observational study and we used the statistical software SPSS-18.
We examined a total of 68 patients (51.5% men) whose average age was 63.72 ± 19.94. The main indications were: dementia in 25% of the cases, head and neck neoplasms in 19%, strokes in 11.8%, demyelinating diseases in 8.8%, anoxic encephalopathy in 7.4%, repeat aspiration pneumonia in 7.4%, and Parkinson's disease in 5.9%.Complications occurred in 4 patients (5.9% of the cases): three cases of wound infections and one case of self-limited bleeding. The nutritional treatment duration was 12.68 ± 11.68 months. In 7.3% of the cases PEG was transient, with a median duration of 5 months. Early delayed mortality (not always related to the per se procedure) was 4.4%, i.e. 3 patients, 2 of them early.
- Percutaneous endoscopic gastrostomy is a safe endoscopic technique, with 5.9% incidence of complications in our unit.
- The main indications in our area were dementia and head and neck neoplasms.
STANDARD CRITERIA INDICATORS All patients with dyspepsia and no response to treatment* shall be subjected to diagnostic gastroscopy within a reasonable time. 90% of patients not responding to empirical treatment undergoing endoscopy / total number of patients with dyspepsia and no response to empirical treatment x 100 90% of endoscopies with less than 30 days delay after the Gastroenterology Service had requested the gastroscopy / Total number of endoscopies x 100 Before undergoing a gastroscopy, all patients shall sign the consent form after being informed
100% of patients undergoing a gastroscopy with signed consent form / Total number of dyspeptic patients with gastroscopy x 100 All patients examined in the Gastroenterology Service shall receive a report for the family physician with the actions to follow, the procedures performed ... 100% of patients examined in the Gastroenterology Service with a report for primary care / Total number of dyspeptic patients examined in the Gastroenterology Service x 100
- The mortality was of 4.4% of the cases, a value lower than that reported in other series (8.2 to 32.8%).
Martín-lagos Maldonado, A.1; Martinez Tirado, M.1; Alcázar Jaén, L.1; Selfa Muñoz, A.1; Florido García, M.1; Salmerón Escobar, F.2
1SAN CECILIO CLINICAL AND UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE. GRANADA. 2SAN CECILIO CLINICAL AND UNIVERSITY HOSPITAL. GRANADA.
Reviewing the frequency, complications and treatment of bezoars that required hospitalization in adults.
Observational, descriptive, retrospective study using the data collected from 1992 to 2010 belonging to the database of our hospital.
36 patients required hospitalization due to phytobezoars. 77.8% of the patients had some contributory factors, being gastrointestinal surgery the most prevalent one. The most common symptoms were intestinal obstruction (69.4%) and abdominal pain (19.4%) and there was only one death case due to perforation. Most phytobezoars were located in the small bowel (61.1%), mainly in the terminal ileum. Surgical treatment was necessary in 23 cases. The rest of cases was resolved with conservative measures or with endoscopy.
Bezoar formation is uncommon in healthy individuals, and there is a history of surgery in 54-80% of cases. We identified 9 cases of patients who had undergone Billroth II, 7 cases of adhesions, 3 vagotomies and 1 bariatric surgery. Conservative treatment with coca-cola, n-acetylcysteine and prokinetics was effective in 11 patients; 2 patients needed endoscopic treatment; cases of intestinal obstruction, and one case that did not respond to medical treatment required surgery.
Phytobezoars shall be included in the differential diagnosis of intestinal obstruction, especially if there is a history of gastric surgery. Conservative treatment is effective in most patients, except in cases with complications.
Alcalde Vargas, A.; Leo Carnerero, E.; Herrera, J.; Márquez Galán, J.
VIRGEN DEL ROCIO UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. SEVILLE.
To describe the gastrointestinal involvement clinical and endoscopic manifestations, seeking differential data.
Retrospective study of 35 patients with intestinal amyloidosis diagnosed between 1989-2009. Hepatic involvement was considered to be taking place if there was an alteration in the results of the liver biochemical testing after ruling out other etiologies, dismissing biopsy due to high risk of bleeding.
The average age was 55.6. Sexes were equally distributed. There was prevalence of secondary amyloidosis (AA, n20) against primary (AL, n13), and there were two cases of hemodialysis related amyloidosis. The most common gastrointestinal symptom was diarrhea in (n19) alternating bowel habits (n10) and abdominal pain (n9). There were frequent extraintestinal manifestations, mainly renal (in 24 patients) and elevation of cholestasis enzymes in 8 patients (3 with hepatomegaly). Poor prognosis was conditioned by renal failure. Of the 17 patients studied until 2000, 9 died within 4 years. Of those patients diagnosed later, 11/18 died with a median survival of 32 months. The rectosigmoidoscopy did not show alterations in 53% of the patients. 7 patients showed endoscopic appearance with superimposed inflammatory bowel disease (IBD), all them with amyloid deposition in the mucosa. The rest (8) showed to have nonspecific alterations. Oral endoscopy showed normal appearance in 8/17 cases and nonspecific in the rest.
- Nonspecific clinical and endoscopic results that make imperative a high degree of suspicion. A differential diagnosis with IBD must be performed when amyloid is deposited in mucosa.
- It should be included in the differential diagnosis of patients with diarrhea and abdominal pain, especially if they have renal failure and rheumatologic involvement.
- Poor prognosis was conditioned by kidney failure.
Garcia, M.; Nuñez, C.; Vázquez, J.; Casado, P.; Cabanillas, M.; Pallarés, H.; Ramos, M.
JUAN RAMÓN JIMENEZ HOSPITAL. GASTROENTEROLOGY SERVICE. HUELVA.
To analyze the epidemiological characteristics of signet ring cell carcinoma of the stomach in our hospital area.
Descriptive, transversal and retrospective study. We selected the cases of patients at our hospital area between September 2002 and December 2010 with signet ring cell carcinoma of the stomach. After reviewing the medical records the following data were collected: sex, age at diagnosis, date, smoking and drinking habits, neoplasm location, tumor stage. Results 45 cases of SRC carcinoma were analyzed (64.4% men; average age at diagnosis was 65). 20 samples were from endoscopic biopsy and 25 from surgical specimens. 2010 was the year with most cases recorded (24.4%), followed by 2006 (17.8%). 31.1% of the patients had been smokers and 8.9% of them drinkers; 4.4% of the patients had a history of peptic disease. The most common location of the SRC carcinoma was the gastric body (48.9%) and the antrum (26.7%), appearing in other areas much less frequently. 30 cases (66.6%) were diagnosed with tumor stage IV. In those cases in which surgery was performed (55.6%), total gastrectomy was the technique most frequently used (56%).
SRC carcinoma is uncommonly diagnosed in our area, being middle-aged men the patients who more frequently suffer from this disease. The smoking history present in a high percentage of patients was the only probable risk factor related. Diagnosis at an advanced stage is common, not being possible a curative treatment.
González Artacho, C.; Matas Cobos, A.; Martos Ruíz, V.; Ruízcabello Jiménez, M.; de Teresa Galván, J.
The normal tone of the lower esophageal sphincter (LES) is considered to be ≤ 30 mmHg, and many authors consider the sphincter to have a hypertonic tone only when it is > 40 mmHg.
To analyze the characteristics of our patients with an increased tone of the LES.
We reviewed the case of patients, from 2002 to 2011, in which we found increased tone of the LES. We conducted a retrospective descriptive study and using the statistical software SPSS-18.
47 patients with LES tone > 30 mmHg were found. This meant an incidence of 1.2/100000 inhabitants, although in the last 3 years it was 2.3/100000 inhabitants, probably by the increased in examinations. The average age of the patients was 52.3. 72.3% of the patients were women and 27.7% of them men. The average tone was 41.2 mmHg, the average length of the LES was 4.5 cm and sphincter relaxation was normal in 89% of the cases. 51.1% of the patients showed typical clinical manifestations for gastroesophageal reflux disease (GERD), 42.6% dysphagia to liquids and/or solids, 23.4% retrosternal chest pain and 14.9% spontaneous retrosternal oppressive pain. Endoscopy was normal in 14 patients; an hiatal hernia was found in 8 patients, esophagitis in 3, Schatzki ring in 3, suspected hypertonic cardia in 6 and suspected motor disorder in 5. PH monitoring was performed in 21 patients showing pathological acid reflux in 8 cases: four with typical clinical manifestations for GERD and three with typical clinical manifestations for GERD and pain; four with LES tone between 31-40 mmHg and four with LES tone > 40 mmHg.
- An hypertonic lower esophageal sphincter is a rare primary motor disorder of the esophagus.
- It is usually diagnosed in middle aged patients, with female predominance in the cases.
- GERD was usually clinically related to dysphagia and/or chest pain.
Alcalde Vargas, A.; Leo Carnerero, E.; Trigo Salado, C.; de La Cruz Ramírez, M.; Herrera, J.; Márquez Galán, J.
To determine the percentage of patients with inflammatory bowel disease (IBD) in maintenance therapy with IFX requiring intensification, response to the intensification and influencing factors.
Retrospective analysis of records of patients with IBD in maintenance therapy with IFX, excluding those who only have been treated with an induction therapy. This study analyzes the IBD type, the phenotypic characteristics, the indication of biological therapy (luminal or perianal disease in CD and severe outbreak or corticosteroid dependence in UC), duration of the disease, concomitant treatment before and at the time of intensification, type of intensification (dose intensification or shortening of dose intervals), time of intensification, response to intensification and consequent approach (suspension, maintenance of the intensified dose, return to a standard dose). Intensification was considered to have failed if IFX treatment was suspended (due to adalimumab or surgery) or if the patient required steroids. Results 122 patients were included in the study out of the 143 patients initially chosen (21 were ruled out as they were only treated with induction therapy); their average age was 31.2; CD was the prevalent disease (72% CD vs 28% UC); from the moment IBD was diagnosed follow-up lasted 64 months. 24 patients (19.7%) required treatment intensification. In all patients the approach followed was to shorten the intervals, to an average of 6.2 weeks, 21.5 months after the patient had started treatment with IFX; no influential factor under study was found. 75% of the patients responded to treatment intensification after 16.8 months of follow-up post-intensification and from these, seven (29.5%) could return to their initial treatment, whereas twelve (50%) remained following the intensification treatment and in five (20.9%) treatment failed despite being intensified.
Rodriguez Sicilia, M.1; Garcia Escaño, M.2; Benitez Rodriguez, B.3; Zafra Jimenez, C.2; Robles Olid, J.2
1VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. GRANADA. 2INFANTA MARGARITA HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA 3JUAN RAMÓN JIMENEZ HOSPITAL, GASTROENTEROLOGY SERVICE. HUELVA.
Eosinophilic esophagitis (EE) is an emerging disease.
To analyze the clinical manifestations and the treatment response.
The patients included in this study were those with EE histology in esophageal biopsies in the last 10 years treated at the Infanta Margarita Hospital. The variables analyzed were age, sex, clinical manifestations, endoscopic findings, treatment and response.
19 cases of EE. 89% of the patients were men; the average age of the patients was 38.Symptoms: 53% of the patients with dysphagia and 37% with food impaction. Endoscopy: 47.5% of the patients showed a ringed esophagus, 21% striation, 16% showed normal results, 10.5% showed erosions and 5% fibrous rings.Treatment: fluticasone + omeprazole was used in 47.5% of the cases, fluticasone in 5%, prednisone + omeprazole in 16%, prednisone + fluticasone in 5% and no treatment was used in 21% of the cases. 74% of the patients were asymptomatic and 5% of them showed recurrence.
EE cases are more common in young men. Dysphagia and food bolus impaction are the most frequent symptoms. Esophageal biopsies shall be taken in these patients. Fluticasone seems to be a good 1st choice treatment.
Ojeda Hinojosa, M.; Martos Ruiz, V.; González Artacho, C.; Redondo Cerezo, E.; de Teresa Galván, J.
Primary pancreatic lymphoma is a rare disease, constituting only 1% of extranodal lymphomas and 0.5% of all pancreatic masses. This type of pancreatic tumor is clinically difficult to differentiate from pancreas adenocarcinoma without the aid of anatomic pathology. Due to the different prognosis of both diseases, the correct diagnosis is essential.
54 year old man with a history of renal transplantation in 2005 and smoking habit was admitted to our service after finding a mass at epigastric level. The results of the laboratory tests showed an LDH value of 1065 and a CRP value of 3.During admission, the patient underwent an abdominal CT scan that showed "a large heterogeneous mass that respects the pancreatic head and invades the rest of the gland. The mass consists of two lobes, a 84 x 68 mm one at tail level, and a 85 x 84 mm one crossed by blood vessels, splenic and hepatic artery. " Subsequently, the patient had a linear endoscopic ultrasonography performed that showed a "large heterogeneous mass of neoplastic appearance occupying almost the entire pancreas. Adenopathies suspicious for malignancy were found in station 9, aortopulmonary window and station 2L." FNA of the lesion was performed with the cytopathologist support "in situ". Later, a "large cell B lymphoma" was described by the anatomopathological report. It was compatible with monomorphic post-transplant lymphoproliferative disorder of B-cell origin." In our case, we wanted to stress the role of endoscopic ultrasonography in the diagnosis of these tumors and, if possible, supported by cytopathologists.
Heredia Carrasco, C.1; Matas Cobos, A.1; González Artacho, C.1; López de Hierro Ruiz, M.2
1VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE; 2VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL. GRANADA.
The tubercle bacillus can affect any tract of the digestive tract although it rarely affects the rectum. Endoscopic findings are variable (circumferential anal stenosis, mass, ...) and it is indistinguishable from neoplasms or inflammatory bowel disease. Diagnosis is difficult when there is no ileocecal involvement.
52 year old man with a history of pulmonary sarcoidosis, active smoking and alcohol intake. He had been suffering 10-12 semisoft liquid diarrheal stools, constitutional symptoms and fever for a year. The physical examination showed unremarkable results except for a 3 cm painless hepatomegaly. Colonoscopy: a circumferential mammillated vegetating lesion was observed at 10 cm from the anal margin, narrowing the lumen and preventing progression (figure 1). Biopsies were taken (nonspecific granulation tissue, negative for malignancy). Immunosuppressive therapy was initiated for suspected pulmonary and intestinal sarcoidosis. Two months later he was admitted to our service because of the persistence of the clinical manifestations. Mantoux skin test: positive. Sputum culture: development of Mycobacterium tuberculosis complex. Colonoscopy: biopsies taken for histology and culture, and development of Mycobacterium tuberculosis complex. Once the (pulmonary and intestinal) disseminated tuberculosis was confirmed, tuberculostatic treatment was started. Discussion Intestinal tuberculosis can occur secondary to pulmonary focus or rarely in isolation. The most common affected part is the ileocecal region, with ulcerative (60% of the cases), hypertrophic (10% of the cases) or ulcerohypertrophic (30% of the cases) pattern. Medical treatment is preferred, surgery being used only for persistent stenosis; it is difficult to rule out neoplasms or possible complications. Balloon dilation is safe for short-length fibrous stenosis.
Rodriguez Sicilia, M.1; Garcia Escaño, M.2; Benitez Rodriguez, B.3; Zafra Jimenez, C.4; Robles Olid, J.2
1VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. GRANADA. 2INFANTA MARGARITA HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA 3JUAN RAMÓN JIMENEZ HOSPITAL, GASTROENTEROLOGY SERVICE. HUELVA. 4INFANTA MARGARITA HOSPITAL. CORDOVA
Microscopic colitis (MC) encompasses two diseases: lymphocytic colitis (LC) and collagenous colitis (CC). It is considered a low frequency disease. New data suggest that it is relatively common.
To estimate the prevalence of LC and CC in biopsies from colonoscopies performed during the study of chronic diarrhea. To analyze clinical and epidemiological characteristics of patients diagnosed with MC.
We included all patients with chronic diarrhea who underwent normal colonoscopy with biopsies to rule out MC. The patients included in this study were those with histological diagnosis of CM between January 2001 and January 2011 treated at the Gastroenterology Service of the Infanta Margarita Hospital. Population at risk: 162904 inhabitants. Variables analyzed: age, sex, presence and type of colitis, concomitant colonic injuries, full examination, ileoscopy and clinical manifestations.
432 colonoscopies were included. 56 patients were diagnosed with MC (12.96%); 75% of the patients were women; their average age was 57. Prevalence: LC (27.01%) and CC (7.37%). Prevalence in the population at risk: 34.38%. Complete colonoscopy: 91.07% of the total number of sick patients. Clinical manifestations: diarrhea (96.4%), weight loss (19.6%), rectal bleeding (9%). Conclusions MC occurs mainly in middle-aged women, more frequently than LC. Watery diarrhea is the main symptom, followed by weight loss. We found a higher prevalence of MC in relation to a study performed in our hospital over a period of 4 years in which the prevalence obtained was: MC 15.7%, LC 12.6% and CC 4.6%. The increase in prevalence appears to be caused by the fact that this pathology is more present in the differential diagnosis of watery diarrhea, getting an increase in the number of diagnosed cases.
López Segura, R.; Martínez Tirado, P.; Selfa Muñoz, A.; Martínlagos Maldonado, A.; Florido García, M.; Salmerón, J.
To analyze the effect of the biological treatment and the characteristics of patients treated with it (2006-2010).
Patients and approaches
This retrospective observational descriptive study included 58 patients, whose average age was 39 years (17-66) (60% of the patients were men).
69% of the patients had Crohn's disease (CD): 17 with the stricturing type, 4 with the penetrating type and 19 with neither non stricturing nor penetrating type, related or unrelated to perianal disease. 31% of the patients suffered from ulcerative colitis (UC): 8 from left-sided colitis, and 10 from extensive colitis. Biological treatment response: 63% of the patients did not respond to treatment and/or showed adverse effects to immunomodulators, 30% of the patients showed extraintestinal involvement and 7% of the patients needed bridging therapy. Infliximab was administered to 46 patients (16 with UC and 30 with CD) and adalimumab to 12 patients (10 with CD, and 2 with UC). The anti-TNF therapy was effective in 79% (46/58) of the cases, with no significant differences between adalimumab/infliximab (p = 0.6) (figure 1). Loss of response took place in 24% of the cases (14/58), with no significant differences between them (p = 0.7) (figure 2). 28% of the cases showed adverse effects, without differences between adalimumab/infliximab (p = 0.3) (figure 3).
In our sample, the failure/contraindication of the immunomodulatory therapy was the main indication for the treatment of patients with the biological therapy (63% of the cases). Anti-TNF therapy was effective in 70% of the cases and loss of response took place in 40% of the cases. In our sample we found better efficiency data and a lower percentage of loss of response (79% of the patients responded to treatment regardless of the type used and 30% of the patients did not respond). In our area, adalimumab/infliximab have proved to be equally effective and safe.
AUTHORS: SILVIA PATRICIA ORTEGA MOYA, ALFREDO LLOMPART RIGO, SAM KHORRAMI MINAEI, JAIME GAYÁ CANTALLOPS Ortega Moya, S.
SON ESPASES HOSPITAL, GASTROENTEROLOGY SERVICE. MALLORCA
A bezoar is a concretion of indigestible material retained in the digestive tract. Its duodenal impaction is a rare cause of high intestinal obstruction. We present the case of a phytobezoar impaction in the duodenum.
66 year old man who was admitted to the emergency services due to 48 hours duration abdominal pain and vomiting. Personal history: vagotomy with pyloroplasty. Physical examination: abdominal distention with mass felt with palpation in epigastrium and rumbling. Normal blood count and biochemical testing results. Plain abdominal radiography showed gastric retention. A nasogastric tube was used and an abdominal CT scan was performed showing a few centimeters long speckled endoluminal mass with air bubbles inside, suggesting bezoar impacted in the distal part of the second duodenal portion (Figure 1). Gastroscopy was performed showing a pyloric stenosis. The impacted phytobezoar was located in the distal part of the second portion of the duodenum completely occluding the lumen. We proceeded to its disimpaction, first by snare polipectomy (Boston Cientific ®, France) and later with a polyp retriever (U.S. Endoscopy ®, USA) without success, as it was not possible to bind it by its periphery (Figure 2). Then, we proceeded to bore a hole in the center of the phytobezoar with the tip of the snare passing a stone extractor balloon (Cook ®, Ireland) without probe or fluoroscopic guidance. Once the balloon was inflated to the medium diameter, it was pulled gently to disimpact the bezoar. Finally, it was broken with the snare and the duodenum was examined, without observing stenosis or other mucosal lesions. The patient was discharged 24 hours later.
Gastrointestinal bezoars are a rare disorder of the digestive tract. Bezoars can be can be classified as phytobezoars and trichobezoars (1-3). Several factors contribute to their formation such as: an excessive intake of food rich in fiber, poor mastication and anatomical or functional alterations. In a series of 56 cases, 84% of the patients had had surgery previously, most of them truncal vagotomy with pyloroplasty (3 patients). Impaction of a bezoar is an indication for an emergency endoscopy. Early endoscopic treatment reduces the need for surgery, complications, hospital stay, morbidity, mortality and costs (4.5). Therapeutic success depends on the experience, ability and adaptive capacity of the endoscopist, as there is no algorithm or guide. Figure 1: CT image showing gastric retention and a bezoar impacted in the second portion of the duodenum. Figure 2: Failure in the disimpaction maneuver of the bezoar located in the duodenum with a polyp retriever.
Marín Pedrosa, S.
REINA SOFIA HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA
To determine the diagnostic value in our area of ambulatory pH monitoring in patients with symptoms attributed to gastroesophageal reflux and without esophagitis findings after UE.
Retrospective study including 82 patients with a clinical diagnosis of gastroesophageal reflux without esophagitis after UE. Patients underwent 24-hour ambulatory pH monitoring with a one-channel probe using conventional techniques. Demographic data and data relating to the De Meester score, total symptoms and symptoms at pH<4 were recorded in an Access database and analyzed using the SPSS statistical software.
The average age of the patients under study was 44.8 years (+/- 15), 58.5% being women. The diagnosis obtained was normal in 59.8% of patients, mild reflux in 20.7% of patients, moderate reflux in 17% of patients and severe reflux in 2.4% of patients. During examination, symptoms appeared in 45.1% of patients and symptoms at pH<4 in 26.8% of patients, the symptomatic index being significant in 59.1% of the latter.
Gastroesophageal reflux could be observed through pH monitoring in 1 out of every 3 patients with symptoms of GERD without esophagitis, with differences between men and women. This made us think that, besides acid reflux, other factors such as visceral hypersensitivity may also affect this pathology.
Gastroesophageal reflux, pH monitoring, esophagitis.
Matas Cobos, A.; González Artacho, C.; Martos Ruíz, V.; Cabello Tapia, M.; Gómez García, R.; de Teresa Galván, J.
Oral iron therapy is sometimes insufficient and poorly tolerated in patients with IBD and iron deficiency anemia. The intravenous iron is a good way to increase treatment adherence and to improve its outcomes.
To evaluate the efficacy of intravenous iron treatment in patients with IBD and chronic anemia refractory to oral iron therapy.
Retrospective observational study in which we evaluated patients with iron deficiency anemia refractory to oral iron therapy and patients with IBD treated with intravenous iron in our service. The variables analyzed were hemoglobin, iron, MCV and ferritin before and after infusions. Data were analyzed using SPSS-15.0. Results 52 patients with IBD and iron deficiency anemia had been treated with intravenous iron (45 with iron sucrose and 7 with ferric carboxymaltose). A statistically significant increase (p <0.001) of hemoglobin (from 9.3 to 12.1 mg/dl and from 9.4 to 12.4 mg/dl) and ferritin values (from 12.4 μg/L to 43.5 μg/L and from 11 μg/L to 86.3 μg/L, respectively) could be observed. The average number of infusions required in the iron sucrose group was 11.6. The average number in the ferric carboxymaltose group was only 3.1. The only adverse effect observed was gastrointestinal intolerance in one patient treated with iron sucrose.
Intravenous iron treatment is effective and safe in patients with iron deficiency anemia and IBD. Ferric carboxymaltose got better results with fewer infusions than iron sucrose, but a larger sample size is required to confirm these results.
Rincón Gatica, A.; Araujo Míguez, M.; Pizarro Moreno, A.
We present two cases of patients with chronic actinic proctitis with transfusion requirements and failure of endoscopic treatment that got benefited from treatment with thalidomide seeking to stop the bleeding.
The two cases were an 80 year old man diagnosed with prostate adenocarcinoma treated with radiotherapy and a 63 year old woman with a history of stage IV cervical neoplasia. Both patients were treated with pelvic radiotherapy and in the two following years they suffered from episodes of substantial rectal bleeding. Both patients were diagnosed with actinic proctitis secondary to radiotherapy. In both patients, rectal bleeding was classified as grade IV, in need of transfusion support; it was refractory to endoscopic treatment with argon plasma coagulation (APC) underwent in several sessions and oral iron supplements. For this reason, thalidomide was indicated as the treatment for both patients: 100 mg every 24 hours in the first case and 100 mg every 12 hours in the second case. Treatment with intravenous iron was also indicated achieving in both cases to stop the bleeding. Both patients suffered from side effects of the medicine: a toxic neuropathy and non thrombotic edema in lower limbs. None of them suffered again from bleedings and hemoglobin remained stable in both patients after a follow-up carried out for over one year.
Thalidomide may be an effective treatment option in patients with severe actinic proctitis refractory to other treatments, in combination with them. The duration of the effects in our patients could be due to the combination with endoscopic therapy.
Benítez Rodríguez, B.1; Osuna Molina, R.1; Rodríguez Sicilia, M.2; Pallarés Manrique, H.1; Ramos Lora, M.1
1JUAN RAMÓN JIMENEZ GENERAL HOSPITAL, GASTROENTEROLOGY SERVICE. HUELVA. HUELVA. 2VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. GRANADA.
Oral iron therapy is sometimes insufficient and poorly tolerated in patients with IBD and iron deficiency anemia. Intravenous iron is a good way to increase treatment adherence and to improve its outcomes.
Ischemic colitis is an underestimated entity as it is oligosymptomatic and not very specific in guiding physicians towards a diagnosis despite being the most common cause of intestinal ischemia (incidence in our population of 16-20 cases/100000 inhabitants). The present study analyzed the demographic characteristics, the clinical manifestations and the utility of colonoscopy in patients diagnosed with ischemic colitis in our center as well as the change of therapeutic approach when it is diagnosed.
Retrospective study of 12 patients diagnosed with ischemic colitis by colonoscopy and biopsy during the period from June 2010 to June 2011. The variables analyzed were age, sex, reason for examination, cardiovascular risk factors, grade of ischemia, change in therapeutic approach, treatment and development.
The average age of our patients was 70.25 ± 15.2 with a higher incidence in women compared to men (66.7% women and 33.3% men). The related risk factors were hypertension (66.7% of cases), history of previous cardiovascular accident (33.3% of cases), smoking (33.3% of cases), diabetes mellitus (33.3% of cases), previous history of abdominal surgery (16.7 % of cases). The most common reason for performing the colonoscopy was rectal bleeding (83.3% of cases), followed by abdominal pain (63.7% of cases), constipation (50% of cases) and fever (33.3% of cases). Colonoscopy was performed urgently in 33.3% of cases. Colonoscopy allowed a change in the therapeutic approach in 66.7% of cases, urgent colonoscopies increasing to 75%. The overall mortality was 17.6%. Severe ischemic colitis occurred in only one of 12 cases (8.3%) which resulted in the death of the patient. The rest of cases were mild to moderate ones without requiring surgical treatment as patients progressed well with the appropriate conservative medical treatment, decreasing the requirement for surgery (5%, p <0.05). Conclusions Ischemic colitis is a pathology that usually appears with rectal bleeding and abdominal pain in patients with cardiovascular risk factors, drawing attention in our review the previous history of abdominal surgery for various reasons (previous surgery for intestinal pseudo-obstruction in one of the patients, surgery for peptic ulcer in another patient). It is more common in older aged patients, being more common in women. Colonoscopy allows to confirm the diagnosis, assess the severity and especially induces a change in the therapeutic approach as the result of performing it. It allows adequate and early medical treatment, a good progression of symptoms with a conservative medical treatment, and surgery remains needed in severe cases only.
Fernández Cano, F.1; Moreno García, A.1; Pérez Aisa, A.1; López Vega, M.1; Rosales Zabal, J.1; Rivas, F.2; Fernández Pérez, F.1; Méndez Sánchez, I.1; Navarro Jarabo, J.1
1COSTA DEL SOL HOSPITAL. GASTROENTEROLOGY SERVICE. MALAGA 2COSTA DEL SOL HOSPITAL. RESEARCH SUPPORT UNIT. MALAGA
The Small Intestine Bacterial Overgrowth (SIBO) has a range of symptoms present in many situations. Among its symptoms we can find: abdominal distension and pain, dermatitis, joint manifestations, liver disorders and fat malabsorption, among others.
To analyze the clinical situations in which we have used the bacterial overgrowth test with measurement of exhaled air.
Of a total of 220 glucose hydrogen breath test for the diagnosis of SIBO performed at our center between January 2008 and December 2010, a random sample (by sequential record number) of 170 tests performed in 122 patients was selected. We discuss the symptoms for which the test was performed. Those with positive results in the tests underwent rifaximin antibiotic treatment.
25 out of 122 patients were diagnosed with SIBO. We analyzed the following indications: -Difficult to control irritable bowel syndrome: 44 patients (36.06%). The test showed positive results in 2 cases (4.54% of those with irritable bowel syndrome and 1.64% of the total). There was no history of surgery.
-Crohn's disease, with unsatisfactory evolution not justifiable by the activity of the disease: 20 patients (16.39%). 6 cases had a history of intestinal resection surgery (30% of those with Crohn's disease and 4.92% of the total). The SIBO test was positive in 1 case (5% of those with Crohn's disease and 0.82% of the total) and that case also had a history of surgery. -Participation in the nutritional status of patients with gastric resection surgery and/or duodenal ulcer: 32 patients (26.23%). 4 gastrectomy cases (12.5% of the group), 2 duodenopancreatectomy cases (6.25%), 20 Y-Roux cases (66.25%), 4 Billroth cases (12.5% of the group), 1 gastroduodenostomy case (3.125%) and 1 esophageal tubulization case (3.125%). The test was positive in 16 cases (50% of patients with previous surgery and 13.11% of total). -Patients with liver disease: 31 patients (25.41%). The test was positive in 6 cases (19.35% of the group and 4.92% of the total). 3 of them had had previous surgery.
SIBO was present in different clinical situations. We believe it is appropriate to think in this situation and make the hydrogen breath test, since it could result in an affordable treatment; its diagnostic test is easily performed, safe, reproducible and it has affordable costs.
Martos-ruiz, V.; Ojeda Hinojosa, M.; González Artacho, C.; Matas Cobos, A.; Redondo Cerezo, E.; de Teresa Galván, J.
-15 year old patient without a significant medical history. The patient did not follow any treatment nor did he take drugs. She was attended at the digestive service of the outpatient clinic for 2 year long diarrhea with nonspecific stool findings, which sometimes occurred at night accompanied by epigastric pain. She had no fever. She had suffered an unquantified weight loss. Examination: sensitive depressible soft abdomen in epigastrium where a smooth "gummy" mass could be felt, with normal bowel sounds. She had no ascites. The patient underwent an abdominal ultrasound scan that showed a bezoar. Abdomen X-ray: gastric chamber occupied by a breadcrumb alike mass. Upper endoscopy: giant trichobezoar in gastric chamber impossible to remove endoscopically. The patient recognized hair intake when feeling very stressed. She was referred to the mental health and general surgery services. At the general surgery services the patient underwent a supraumbilical midline laparotomy, a longitudinal gastrostomy at the anterior gastric wall and a large trichobezoar of about 10x6 cm was removed.
- Trichobezoars occur mainly in young women with psychiatric disorders, trichotillomania/trichophagia preceding their appearance. - They are usually discovered incidentally.
- Trichobezoars can appear as a mass or filling defects when X-ray, CT scan or barium transit are performed.
- Surgical removal should be considered in patients in whom medical-endoscopic therapy has failed or if there is significant bleeding or obstruction.
Ojeda Hinojosa, M.; Martos Ruiz, V.; Matas Cobos, A.; Redondo Cerezo, E.; de Teresa Galván, J.
In patients undergoing liver transplantation biliary complications are a major cause of morbidity and mortality. With this study we analyze the incidence of biliary complications, and factors related to survival in these patients.
This is a retrospective descriptive study of a cohort of 187 patients who underwent liver transplantation between 2002 and 2010. We used SPSS 18.0 for statistical calculations and significance was considered to be p <0.05.
During the study period, 190 liver transplants were performed in 187 patients. The most frequent complication was extrahepatic biliary stricture (13.4%). The average time for the symptoms to show up was 12.73 months. 46.2% of cases had vascular complications related, hepatic artery stenosis being the most frequent one (29.6%). Complications were mostly treated by means of ERCP (24%). In the survival analysis (Kaplan-Meier), the median survival in patients with biliary complications without vascular problems was 82.96 ± 2.98 months, versus 60.38 ± 9.51 in patients with vascular problems, resulting in a statistically significant difference (p = 0.01) (Log-rank test, Figure 1). There were no statistically significant differences in survival when comparing the type of biliary complication (p = 0.58), the primary cause of transplant (p = 0.841), the Child-Pugh stage (p = 0.828), or the type of therapeutic intervention (p = 0.845).
Biliary complications are responsible for high morbidity and mortality (14.9% of patients died or underwent a retransplantation). Anomalies of the hepatic artery is a factor directly related to the survival of the transplantation.
Rodriguez-oballe, J.1; Arroyo-martinez, Q.2; de Sola-romero, M.2; Rodriguez-téllez, M.2; Gómez-parra, M.2; Pellicerbautista, F.2; Herrerias Gutierrez, J.2; Caunedo-alvarez, A.2
1VIRGEN MACARENA UNIVERSITY HOSPITAL, CLINICAL MANAGEMENT UNIT , GASTROENTEROLOGY SERVICE. SEVILLE. 2VIRGEN MACARENA UNIVERSITY HOSPITAL, CLINICAL MANAGEMENT UNIT , GASTROENTEROLOGY SERVICE. SEVILLE.
Several authors have described in recent years a decrease in the effectiveness of the eradication of H. Pylori with the classical OCA triple therapy (omeprazole, clarithromycin and amoxicillin, administered during 7 to 10 days). There is no data available in relation to the current eradication rate in our area, so that in designing this study our goal was to know that eradication rate in our hospital area.
This is a retrospective study which reviewed all the C13 urea breath test for the detection of H. pylori performed in dyspeptic patients treated with eradication therapy and previously diagnosed with infection by serology, breath test, rapid urease test or histology, in the period between June 2010 and June 2011 in our hospital area. Demographic data and treatment regimen were obtained from the review of medical records. Student's t-distribution test and Chi-square tests were used for the statistical analysis of the variables under consideration. Results A total of 276 dyspeptic patients (56.04% women, age: 48.84 ± 13.85) infected with H. pylori were reviewed, of whom 267 patients (96.73%) were treated with OCA and 9 (3.27%) with OLA (omeprazole, levofloxacin and amoxicillin). Of all patients treated with OCA, 203 patients (76.02%) had negative results in the verification test and 64 patients (23.98%) had positive results in it; 9 of the patients treated with OLA, (100%) had negative results in the verification test. No differences were observed in the eradication rates in both sexes (women 116/153, 75.82% vs. men 96/123, 78.05%, p = 0.66). Although the efficacy of eradication was lower in older aged groups, this difference did not reach statistical significance (Table 1).
The success rate for eradication of H. pylori with classic triple therapy in dyspeptic patients is 76.02% in our area. We believe that this fact justifies the design of large studies to determine the causes in the decline of the effectiveness of this treatment and whether or not to recommend other eradication patterns.
Rosales Zábal, J.1; Pérez Aisa, Á.1; López Vega, M.1; Fernández Cano, F.1; Romero Ordoñez, M.1; Rivera Irigoín, R.1; Rivas Ruiz, F.2; Navarro Jarabo, J.1; Sánchez Cantos, A.1
1COSTA DEL SOL HEALTH AGENCY. GASTROENTEROLOGY SERVICE. MARBELLA; 2COSTA DEL SOL HEALTH AGENCY. RESEARCH SUPPORT UNIT. MARBELLA. MALAGA.
Barrett's esophagus represents the most severe manifestation of gastroesophageal reflux diseases (GERD) within the clinical spectrum. Several factors have been associated with the development of Barrett's esophagus, including the decrease in body motility and the decrease of the lower esophageal sphincter (LES) pressure, which may increase acid exposure.
To determine whether the presence of Barrett's esophagus is relate to a higher incidence of esophageal motility and to a higher acid exposure.
Retrospective analysis of patients with symptomatic GERD who underwent an esophageal manometric study and 24-hour ambulatory pH monitoring at the Costa del Sol Health Agency. Patients were classified into three groups for their analysis based on endoscopic data: Barrett's esophagus (confirmed histologically), non erosive esophagitis and erosive esophagitis without Barrett's esophagus. Results 228 individuals, 39 (17.1%) with Barrett's esophagus, 151 (66.2%) with non erosive esophagitis and 38 (16.6%) with erosive esophagitis without Barrett's esophagus. Barrett's esophagus is 3 times more frequent in men (p <0.001). Hiatal hernia is more frequent in erosive esophagitis and in Barrett's esophagus (p <0.001). We found no relation between BMI and the presence of Barrett's esophagus (p = 0.655). 12.5% of patients suffering from Barrett's esophagus had a normal LES tone, compared to 36.7% of patients who showed a severe hypotonia (p = 0.051). There is no relationship between the hypomotility of the esophageal body and the presence of Barrett's esophagus (p = 0.446). Barrett's esophagus and erosive esophagitis are related to more severe acid exposure, particularly to mixed forms of severe GERD (p = 0.007) and with a higher percentage of acid exposure time and with a higher DeMeester score (p <0.001).
Our results are consistent with the literature on Barrett's relationship with disorders caused by LES hypotonia, with being a man and with the presence of a higher acid exposure. However, no significant relation was found with peristaltic disorders of the esophageal body or with obesity.
Rosales Zábal, J.1; Pérez Aisa, Á.1; López Vega, M.1; Fernández Cano, F.1; Romero Ordoñez, M.1; Rivera Irigoín, R.1; Navarro Jarabo, J.1; Rivas Ruiz, F.2; Sánchez Cantos, A.1
To analyze manometric pH monitoring data in a cohort of patients with symptoms of gastroesophageal reflux disease.
Retrospective analysis of 228 individuals with symptomatic GERD who underwent an esophageal manometric study and a 24-hour ambulatory pH monitoring. The variables recorded were age, sex, body mass index (BMI), presence or absence of hiatal hernia, endoscopic data, esophageal body motility, lower esophageal sphincter (LES) tone and the values from the pH monitoring.
108 men (47.4%), 120 women (52.6%). Average age: 48.73 ± 14.52. 166 patients with hiatal hernia (72.8%). BMI: 2 patients considered to be slim (0.9%), 78 normal patients (34.2%), 95 overweight patients (41.7%), 53 obese patients (23.2%). Endoscopy: 151 (66.2%) non-erosive esophagitis, 22 (9.6%) esophagitis grade I, 13 (5.7%) esophagitis grade II, 3 (1.3%) esophagitis grade III, 39 (17.1%) esophagitis grade IV-Barrett's esophagus. Esophageal manometry: 140 (61.4%) normal, 88 (38.6%) hypomotility. LES tone: 112 (49.1%) normal, 116 (50.9%) hypotonia. Gastroesophageal reflux: 66 (28.9%) physiological, 64 (28.1%) severe mixed. Time (%) pH <4: 8.8 ± 9.1 minutes. DeMeester: 35.5 ± 33.7.
Gastroesophageal reflux disease is related to the presence of hiatal hernia and obesity. Contrary to expectations, we did not appreciate a higher prevalence of esophageal body motility disorders or hypotonia of the LES in GERD. Likewise, although it is common to find acid reflux disease, the most severe forms occur with the same frequency as the physiological reflux.
Benitez Rodriguez, B.; Nuñez Sousa, C.; García Esteban, M.; Pallares Manrique, H.; Ramos Lora, M.
JUAN RAMÓN JIMENEZ GENERAL HOSPITAL, GASTROENTEROLOGY SERVICE. HUELVA.
To assess the relationship between the histological grade of cirrhosis and the existing data on abdominal ultrasound in patients with known chronic liver disease of diverse etiology.
Descriptive, retrospective, observational study which included a total of 15 patients with chronic liver disease followed up in our hepatology unit from January 2010 to January 2011 who had undergone a liver biopsy and an abdominal ultrasound during the same period of time. The inclusion criteria taken into account were: age (patients older than 18), known and diagnosed chronic liver disease of diverse etiology (viral, alcoholic, autoimmune, cryptogenic), abdominal ultrasound performed by the same experienced radiologist, histology performed by the same experienced anatomopathologist.
The study included 15 patients, 9 men and 6 women, aged between 26 and 71 (average age 48). The etiology was chronic HCV infection in 10 patients (66.7%), autoimmune hepatitis in 4 patients (26.7%) and hemochromatosis in 1 patient (6.7%). One ultrasound showed normal results in 12 of the 15 patients, with the following Knodell index values: 5, 9, 9, 8, 10, 11, 6, 8, 7, 9, 11 (average of 7.75), compared with another ultrasound that showed typical signs of chronic liver disease in 2 of the 15 patients, in which the Knodell histology activity index was 4 and 7, respectively (average of 5.5; p <0.05).
Liver biopsy has proved to be more specific than ultrasound in detecting fibrosis in the liver parenchyma. Although this study is limited by the low number of patients, we found it interesting to compare the results with those obtained with FibroScan, with a view to early diagnosis of liver fibrosis with non-invasive methods.
León Montañés, R.1; Alcalde Vargas, A.2; Gutierrez Domingo, I.2
1VIRGEN DEL ROCIO HOSPITAL, HEPATOLOGY UNIT; 2VIRGEN DEL ROCIO HOSPITAL, HEPATOLOGY UNIT. SEVILLE.
Over 96% of patients with cirrhosis may be carbohydrate intolerant, and up to 25-30% may be clinically diabetic. In the presence of liver disease, the homeostasis of glucose metabolism is altered as a result of disorders such as insulin resistance, carbohydrate intolerance and diabetes. According to the liver cirrhosis etiology, the DM prevalence varies; literature describes a DM increase in patients with alcoholic liver disease, NASH, HCV and hemochromatosis.
The aim of this study was to determine the prevalence of diabetes mellitus in pre-liver transplantation cirrhotic patients, identifying the types of liver cirrhosis most often associated with diabetes mellitus.
Cross-sectional observational study or prevalence study. The study included 514 patients admitted with liver cirrhosis at the Virgen del Rocio University Hospital from 2002-2010, to undergo a study before liver transplantation was performed. The study patients admitted to the hospital lived in the area Seville and Huelva. Statistical analysis: descriptive statistical analysis of study variables. Chi-square test or Fischer's exact test was performed when necessary for qualitative variables. The Mann-Whitney U-test was performed for quantitative variables according to the two study groups. A bivariate and multivariate logistic regression were performed. Results The study included 457 patients, 100 women (21.9%) and 357 men (78.1%). The average age was 54.43 ± 8.53. Our study shows a 23.4% prevalence of type 2 diabetes mellitus in patients with cirrhosis, much higher than that observed in adult population without liver disease (10-15%). We found no relationship between HCV and DM, as we have found an OR in the bivariate analysis of 0.379 (95% CI: 0.221-0.652) with p <0.001 and OR in the multivariate analysis of 0.453 (95% CI: 0.249-0.823) with p <0.009. In our study, HCV appears to be a protective factor against diabetes mellitus. NASH was related to DM, since 15 patients had DM, and only 1 did not (OR 56.902, CI 95%: 7.49-436.403, p <0.001). An association between NASH and an increase in BMI in diabetic patients has also been demonstrated (median of the group not suffering from DM: 27.35; median of the group suffering from DM: 30.35) and it has also been demonstrated statistically (p <0.002).We have not found an statistically significant relation between alcoholic cirrhosis and the presence of DM (OR 0.806, CI 95%: 0.522-1.246, p <0.332). Nor have we found a statistically significant relation in cirrhosis due to HBV, secondary biliary cirrhosis and autoimmune hepatitis (AIH) (see Table 2). We found no relation between cryptogenic cirrhosis and diabetes mellitus, behaving as a risk factor for the development of the latter (OR 3.406, CI 95%: 1.075-10.790, p <0.037). PBC behaves as a protective factor for DM, as only 1 from the 17 patients had DM (OR 0.197, CI 95%: 0.026-1.503 p <0.117).
It is possible to confirm that the prevalence of DM increases in patients with liver cirrhosis. There is a variety of etiologies more often related to the appearance of DM.In our study, due to variables not included that may act as confounding factors (family history, hepatocellular carcinoma), we have only been able to demonstrate an increased incidence of DM in NASH and cryptogenic cirrhosis.
Ortiz, N.1; García-muñoz, B.2; Borraz, Y.3; Robles, M.2; Castiella, A.4; Fernández, M.5; Pérez-álvarez, R.6; Blanco, S.7; Ávila, S.8; Lucena, M.2; Andrade, R.2
1XANIT BENALMADENA HOSPITAL; 2VIRGEN DE LA VICTORIA HOSPITAL; 3NETWORKING BIOMEDICAL RESEARCH CENTRE IN LIVER AND DIGESTIVE DISEASES, CIBEREHD. 4MENDARO HOSPITAL; 5TORRECARDENAS HOSPITAL; 6ASTURIAS CENTRAL HOSPITAL; 7BASURTO HOSPITAL; 8XERAL-CALDE HOSPITAL.
Toxic liver disease is a relatively rare adverse reaction to drugs but potentially serious. There are few data on the impact of DILI in patients with previous liver disease.
We identified the liver toxicity cases from the Spanish Registry which met the criteria for underlying liver disease and we analyzed their demographic characteristics, the clinical expression of the hepatotoxicity and causation compared with patients selected also from the Spanish Registry without pre-existing liver disease. Causality assessment was carried out by clinical judgement based on chronological criteria, exclusion of alternative causes and then by applying RUCAM scale.
22 (3.7%) out of the 602 patients included in the Spanish Liver Toxicity Registry from April 1994 to December 2006 showed to have pre-existing liver disease (11 cases of chronic viral hepatitis, 5 cases of cirrhosis, 3 cases of autoimmune hepatitis, 2 cases of alcoholic cirrhosis and 2 cases of cryptogenic cirrhosis). Antibiotics in 5 cases (22.7%), amoxicillin-clavulanate in 2 cases and anti-TB drugs (13.6%) were the drugs involved. No differences were found between patients with and without pre-existing liver disease with respect to demographic variables, clinical manifestations and severity of injury (see Table). In addition, causality assessment using the RUCAM scale classified both groups of patients in similar probability categories.
The underlying liver disease does not imply a particular DILI phenotype or more severity nor it affects the assessment of causality and shall not be considered as a criterion for excluding patients in hepatotoxicity databases.
Mercedes Norberto, R.; Leo Carnerero, E.; Alcivar Vasquez, J.; Ciria Bru, V.; de La Cruz Ramirez, M.; Herrera Justiniano, J.; Marquez Galan, J.
VIRGEN DEL ROCIO UNIVERSITY HOSPITAL, CLINICAL MANAGEMENT UNIT, GASTROENTEROLOGY SERVICE. SEVILLE.
Knowing the side effects (SE) of azathioprine (AZA) in patients with inflammatory bowel disease (IBD) in our area, as well as the differences between Crohn's disease (CD) and ulcerative colitis (UC).
Retrospective study of 332 patients with IBD (264 with CD and 63 with UC) treated with AZA. We analyzed the side effects and the need to stop treatment, depending on the type of IBD, TPMT activity and NOD2/CARD15 mutations. We used Student's t test for quantitative variables and Chi-square test for qualitative variables.
31.9% (106/332) of patients had some SE, requiring to stop treatment in 74 cases (69.8% of patients with SE and 22.2% of the total patients under treatment). No differences between CD and UC were found. The most frequent SE are the following: leukopenia (28 cases), gastrointestinal intolerance (24), acute pancreatitis (19) and liver toxicity (16), with similar results in patients with CD and UC cases, except that the 19 cases of pancreatitis occur in CD (7.2% in CD vs 0% in UC). No relation was found with TPMT activity (dose of AZA adjusted to enzyme activity). NOD2/CARD15 mutations were not related to SE caused by AZA in CD (25.7% vs 39.7% in patients without mutations).
SE caused by AZA in IBD are often cause for discontinuing treatment permanently. There are no differences according to the IBD type, although in our series acute pancreatitis only occurred in CD cases for unexplained reasons, finding no relationship with NOD2 mutations or with the TPMT activity.
Leo Carnerero, E.; Ciria Bru, V.; Trigo Salado, C.; Rojas Mercedes, N.; Herrera Justiniano, J.; Marquez Galan, J.
Determine whether there are differences in TPMT enzyme activity in patients with Crohn's disease (CD) and ulcerative colitis (UC).
Retrospective descriptive study of 205 patients with inflammatory bowel disease (161 cases with CD, 41 cases with UC and 3 cases with an unclassified colitis). This study analyzes IBD characteristics and TPMT activity, quantifying and grouping patients in groups with low activity (<5 U/ml), intermediate activity (5 to 13.7) or high (> 13.7). NOD2 mutations were also determined in some of the patients with CD, assessing its relationship with the said enzymatic activity. Quantitative variables were compared using the T-student method and qualitative variables with chi-square distribution.
The TPMT mean value is 18.5 U/ml, with no significant differences between CD (18.4) and UC (19.0). We found no patients with low activity, 35 (17.1%) with intermediate and 170 (82.9%) with high activity, and there was no difference in the type of disease. We found a higher percentage of patients with intermediate activity between CD patients with NOD2 mutations (36.4 vs 16.3%, p 0.06), but the mean value is similar in both groups.
The percentage of patients with intermediate activity is somewhat higher than that described in the literature. We found no differences in TPMT enzyme activity in patients with CD and UC, so the controls to be performed are similar. A larger number of patients did show an intermediate activity with CD and NOD2 mutations, although more studies are needed to confirm that this subgroup of patients has lower enzyme activity.
Cotta Rebollo, J.1; López Vega, M.2; Toscano Castilla, E.2; Lozano Lanagrán, M.2; Rosón Rodríguez, P.3
1MALAGA QUIRON HOSPITAL, GASTROENTEROLOGY SERVICE; 2MALAGA QUIRON HOSPITAL, GASTROENTEROLOGY SERVICE; 2MALAGA QUIRON HOSPITAL, HEAD OF THE GASTROENTEROLOGY SERVICE;
This study shows a case of acute fatty liver of pregnancy (AFLP). The incidence is 1/6000-15000 pregnancies, usually during the third trimester, although there are cases described in the second trimester and in the post-partum period. It consists of a microvesicular fatty infiltration of the liver that triggers an acute liver failure. It is related to high maternal and fetal morbidity and mortality, so early diagnosis and treatment are vital.
38 +4 weeks primigravida woman, with twin pregnancy, who was 27 years old. Family history: mother with chronic hepatitis C and maternal aunt with "liver disease" during pregnancy. The patient was admitted twice previously for risk for preterm labor, undergoing tocolysis and fetal lung maturity. She had a five-day history of nausea, vomiting and abdominal pain, being admitted due to prodromal labor. In previous laboratory tests she showed an isolated mild elevation of alkaline phosphatase (455 U/L, normal <300) and 60.4% prothrombin activity (normal 70-110%) one month before the current episode. Results of the laboratory tests before classical cesarean: 13630 leukocytes, 32.1% prothrombin activity, 83 glucose, 494 GOT (normal <40), 700 GPT (normal <40), 74 GGT (normal <76), 1925 alkaline phosphatase (normal < 300). Torpid evolution with uterine atony solved with misoprostol, however she was taken to an ICU. During the following hours she suffered a progressive clinical deterioration, with grade I encephalopathy, hypoglycemia requiring treatment with 10% dextrose, metabolic acidosis, hypokalemia, polyuria, polydipsia, and anemia and hypoprothrombinemia requiring red blood cells and plasma transfusions. Differential diagnosis of HELLP syndrome (absence of thrombocytopenia, proteinuria and arterial hypertension). The patient underwent a liver doppler ultrasound that did not show any liver disorders and the only remarkable images obtained were a bilateral renal pelvicalyceal ectasia and an abdominal wall hematoma in the incision area. Serological testing was negative for hepatotropic viruses, as well as it was negative for autoimmune hepatitis and genetic testing for LCHAD deficiency (LCHAD: Long Chain Hydroxyacyl-CoA dehydrogenase). The patient was referred to a referral center for liver transplantation, being transferred to our hospital due to improvement after 72h, where she recovered with conservative treatment. The genetic testing for LCHAD deficiency was negative.
The AFLP etiology is unknown. A relationship was observed with a genetic disorder in the metabolism of long chain fatty acids (fetus homozygous for LCHAD deficiency with heterozygous mother carrying the fetus). It is a liver disease that takes place during pregnancy that occurs preferentially in the third trimester, associated with twin pregnancies in young and primiparous mothers. The disease may lead to an acute liver failure with a fatal outcome, so an early diagnosis and an appropriate management in a unit that provides advanced support and liver transplantation are very important. Recurrence in future pregnancies is common in cases with LCHAD deficiency.
Martos-ruiz, V.; Ojeda Hinojosa, M.; González Artacho, C.; Matas Cobos, A.; Nogueras López, F.
To analyze the death cases occurred during the 9 years of the liver transplantation program at our hospital.
Among the death cases studied, various parameters, like the following, have been selected: age, sex, indication for transplantation, MELD score and Child-Pugh score at the moment of transplantation, time elapsed since the completion of surgery until death occurred, and causes of death. The cumulative percentage of deaths was calculated at 6 months, 1 and 5 years after transplantation.
The percentage of patients who died out of the 219 transplanted patients analyzed was 29.76%. The main indications for transplantation were HCV cirrhosis in 39% of cases, alcoholic cirrhosis in 26% of cases and hepatocellular carcinoma in 15% of cases. The average MELD score at transplantation was 17.17. The cumulative percentage of deaths at 6 months, 1 and 5 years was 43%, 59% and 90% respectively. The most frequent causes of death were recurrent HCV (17.5% of cases). The intraoperative mortality represented 10.9% of death cases.
The most common cause of death in patients was the recurrence of liver disease. 59% of death cases occurred the first year after transplantation.
Tercero Lozano, M.; García Robles, A.; del Castillo Codes, I.; Gordo Ruíz, M.; Padilla Ávila, F.; Baeyens Cabrera, E.
CIUDAD DE JAEN HOSPITAL. GASTROENTEROLOGY SERVICE.
Acute necrotizing esophagitis (ANE), also called "black esophagus" is a rare entity with multifactorial pathogenic mechanism whose etiology is unknown; it is related to ischemic compromise, obstruction of the upper digestive tract and malnutrition. It was described by Goldenberg in 1990.
Since 2009 there have diagnosed two cases of ENA in our center. Case 1: 80 years old man with a history of ischemic heart disease, diabetes mellitus, hypertension and COPD who was admitted because of melena with hemodynamic effects, requiring 4 transfusions of packed red blood cells. Laboratory test results: Hb 4 g/dl, hematocrit 12.2%, 20730 leukocytes with 88.1% PMN, Urea 90, Crea 1.90. Urgent gastroscopy: black esophageal mucosa, friable to the touch, continuously affecting almost the entire esophagus, respecting the gastroesophageal junction (Fig. 1). Anatomic pathology: severe mucosal and submucosal necrosis with swelling and partial destruction of adjacent muscle fibers and vascular thrombosis; viral cytopathic signs and fungal infection ruled out. The patient progressed unfavorably, dying a few days later due to a multiple organ failure. Case 2: 52 years old man with a history of advanced stage of alcoholic cirrhosis and repeated episodes of deep vein thrombosis treated with acenocoumarol who complains of vomiting. Laboratory test results: Hb 10.2 g/dl, hematocrit 38%, prothrombin activity 37%, INR 2, prothrombin time 23.4 sec, Urea 51, Crea 3, GOT 102, total Br 2.3. Urgent gastroscopy: friable necrotic esophageal mucosa, with cardia, fundus, gastric body, notch and antrum normal to biopsy. Anatomic pathology: necrotic mucosa limited by leukocyte infiltration in the upper submucosa, consisting of neutrophils and macrophages, with no hemosiderin deposits showing ANE. During endoscopy the patient went into cardiorespiratory arrest. Resuscitation attempts were unsuccessful and the patient died.
ANE is an extremely rare disease, hence the interest in this case, with an incidence ranging between 0.0125% and 0.2%. In 80% patients it is clinically related to hematemesis, as its most characteristic manifestation, and it may be related to other symptoms such as epigastric pain, anemic syndrome, vomiting and dysphagia. The endoscopic diagnosis showed a friable hemorrhagic blackish esophageal mucosa, located in the distal esophagus with proximal extension and normal esophagogastric transition zone. Biopsies shall be taken for histology and it is necessary to carry out a differential diagnosis with other entities such as melanosis or pseudomelanosis, malignant melanoma, acanthosis nigricans or ingestion of caustic substances. Treatment consists of adequate hydration, bowel rest and proton pump inhibitors associated with the specific management of the underlying diseases and adequate nutritional support. It is associated with high mortality (up to 50%), although this is related to the patient's underlying disease.
Argüelles Arias, F.1; Rodríguez Oballe, J.1; Castro Laria, L.1; Gómez Rodríguez, B.1; Rojas Feria, M.2; Soto Escribano, P.3; Iglesias, E.4; García Sánchez, V.5; Gómez Camacho, F.4; Barreiro Acosta, M.6; Domínguez Muñoz, E.6; Hernández Durán, M.7; Fernández Villaverde, A.8; Herrerías Gutiérrez, J.1
1VIRGEN MACARENA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE; 2VALME HOSPITAL, GASTROENTEROLOGY SERVICE; 3REINA SOFIA HOSPITAL, GASTROENTEROLOGY SERVICE; 4REINA SOFIA HOSPITAL, GASTROENTEROLOGY SERVICE; 5REINA SOFIA HOSPITAL, GASTROENTEROLOGY SERVICE; 6SANTIAGO UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE; 7PLASENCIA REGIONAL HOSPITAL, GASTROENTEROLOGY SERVICE; 8LUGO POVISA HOSPITAL, GASTROENTEROLOGY SERVICE;
Extraintestinal manifestations complicate the symptoms and treatment of inflammatory bowel disease (IBD) in a significant percentage of patients. Among the mucocutaneous lesions in extraintestinal manifestations, pyoderma gangrenosum (PG) occurs in 1-5% of patients. Its etiology and natural history are unknown, and there is no defined treatment for its management.
Determine the types of symptoms, the behavior and response to treatment of PG in patients with IBD in our country.
Patients from six Spanish hospitals with IBD who had PG were retrospectively studied. IBD activity was assessed by means of the Crohn's disease Activity Index (CDAI) and the Truelove-Witts Index was used in ulcerative colitis at the time of onset of pyoderma. The location, size, and treatments received for the disease as well as the time and the response to them were also evaluated.
The study included 26 patients, 18 women/8 men (p <0.05), whose average age was 46 and for whom the mean duration of the disease was 12 years. 15 patients had Crohn's Disease (CD) and 11 Ulcerative Colitis (UC). At the time of onset of pyoderma, 10 patients were in remission and 16 had active disease. Lesions appeared after an average time of 6 years duration of IBD. In most patients (18 cases), PG was located in the lower limbs, in 1 in the upper limb, in 1 in the breast, 1 was peristomal, 1 was supraumbilical, 1 was perivulvar and in 3 cases it appeared in several different places. The average size was 8 cm. Healing was achieved in 25/26 patients: 11 of them were treated with biological therapies obtaining a faster response. The median time to remission of lesions was 5 months.
In our experience, pyoderma gangrenosum occurs more frequently in women and its most frequent location is the lower limb. Biological therapies are probably the most effective treatments to achieve the patients' healing. It is clear that further prospective, randomized studies are needed to evaluate which treatments are most effective for this type of lesions.
Carrillo Ortega, G.; Morales Alcázar, F.; Gálvez Fernández, R.; Baeyens Cabrera, E.; Garcia Robles, A.; del Castillo Codes, M.
Refractory ascites does not respond to low sodium diet and treatment with high dose diuretics, manifesting as ascites resistant to diuretics or diuretic intractable ascites, due to complications. Refractory ascites was observed in 10% of patients admitted with tense ascites, for which liver transplantation, serial paracentesis or TIPS is the 2nd line treatment, leaving peritoneovenous shunting as 3rd line treatment.
- To estimate the prevalence of refractory ascites and its relationship to etiology, active alcoholism and salt intake.
- Determine the existence of renal failure when patients are admitted for the first time and during their clinical course.
- Appearance of SBP and other complications.
- Estimate 2nd line treatments.
Descriptive, retrospective study which includes 28 cirrhotic patients with refractory ascites admitted to the Ciudad de Jaén Hospital between January 2009 and December 2010. Results 28 patients were analyzed, 82.14% being men and 17.86% women. The most common cause of cirrhosis was alcoholism in 57.14% of cases, followed by mixed etiology (alcohol + HCV) in 25% of cases. 50% of patients did not make a low sodium diet and 28.57% continued with active alcoholism. When first admitted the urea average value was 38.79 mg/dl and that of creatinine 1.27 mg/dl, showing 28.57% of patients renal failure at first admission and 75% of patients developing functional renal failure during the clinical course. 25% of patients developed SBP, all being treated with IV cefotaxime. 7.14% of cases were treated with norfloxacin as secondary prophylaxis, followed by ofloxacin, ciprofloxacin and cefuroxime-axetil in 3.57% of cases respectively. Other complications: hepatic encephalopathy in 60.71% of cases and UGIB in 28.57% of cases. 10.71% of patients had TIPS placed and 10.71% of patients underwent successful OLT, one of them dying in the postoperative period. The overall percentage of death cases was 39.3%. The remaining patients continued with active alcoholism, not being candidates for OLT.
- In patients with cirrhosis, refractory ascites was found to be related to active alcoholism and salt intake.
- The occurrence of renal failure is a phenomenon often related to refractory ascites, which requires adjustment or withdrawal of diuretics.
- The appearance of SBP and other complications worsen the prognosis, if patients do not undergo the OLT, encephalopathy being the most common complication observed.
Carrillo Ortega, G.; Gálvez Fernández, R.; Padilla Ávila, F.; Jamal Ismail, S.; Morales Alcázar, F.; Tercero Lozano, M.
Capsule endoscopy is a first choice diagnostic procedure for the study of the small bowel. While it is currently the main indication for gastrointestinal bleeding of unknown origin its use is being investigated for inflammatory bowel disease, for the detection of polyps in the small bowel, for intestinal functional disorders and for intestinal involvement in systemic diseases, such as AIDS. There are some definite contraindications in using the capsule, such as small bowel stenosis, being convenient to perform a plain abdominal x-ray, and a small bowel transit time test in cases of suspected stenosis in the gastrointestinal tract. It has shown better results than other techniques such as push enteroscopy, enteroclysis and bowel transit time test, that also evaluate the small intestine.
- To analyze the most common indications and endoscopic findings.
- Diagnostic yield of capsule endoscopy in small bowel study.
- Estimate complications and/or incomplete studies.
Retrospective study involving 100 patients examined by capsule endoscopy at the Ciudad de Jaén Hospital from May 2009 to July 2011. Capsule Endoscope Set A. MAJ-14-69 was the capsule used in our hospital. The data collected was statistically analyzed using SPSS 15.0.
Capsule endoscopy was performed on 100 patients, 56% women and 44% men, whose average age was 57.42 ± 19.57. In 17% of cases the study was conducted in hospitalized patients and the remaining 83% of patiens on an outpatient basis. The indications for the use of CE was: anemia in 54% of cases, OGB in 30% of cases, abdominal pain in 12% of cases and diarrhea in 4% of cases. The most evident endoscopic finding was angiodysplasia in 39% of patients, followed by LAMI in 35% of patients. Lesions in small bowel: duodenum: angiodysplasia 9% of cases; jejunum: angiodysplasia 29% of cases, LAMI 16% of cases, lymphangiectasia 6% of cases; ileum: angiodysplasia 23% of cases. The examination was complete in 97% of cases, and no complications were observed in our series.
Capsule endoscopy allows a correct view of the entire small bowel, anemia being the most common indication for the study and angiodysplasia the most common finding. Patients tolerate well this safe and relatively easy to perform examination with rare complications.
Carrillo Ortega, G.; Morales Alcázar, F.; Tercero Lozano, M.; Pérez Durán, M.; Martínez García, R.; García Robles, A.
Gastroinstestinal stroma tumors are the most common mesenchymal tumors of the gastrointestinal tract, accounting for 1% of all gastrointestinal malignancies. Up to 50% of them occur in the stomach, being less frequently located in the small bowel and exceptionally located in the colon. They appear to originate from interstitial cells of Cajal, and the presence of CD 117 and C-KIT allows to differentiate them from other tumors of similar histological appearance. We describe 2 cases of uncommon locations: jejunum and sigma.
CASE 1. 50 year old man with no remarkable history who complains of melena. Physical examination: hemodynamic instability. Abdomen: globular, depressible, painful on palpation. Other examinations: Laboratory tests : CBC: Hb 9 g/dl, hematocrit 26.9%. Coagulation and biochemical testing: normal. UE: uncomplicated hiatal hernia. Colonoscopy: scanned up to the cecum, showing abundant hematic content without lesions. Faced with persistent bleeding with hemodynamic consequences and after the angiography showed no remarkable findings, the patient underwent a capsule endoscopy. Capsule endoscopy showed a bleeding point with clot blocking a vascular injury in the medium jejunum. After surgical evaluation the patient underwent a 7 cm resection of the jejunum encompassing a tumor of about 3 cm in diameter. Histologically, it was described as a spindle cell GIST pattern, of 2.5 cm size, with mitotic activity: 0/10, C-KIT and CD 34 + + +. The patient remained asymptomatic during a 15 month follow-up period.
CASE 2: 49 year old woman, who had underwent a hysterectomy, who complains of pain in left iliac fossa for the last few months and altered bowel habit. Physical examination: ACR: normal. Abdomen: infraumbilical scar, abdominal pain in the left iliac fossa without peritonitis. Other examinations: Laboratory test results: Hb 10.3 g/dl, hematocrit 33%; 78.8 MCV. 435000 platelets. Normal coagulation, biochemical testing and tumor markers. Abdominal CT scan: 54x43 mm left pelvic sigma-dependent mass with lower central attenuation, suggestive of GIST. Anatomic pathology: infiltration of mucosa with superficial ulceration by malignant neoplasm with epithelioid and spindle cells with areas of necrosis. The patient underwent surgery to confirm diagnosis.
GISTs are slow-growing lesions, often diagnosed incidentally. 20% of them has no symptoms, presenting as gastrointestinal bleeding, abdominal mass or pain. The risk of malignancy is based on the tumor diameter and on the mitotic count. A mitotic index of more than 5/50 CGA or larger than 5 cm are poor prognostic factors. Surgical excision is the primary treatment of the disease. Surgical recurrences or metastatic tumors can be treated with imatinib.
Morales Alcázar, F.; Carrillo Ortega, G.; García Robles, A.; del Castillo Codes, I.; Gálvez Fernández, R.; Pérez Durán, M.
A CRC process consultation has been implemented in our hospital. The CRC process is a sequence of activities designed to provide any person coming from any healthcare level with suspected or confirmed diagnosis of colorectal cancer, with a comprehensive study of the disease, adequate information on the different therapeutic possibilities, a comprehensive treatment and an appropriate follow up until the patient has finally been discharged or follow up on the development of recurrence or with a progression of the disease not amenable to active cancer treatment.
Knowing the cost of such a consultation analyzing the reasons for referral from Primary Care, assessing if they meet the referral criteria of the protocol, and if the time limits provided in the said process are met.
Retrospective study in which data was collected from 212 patients who were treated in our clinic from January 2010 to June 2010.
The average age was 55.51 ± 17. 50% of the patients were men and 50% women. The reasons for referral were rectal bleeding (17.2% of cases), diarrhea or constipation (8.8% of cases), family history (28.9%), anemia (4.3%) or a history of polyps (9.2%). 27.5% of patients were referred for symptoms that are not included in the protocol. The average time from referral to consultation was 34.42 ± 12.825 days, being 15 days the time stipulated in the protocol. Of all referred patients, 76.4% (162) attended the consultation. Colonoscopy was performed in 72.2% of patients (117) who attended the consultation. The percentage of patients who did not undergo colonoscopy coincides with the percentage of patients who were not referred correctly. The delay in colonoscopy was 18.71 days (median: 14 days), with the expected time in the process being 10 days.
- There exist possibilities to reduce diagnostic delay times. Primary Care has a key role in identifying individuals at risk who may benefit from specific measures to optimize the time of diagnosis, which means better staging and prognosis. Patients should have more information about the symptoms and/or signs for suspicion of CRC.
- The delay in care time in consultation regarding the time provided in the protocol was explained by the high number of patients who had not been correctly referred. A good clinical practice and coordination within and between healthcare levels as well as the proper management of waiting lists would help to reduce delays in diagnosis, thus obtaining a higher diagnostic yield.
Morales Alcázar, F.; Gálvez Fernández, R.; Martínez García, R.; Gordo Ruiz, M.; Tercero Lozano, M.; García Robles, A.
Colorectal cancer (CRC) is a major public health problem due to its high frequency of occurrence and mortality. CRC is the second leading cause of cancer death in Andalusia and accounts for 11% of all cancer deaths. Several features make CRC a suitable candidate for carrying out a process leading to its early detection in selected patients. Diagnostic colonoscopy is the gold standard diagnostic test for the diagnosis of colorectal cancer and colon polyps. Cohort studies indicate that colonoscopy and polypectomy prevent 80% of colorectal cancers.
To perform colonoscopies at an early stage in patients with CRC alarm symptoms after being attended in consultation. To analyze the number of referred patients who undergo colonoscopy as well as the percentage of cancers diagnosed and the percentage of diagnosed and removed polyps.
Descriptive study in which data was obtained from 212 patients who were treated in our clinic from January 2010 to June 2010.
Colonoscopy was performed in 72.2% of patients who attended the consultation, which coincides with those whose symptoms were rectal bleeding (25.7%), diarrhea (12.4%), constipation (16.2%). Colonoscopy was performed up to the cecum in 84.4% of all patients. The preparation of colonoscopy was good in 84.3% of cases, regular in 5.6% of cases and poor in 10.1% of them. Polyps were visualized in 27.4% of patients, performing polypectomy in all them. From all patients who underwent colonoscopy only 5 were diagnosed with colorectal cancer, which represents only 2.4% of those referred to our consultation, and 5.2% of the colonoscopies performed.
- Colonoscopy, with polypectomy if required, in patients with alarm symptoms remains being the technique of choice for early diagnosis and prevention of CRC in selected patients.
- The low number of diagnosed cancers could be explained by the high number of patients referred for consultation for reasons and symptoms different from that stated in the process.
- We shall get a better selection of patients referred to our consultation updating the process protocols, and improving the information reception process from primary care physicians.
Benítez Rodríguez, B.; Cabanillas Casafranca, M.; Núñez Sousa, C.; Pallarés Manrique, H.; Ramos Lora, M.
The Epstein-Barr virus (EBV) is the causative agent of infectious mononucleosis whose condition is characterized by fever, lymphadenopathy, hepatosplenomegaly and atypical lymphocytosis, and in rare cases it may cause an acute hepatitis.
We present the case of a 20 year old woman with no remarkable history, no toxic habits or medication consumption admitted because of epigastric pain irradiated to right upper quadrant and fever of 39 C, arthralgia, general breakdown, nausea and occipital headache. Physical examination revealed slight cutaneous and mucosal jaundice, abdominal pain in the right upper quadrant and epigastrium with 1 cm hepatomegaly of elastic consistency, no peritonitis, preserved bowel sounds and enlarged parotid glands, painful to the touch, being the rest of examination normal. Study was completed with the following laboratory test results: hemoglobin 12.5 g/dl, hematocrit 39%, MCV 80 fl, MCH 27.2 pg, 10600 leukocytes with 48% lymphocytes, 126000 platelets, 27.1 seconds prothrombin time, glucose 98 mg/dl, creatitine 0.43 mg/dl, total bilirubin 4.54 mg/dl, GOT 683 u/l, GPT 779 u/l, amylase 62 u/l, lipase 32 u/l. Negative HAV, HBV, HCV. Negative ANA, ASMA, AntiLKM. Given these data and the high suspicion of infectious mononucleosis an abdominal ultrasound was performed showing enlarged periportal spaces and slight thickening of the gallbladder wall suggestive of acute hepatitis; finally, heterophile antibodies were found (Pul-Bunnell test), being positive, confirming the suspicion of acute viral hepatitis caused by Epstein-Barr virus in the context of infectious mononucleosis. She was treated symptomatically, without isolation, with good results and outpatient follow-up without liver complications or sequelae in successive examinations.
Benítez Rodríguez, B.1; Bermejo Vázquez, S.2; Barón Franco, B.2; Pallarés Manrique, H.1; Ramos Lora, M.1
1JUAN RAMÓN JIMENEZ GENERAL HOSPITAL, GASTROENTEROLOGY SERVICE. HUELVA; 2JUAN RAMÓN JIMENEZ GENERAL HOSPITAL, INTERNAL MEDICINE SERVICE. HUELVA.
Hypercoagulable states are a rare disorder with an infrequent incidence of less than 1% and the 2nd cause of prehepatic portal hypertension in the western world. In up to 60% of cases it is possible to identify an underlying prothrombotic disorder. This year we had three cases of portal vein thrombosis caused by hypercoagulability, one of which is detailed below.
We present the cas of a 41 year old man with no remarkable history or toxic habits admitted with epigastric pain radiating to both hypochondria of 8 days duration. He had no fever or altered bowel habit. He denied hepatotoxic medication use or contact with fumigants. Physical examination revealed no pathological findings in cardiopulmonary auscultation. There was no jugular venous distention. Abdomen did not have masses but was painful in the right upper quadrant. There was no peritoneal irritation. There were no adenopathies. There were no pedal edema or signs of deep vein thrombosis, or signs of hepatic encephalopathy. Among the laboratory findings the following could be highlighted: Creatinine 0.86, Urea 20, Na 136, K 4.2, GOT 59, GPT 59, LDH 243, Amylase 84, Lipase 25, total bilirubin 0.45 mg/dl. Hemoglobin 15.3 g/dl, hematocrit 45%, leukocytosis of 12700 with 68% segmented leukocytes and 246000 platelets, prothrombin time 1.12 and INR 0.92. Negative HAV, HBV, HCV. Negative ANA, ASMA, ANCA and AntiLKM. Abdominal ultrasound showed complete thrombosis of portal vein, intrahepatic branches, splenic and superior mesenteric vein. Liver showed a moderate enlargement of the left lobe and atrophy of the right one. Normal bile duct. Mild diffuse ascites. The contrast-enhanced thoraco-abdominal CT scan showed an extensive portal vein and esplenoportal axis thrombosis with changes in hepatosplenic perfusion and submucosal edema of loops with ascites. Given the finding of portal vein thrombosis in patients without prior history of cirrhosis and as scan imaging did not show underlying malignancy it was decided to extend the study to rule out thrombophilia, obtaining the following results (1st step): prothrombin gene mutation, Factor V Leiden, activated protein C resistance, homocysteine and anticardiolipin and anti-b2GI antibodies which were normal. The patient initiated anticoagulant and analgesic therapy. The patient underwent biological tests for thrombosis (2nd step). The hypercoagulability testing showed presence of positive lupus anticoagulant, and antithrombin III deficit with activity reduced to 50%. This patient had a first episode of acute extensive thrombosis of the spleno-mesenteric-portal with portal cavernoma and a hypercoagulable disorder as underlying cause. On the one hand, the patient met the clinical and laboratory criteria for diagnosis of primary antiphospholipid syndrome and also had an isolated antithrombin III deficiency. In this case, as the patient only had a single episode of extensive thrombosis in an unusual location and as he had a primary antiphospholipid syndrome and antithrombin III deficiency as underlying hypercoagulable states he was included in the high thrombotic risk group with indication to maintain anticoagulant therapy indefinitely.
Garcia, M.1; Cano, I.2; Perez, J.2; Sanchez, M.3; Toledo, S.4; Haro, M.2; Rey, M.2
1PUERTO REAL UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE. CADIZ 2PUERTO REAL UNIVERSITY HOSPITAL. CADIZ. 3REINA SOFIA HOSPITAL. CORDOVA 4CARLOS HAYA HOSPITAL. MALAGA.
Clinical management units are being given more prominence these days, as they are gradually being given more responsibility to achieve their own goals. In this sense, the current contract-program includes as target for different services and clinical management units a Bed Utilization Rate lower than 1, in an increasingly complex environment. This paper shows the evolution in management indicators related to Hospital Stays and to the Gastroenterology Service Clinical Management Unit at Puerto Real University Hospital from 2000 to 2011 compared with the Andalusian Health Service (SAS) standard from 2010.
We analyzed the timing of the Gastroenterology Service Clinical Management Unit at Puerto Real University Hospital (PRUH) in relation to the above said indicators, and compared it with the SAS standard, using the MDS from the hospital for the said years, supplied by the Documentation and Information Service at the PRUH, and the data from the SAS standard provided by the Andalusian Health Central Services in relation to the discharges that took place in 2010.
In the year 2000, with a 1.4 complexity, the average stay in hospital was 9.12 days. The growth of complexity was joined by a decrease in hospital stays. In the year 2011, with a 1.7 complexity, hospital stays were reduced to 7.42 days, improving the SAS standard.
We confirmed the continuous improvement of the Gastroenterology Service Clinical Management Unit at PRUH, which has achieved the goal of the contract-program in the last three years, exceeding the standard.
Garcia, M.1; Lopez, J.2; Haro, M.2; Cano, I.2; Perez, J.2; Sanchez, M.3; Toledo, S.4; Rey, M.5
1PUERTO REAL UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE. CADIZ 2PUERTO REAL UNIVERSITY HOSPITAL. CADIZ. 3REINA SOFIA HOSPITAL. CORDOVA 4CARLOS HAYA HOSPITAL. MALAGA. 5PUERTO REAL UNIVERSITY HOSPITAL. CADIZ.
Studies on alcohol consumption as the cause of many diseases and complications that increase considerably the mortality rate are often conducted in hospitals.
Using the MDS from 2007 to 2010 supplied by PRUH we intended to establish the relationship between alcohol consumption and digestive tract neoplasms. We considered only digestive tract neoplasms established as the primary diagnosis (ICD-9-CM Codes 150-159), which have an alcohol dependence syndrome code (ICD-9-CM Codes 303 and 305.0) associated as secondary diagnosis (C2-C15), secondary metastasis and neoplasms being discarded for this study.
Data presented shows that alcohol increases the risk of developing a neoplastic disease, with a higher frequency in men than in women, and more frequent in the first part of the digestive tract (mouth and esophagus). As we descend through the digestive tract we find that the risk of developing a neoplastic disease decreases and the Cancer-Alcohol ratio becomes negligible in the latter part of the tract (colon and rectum), where "non-drinker" values are higher than "drinker" values.
After this statistical approach to information linking alcohol consumption and malignant neoplasms, it could be noted that in the case of digestive cancers the relationship between the two concepts was right, although colon and rectum neoplasms do not follow this trend.
Garcia, M.1; Haro, M.2; Cano, I.2; Perez, J.2; Sanchez, M.3; Toledo, S.4; Rey, M.5
1PUERTO REAL UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE CLINICAL MANAGEMENT UNIT. CADIZ 2PUERTO REAL UNIVERSITY HOSPITAL. CADIZ. 3REINA SOFIA HOSPITAL. CORDOVA 4CARLOS HAYA HOSPITAL. MALAGA. 5PUERTO REAL UNIVERSITY HOSPITAL. CADIZ.
Cholelithiasis is one of the most common disordes of the digestive tract. Cholecystectomy is the treatment of choice. Puerto Real University Hospital does not have an intervention protocol for this disorder, so our study is aimed at analyzing why this unit of the hospital is full for this cause and the benefits that could be achieved applying such a protocol.
We have formed a working group to analyze the successive admissions for the same cause experienced by patients in the Gastroenterology Service of our hospital for one year. Data was taken from the 2010 MDS from patients who had a cholecystectomy performed.
The availability of a protocol agreed with the admissions unit. We observed that patients suffering from this disorder often require a second surgical admission to hospital when medical treatment fails. This implies that the process requires being regularized and protocolized.
In the Gastroenterology Service of the Puerto Real University Hospital this pathology frequently requires the same patients being readmitted, so this hospital unit is full with patients suffering from this disorder that, with a protocol governing the procedure for each case would not only decrease the hospital stays of those patients affected, but also the resources necessary in their assistance. This way more beds are available for other patients.
Garcia, M.1; Sanchez, M.2; Toledo, S.3; Haro, M.4; Cano, I.4; Perez, J.4; Rey, M.4
1PUERTO REAL UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE CLINICAL MANAGEMENT UNIT. CADIZ 2REINA SOFIA HOSPITAL. CORDOVA 3CARLOS HAYA HOSPITAL. MALAGA. 4PUERTO REAL UNIVERSITY HOSPITAL. CADIZ.
1. Comparing the following DRGs behavior at Puerto Real University Hospital (PRUH) and other public hospitals in Andalusia in 2010. 494 DRG Laparoscopic cholecystectomy without common bile duct exploration without CC. 557 DRG Hepatobiliary and pancreas disorders with major CC.
2. Comparing the Expected Average Stay (EAS) of the above said DRGs in PRUH and other public hospitals in Andalusia to understand the PRUH behavior.
DRG is a patient classification system that takes casuistry and resource consumption into account. The information source is the 2010 MDS from Andalusia and from the PRUH. DRGs with the 30 more common digestive diseases have been selected from public hospitals in Andalusia, which coincide with those from PRUH. We compared the EAS from public hospitals in Andalusia and the EAS from PRUH with the common DRGs. The comparison has been made to determine the DRGs impact in terms of hospital stay. Results In the 2010 MDS and in PRUH, the two DRGs under study behaved as follows:
1 .- 494 DRG EAS in Andalusia 14.00 ... EAS in PRUH 3.122 .- 557 DRG EAS in Andalusia 3.36 ... EAS in PRUH 11.65 Conclusions 1. PRUH has a lower hospital stay average than hospitals in Andalusia. 2. PRUH behaved better for the DRGs studied with digestive pathologies as the hospital helped the same type of patients with shorter stays.
Garcia, M.1; Toledo, S.2; Rey, M.3; Haro, M.3; Cano, I.3; Sanchez, M.4; Perez, J.3
1PUERTO REAL UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE CLINICAL MANAGEMENT UNIT. CADIZ 2CARLOS HAYA HOSPITAL. MALAGA. 3REINA SOFIA HOSPITAL. CORDOVA
Liver transplantation is the current treatment of choice for many acute and chronic hepatobiliary diseases. The main objectives of this study are the following: 1. Understanding the evolution of these surgeries in Andalusia from the first time they were performed to date. 2. Identifying the factors that make Andalusia one of the most active regions in liver transplantation of the country.
A working group was created in order to review surgery developments in several Andalusian hospitals, from the first time a liver transplantation was performed in 1989 at the Reina Sofia Hospital in Cordoba two decades ago until now. Data used are from the Minister for Health, Social Policy and Equality, National Transplant Organization and various Andalusian hospitals.
There are currently 4 centers performing liver transplants in Andalusia: Reina Sofia Hospital (Cordova), Virgen del Rocio Hospital (Seville), Carlos Haya Hospital (Malaga) and Virgen de las Nieves Hospital (Granada). In 22 years, 2496 liver transplants have been performed (adults and children), of which 1.4 percent are from living donors, a practice that began in 2002 in Andalusia at the Reina Sofia Hospital (Cordova), due to the advances in surgery and the increasing number of donors.
The future developments should be aimed at getting a better match between the progressive increase in recipients and available donors and finding treatments and strategies to reduce or prevent the recurrence of the diseases that led to liver transplantation, selecting the best possible candidates. It is currently possible to talk about 10-year survival in around a 60% of cases and a great quality of life.
Ruiz Cuesta, P.; Jurado García, J.; Benítez Cantero, J.; García Caparrós, C.; García Sánchez, V.; González Galilea, Á.; Gálvez Calderón, C.
GASTROENTEROLOGY SERVICE. REINA SOFIA HOSPITAL. CORDOVA
Determine the concordance of two different laboratory tests, venous blood gases (VBG) and conventional laboratory tests in patients with gastrointestinal bleeding.
Prospective observational study of patients admitted to the Gastrointestinal Bleeding Unit. In the acute form of the disease simultaneous samples from the vascular access were obtained for VBG and for conventional laboratory tests. Demographic, clinical and biochemical variables (Hb, hematocrit, sodium, potassium and glucose) were collected. Concordance was compared in the estimates obtained with both methods of measurement by calculating the intraclass correlation coefficient (ICC), considering the concordance to be a good match if ICC > 0.9; good if it was between 0.71 and 0.9; moderate if it was between 0.51 and 0.7; low if it was between 0.31 and 0.50 and no concordance if it was <0.3. Results 132 patients whose average age was 66.7 ± 15 were analyzed. 87 (65.9%) of them were men. Bleeding causes: 20.5% peptic ulcer, 26.5% portal hypertension, 32.6% lower gastrointestinal bleeding and 20.5% other. Mean values obtained by VBG and conventional laboratory tests, respectively: Hb 9.97 ± 3.37 and 9.48 ± 3.08 g/dl (p <0.001); hematocrit 29.9 ± 10.2 and 29.1 ± 9% (ns); sodium 136.4 ± 6 and 136.5 ± 5.8 mEq/l (ns); potassium 4.15 ± 0.8 and 4.18 ± 0.6 mEq/l (ns); glucose 153.8 ± 74.1 and 155.1 ± 74.4 mg/dl (ns). ICCs were: 0.931 (0.90 to 0.95) for Hb; 0.899 (0.85 to 0.92) for hematocrit, 0.917 (0.88 to 0.94) for sodium, 0.896 (0.85 to 0, 92) for potassium, 0.953 (0.93-0.96) for glucose; there was statistically significance in all cases (p <0.001).
The concordance of the parameters obtained with conventional laboratory tests and VBG was very good. These results support the reliability of the use of the VBG in patients with acute gastrointestinal bleeding. Results are more easily and earlier obtained this way in an emergency situation.
Andrade, R.1; Ulzurrun, E.2; Stephens, C.3; Crespo, E.4; Ruizcabello, F.5; Robles, M.1; Borraz, Y.2; Cabello, M.2; Pelaez, G.6; Hallal, H.7; Romero-gomez, M.8; Guarner, C.9; Soriano, G.9; Castiella, A.10; Moreno-herrera, I.2; Moreno-planas, J.11; Lucena, M.2
1HEPATOLOGY UNIT. VIRGEN DE LA VICTORIA HOSPITAL. SCHOOL OF MEDICINE. MALAGA. NETWORKING BIOMEDICAL RESEARCH CENTRE IN LIVER AND DIGESTIVE DISEASES, CIBEREHD; 2CLINICAL PHARMACOLOGY SERVICE. VIRGEN DE LA VICTORIA HOSPITAL. SCHOOL OF MEDICINE. MALAGA. NETWORKING BIOMEDICAL RESEARCH CENTRE IN LIVER AND DIGESTIVE DISEASES, CIBEREHD; 3CLINICAL PHARMACOLOGY SERVICE. VIRGEN DE LA VICTORIA HOSPITAL. SCHOOL OF MEDICINE. MALAGA. NETWORKING BIOMEDICAL RESEARCH CENTRE IN LIVER AND DIGESTIVE DISEASES, CIBEREHD; 4PHARMACOLOGY UNIT. SCHOOL OF PHARMACY. GRANADA; 5CLINICAL ANALYSIS SERVICE. IMMUNOLOGY LABORATORY. VIRGEN DE LAS NIEVES HOSPITAL. GRANADA, CANCER GENETICS NETWORK ; 6CLINICAL PHARMACOLOGY SERVICE AND PRIMARY CARE UNIT. GASTROENTEROLOGY SERVICES. TORRECARDENAS HOSPITAL. ALMERÍA; 7GASTROENTEROLOGY SERVICE. MORALES MESEGUER HOSPITAL. MURCIA; 8HEPATOLOGY UNIT, NUESTRA SEÑORA DE VALME HOSPITAL, SEVILLE. NETWORKING BIOMEDICAL RESEARCH CENTRE IN LIVER AND DIGESTIVE DISEASES, CIBEREHD; 9HEPATOLOGY UNIT, SANT PAU HOSPITAL, BARCELONA. NETWORKING BIOMEDICAL RESEARCH CENTRE IN LIVER AND DIGESTIVE DISEASES, CIBEREHD; 10PRIMARY CARE UNIT. GASTROENTEROLOGY SERVICES. MENDARO HOSPITAL, GUIPÚZCOA; 11PRIMARY CARE UNIT. GASTROENTEROLOGY SERVICES. LA RODA HOSPITAL. ALBACETE
To analyze the role of variant genotypes at position 2677 in exon 21 of the ABCB1 gene in the transport of bilirubin based on its chemical structure and the risk of DILI. The chemical structure of bilirubin includes linking groups containing one carbon atom. An association between this chemical moiety and P-gp polymorphisms in DILI development has been demonstrated previously (Ulzurrun et al. J Hepatol, 2011).
The polymorphism ABCB1 2677G>T,A was genotyped in 160 Spanish patients with DILI, from whom 102 patients had total bilirubin (TB) 2 times bigger than the upper limit of the normal range and 58 patients had TB 2 times smaller than the upper limit of the normal range. Genotyping was performed using direct sequencing. Chemical structures contributing to ABCB1 ATPase activity were determined according to Sakurai et al. (Biochemistry, 2007). Results TT genotype distribution was significantly different between patients with DILI with a BT 2 times bigger than the upper limit of the normal range and patients with TB 2 times smaller than the upper limit of the normal range (Pc= 0.045; OR= 6.4). Allele frequencies showed a protective effect of 2677G allele in patients with BT 2 times bigger than the upper limit of the normal range (P = 0.033, OR = 0.5).
Patients with a TT genotype with BT 2 times bigger than the upper limit of the normal range have a higher risk of bilirubin toxicity, suggesting that linking groups containing a carbon atom are important structural components of the P-glycoprotein substrate specificity.
Funding: Spanish Agency for Medicines and Health Products and grant PS FIS 09/01384. CIBERehd and Cancer Genetics Network are financed by the ISCIII.
López Vega, M.1; Fernández Cano, F.1; Moreno García, A.1; Rivas Ruiz, F.2; Rosales Zábal, J.1; Fernández Pérez, F.1; Méndez Sánchez, I.1; Navarro Jarabo, J.1; Pérez Aisa, A.1
Bacterial overgrowth (BOS) generates fat malabsorption causing malnutrition. The presence of predisposing factors condition the persistence of the pathology so appropriate strategies shall be decided in the design of treatment.
Evaluating treatment strategies in BOS. To identify predictors of poor response to treatment. Methodology 220 glucose hydrogen breath test were performed in our hospital for the diagnosis of BOS between January 2008 and December 2010, among which 170 were selected. We collected demographic and epidemiological variables. BOS cases treated according to the standard regimen of rifaximin 400 mg every 8 hours for 10 days were identified. A second test evaluated the BOS persistence or absence. Variables were analyzed to identify predictors of response.
From 122 patients (average age: 51'5, 50% men (61)) 35 were diagnosed with BOS, and from these, 25 met the criteria to be included in the analysis. 14 patients (56%) had a positive control test. The median age of respondent patients was 58, compared to that of non-responders which was 68.There is a statistically insignificant trend to worse response (p = 0.115). The predisposing pathologies to suffer from BOS were analyzed (liver disease, surgical resection, surgery for inflammatory disease...) and in patients with liver disease there was a trend to better response to the first line of treatment (p = 0.18).
It is necessary to check the negative result for BOS after treatment with rifaximin given the likelihood of poor response (55.6%). Patients with liver disease appear to be better responders to treatment with rifaximin.
Serrano Leon, M.; Soria de La Cruz, M.; Ramos-clemente Romero, M.; Iglesias Arrabal, M.; Rivas Rivas, M.; Ruiz Santiago, C.; Naranjo Rodriguez, A.
PUERTA DEL MAR UNIVERSITY HOSPITAL. CADIZ
Steinert's disease or myotonic dystrophy is a congenital disease that affects striated muscle, sometimes other organs such as the heart, endocrine glands, and rarely the intestinal smooth muscle fibers. In the adult form, it usually presents on the second or third decade of life, with weakness and atrophy of facial muscles, eyes, forearms, hands, legs and feet. In this study we present the cases of two young patients suffering from Steinert's disease in which gastrointestinal symptoms led to functional tests that confirmed abnormalities by affecting intestinal smooth muscles and sphincters. The first case was that of a 30 year old man, already diagnosed, with a family history of myotonic muscular dystrophy, and mild psychomotor retardation. He complained of chronic constipation. In barium enema he showed megacolon with no stenosis nor organic lesions. An anorectal manometry was then performed in which we could observe severe basal hypotonia of the anal canal with an average basal tone of 35 mmHg, and a significant deficit in voluntary anal contraction capacity, decreased rectal sensation without defecatory sensation despite progressive rectal balloon filled to 100 cm3. Rectoanal inhibitory reflex without paradoxical contraction during the defecatory maneuver. The patient improved with osmotic laxatives and prokinetics. The second case was that of a 22 year old man without personal or family history of Steinert's disease, who complained of intermittent diarrhea and high dysphagia of 2 years duration. Barium intestinal transit showed an abnormal retention of the contrast filling in the cervical esophagus. Esophageal manometry ruled out Achalasia and a nonspecific esophageal motor disorder with global esophageal hypomotility, low-amplitude peristaltic waves and baseline hypotonia of the upper and lower sphincters was detected, suggesting neuromuscular involvement of the hypopharynx and esophagus. The patient was then referred to the neurology service where he was diagnosed Steinert's disease after genetic analysis. Dietary measures and rehabilitation were recommended. Steinert's disease is the most common muscular dystrophy in adults. It is hereditary, autosomal dominant, and it has variable clinical expression features and it characteristically affects striated muscle. The involvement of smooth muscles of the digestive tract can cause characteristic symptoms, which occur less frequently than other systemic disorders. Dysphagia is the most observed disorder (25-45% of cases). Gastroparesis, steatorrhoea, constipation and megacolon occur less frequently. Pseudo-obstruction may occur at any development stage of the disease, even years before diagnosis. The development of the disease is very variable, sometimes being benign, but it can also have disabling consequences for the patient. As it has no specific treatment emphasis is made on rehabilitation and psychotherapy. Early diagnosis allows treatment of symptoms and prevention of complications.
Perez Rodriguez, E.1; Marin Pedrosa, S.2; Naveas Polo, C.3; Hervas Molina, A.3
1REINA SOFIA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA; 2REINA SOFIA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA; 3REINA SOFIA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. CORDOVA.
To evaluate the diagnostic results of conventional pH monitoring in patients from our area referred to our service for various respiratory symptoms, taking into account their age and sex.
120 patients referred for symptoms such as chronic cough, posterior laryngitis, asthma, or chronic hoarseness who underwent 24-hour ambulatory pH monitoring, with a one-channel probe using conventional techniques. Data relating to the De Meester score and symptoms were recorded in an Access database and analyzed using the SPSS statistical software.
The test was normal in 62% of cases, being significant differences between men and women. 34.2% of the patients showed symptoms related to a pH below 4, the symptomatic index being positive in 21% of the cases. Chronic cough was the most frequent complaint in age groups older than 45, while posterior laryngitis was the most common reason for referral in younger groups.
PH monitoring detected reflux disease in approximately one third of patients with respiratory symptoms, most frequently in men. Even in the few cases in which there is no symptomatic relation to episodes of reflux disease, a causal relationship is uncertain.
Gastroesophageal reflux, respiratory symptoms, pH monitoring.
Belda Cuesta, A.; San Juan Acosta, M.; Argüelles Arias, F.; Caunedo Álvarez, Á.; Romero Vázquez, J.; Pellicer Bautista, F.; Herrerías Gutiérrez, J.
VIRGEN MACARENA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. SEVILLE.
According to some studies, colon capsule (CC) endoscopy may play an important role in the diagnosis of colonic lesions, although there are aspects that should be improved. One of them is preparation, since CC endoscopy cannot pick up the stool remains, so that different cleansing schemes have been proposed, but it has not been yet defined which might be the best.
The main objective of this study was to compare the degree of colonic cleansing with two different preparation regimens. Secondary objectives were to analyze the presence of bubbles in the colon that prevent the correct visualization of the mucosa and full scan rate (considering the hemorrhoidal plexus visualization) according to each preparation regimen.
This is a prospective, open and blind (to the investigator) study in which two different laxative preparations were administered to two different group of patients chosen for the detection of colonic polyps technique. In the first group (A), patients were administered a PEG lavage solution together with 2 liters of ascorbic acid (MOVIPREP ®) and in the second group (B) patients were administered 4 liters of PEG lavage solution (Klean-Prep ®). The degree of cleanliness was measured according to the recently published Leighton scale grouping preparation in "good-excellent" and "fair-poor." The presence of bubbles was analyzed according to the said scale as well as the rate of hemorrhoidal plexus visualization as a parameter to assess whether the entire colonic mucosa can be observed. PillCam Colon 2 ® was used in all cases.
Group A included 13 patients (5 of them men) whose average age was 52 ± 19 and group B included 11 patients (7 of them men) whose average age was 54.44 ± 10 years. There were no statistically significant differences regarding age and sex. The results on the quality of colon cleansing are included in the table below. The percentage of patients with "good-excellent" preparation was higher in group A, both in the overall assessment as well as in cecum, ascending and transverse colon, although the difference did not reach statistical significance. There was no significant difference in the amount of patients without bubbles in both groups: 79.9% of patients in group A compared with 76.3% in group B (p = NS). Hemorrhoidal plexus was visualized in 84.6% of patients in group A and in 81.8% of patients in group B (p = NS). No adverse effects were observed in either group.
Preliminary results of this study showed a trend showing the superiority of PEG + ascorbic acid (2 liters) over PEG (4 liters) regarding the preparation regimens to study the colon before performing colon capsule endoscopy. However, with the data analyzed it was not possible to reach statistical significance, making it necessary to increase the sample size. Results Good-Excellent PEG + ascorbic acid PEG P CECUM 76.92% 36.36% 0.095, ASCENDING COLON 76.91% 54.54% NS, TRANSVERSE COLON 69.22% 36.36% NS, DESCENDING COLON 61.53% 63.63% NS, RECTUM 61.53% 72.72% NS, TOTAL 69.22% 52.72% NS.
Garcia, M.1; Perez, J.2; Sanchez, M.3; Toledo, S.4; Cano, I.2; Rey, M.2; Haro, M.2
1PUERTO REAL UNIVERSITY HOSPITAL. GASTROENTEROLOGY SERVICE CLINICAL MANAGEMENT UNIT. CADIZ 2PUERTO REAL UNIVERSITY HOSPITAL. CADIZ; 3REINA SOFIA HOSPITAL. CORDOVA 4CARLOS HAYA HOSPITAL. MALAGA.
Colorectal cancer is the second leading cause of cancer death in Andalusia. This disease is more common in aged population. This disease has been included within the integrated care pathways in the Health Department Quality Plan, describing the set of actions and tasks that are sequentially and orderly linked in order to get optimal results in terms of resources and user satisfaction. Our goal is to analyze the following indicators: number of reinterventions performed and readmissions that took place in the PRUH due to CRC in the last four years. Methodology Hospital efficiency analysis, using data from PRUH MDS, taking into account the readmission and reintervention indicators due to CRC described in the quality plan by the integrated care pathways, which shall be lower than 3% and 5% respectively of all the hospital cases.
In the MDS data for the last four years, both readmissions and reinterventions have fallen to improve the standard.
The implementation of the treatment of certain diseases such as an integrated care pathway has allowed a significant improvement in their management, with the benefit it brings to both patients and hospital in terms of value for money. Without an effective information system, designed to show the data of surgical procedures to detect failures in the process, it is not possible to improve the quality of service.
Benítez Rodríguez, B.1; Pallarés Manrique, H.1; Ramos Lora, M.1; Rodríguez Sicilia, M.2
1JUAN RAMÓN JIMENEZ GENERAL HOSPITAL, GASTROENTEROLOGY SERVICE. HUELVA. 2VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. GRANADA
We present the case of a 33 year old woman who 8 months before was diagnosed with ileal Crohn's disease by colonoscopy with ileoscopy described as suspected Crohn's ileitis with histological report showing moderate-severe chronic inflammation and cryptitis. The following information from her history was found remarkable: hormonal contraception (vaginal ring), abortion in the 5th week of pregnancy 5 years before, twins birth by caesarean one year later. She underwent home treatment with mesalazine 3 g/24 hours. She was admitted because of 2 weeks fever and arthralgia, cough and white expectoration, followed by progressive dyspnea on moderate activity. The patient underwent a chest x-ray showing left pleural effusion with non homogeneous bilateral alveolar infiltrates, mainly on the left one. A chest CT angiography was performed showing basal alveolar infiltrates in left lower lobe, which extends to the lower lobe and lingula with a peribronchial thickening pattern and small peripheral opacities of ill-defined borders, all suggestive of an inflammatory-infectious process without being able to rule out Pulmonary Thromboembolism (PE). In a pulmonary ventilation/perfusion scan, perfusion defects were observed in the medial basal segment of the right lower lobe and in the anterior and posterior basal segments of the left lower lobe with continued ventilation, all this being suggestive of with bilateral pulmonary thromboembolism. The laboratory tests showed the following: hemoglobin 11.7 g/dl, hematocrit 33.6%, MCV 90.7 fL, 15100 leukocytes with moderate neutrophilia and 544000 platelets. Clotting was normal. D-dimers 3530 mcg/l. Biochemical testing showed normal results (for CPK enzyme, ion levels in blood, liver function, and renal function). CRP 2.2 mg/dl. Venous blood gas: pH 7.42, pCO2 45 mmHg, bicarbonate 29.2 mmol/l. Candida albicans isolated in sputum culture, which was negative for mycobacteria. Proteinogram: albumin 50.1%, alpha1 6.4%, alpha2 15.8%, Beta 13% gammaglobulin 14.7%, albumin/globulin index 1 (electrophoretic profile showing moderate inflammatory syndrome). ANA 1/320; anti-native DNA antibodies <1/10; negative C-ANCA and P-ANCA. IgG anticardiolipin antibodies 47 UGPL/mL (tested on two laboratory tests), IgM anticardiolipin antibodies <12 UMPL / mL; anti-B2-glycoprotein-1 IgG antibodies 1.9 EU/mL. Homocysteine level 7.7 pmol/l. Negative results in Infectious Serology tests for CMV, Legionella, HIV, Chlamydia pneumoniae, Coxiella burnetii, Mycoplasma pneumoniae. It was therefore a bilateral pulmonary embolism associated with antiphospholipid syndrome in a young woman with Crohn's disease and hormonal contraception by vaginal ring. The patient started a parenteral treatment regimen with carbapenem, bronchodilators, inhaled corticosteroids and anticoagulants, with good results and normalization of chest X-rays in subsequent tests.
Muñoz García, Á.1; Robles Díaz, M.2; Borraz Pereira, Y.3; Lucena, M.4; Navarro, J.5; Fernández, M.6; Pérez Romero, J.7; Romero, M.8; García Ruiz, E.9; Durán Jiménez, J.10; Andrade Bellido, R.11
1VIRGEN DE LA VICTORIA CLINIC AND UNIVERSITY HOSPITAL, MALAGA. GENERAL AND DIGESTIVE SURGERY SERVICE 2MALAGA UNIVERSITY SCHOOL OF MEDICINE, CIBEREHD, HEPATOLOGY UNIT. 3MALAGA UNIVERSITY SCHOOL OF MEDICINE, CIBEREHD, PHARMACOLOGY SERVICE. 4MALAGA UNIVERSITY SCHOOL OF MEDICINE, CIBEREHD, PHARMACOLOGY SERVICE; 5COSTA DEL SOL HOSPITAL. MARBELLA. MALAGA. GENERAL AND DIGESTIVE SURGERY SERVICE 6TORRECARDENAS HOSPITAL, ALMERIA, PHARMACOLOGY SERVICE. ALMERÍA 7PUERTO REAL HOSPITAL, CADIZ, GENERAL AND DIGESTIVE SURGERY SERVICE 8VIRGEN DE VALME HOSPITAL, SEVILLE, GENERAL AND DIGESTIVE SURGERY SERVICE; 9LINEA DE LA CONCEPCION HOSPITAL, CADIZ, GENERAL AND DIGESTIVE SURGERY SERVICE; 10VIRGEN DE VALME HOSPITAL, SEVILLE, GENERAL AND DIGESTIVE SURGERY SERVICE; 11VIRGEN DE LA VICTORIA CLINIC AND UNIVERSITY HOSPITAL, MALAGA. CIBEREHD. GENERAL AND DIGESTIVE SURGERY SERVICE.
Drug hepatotoxicity is the adverse drug reaction that leads to more regulatory measures. Ibuprofen has been traditionally considered a safe drug in this regard. However, there have been cases of hepatotoxicity attributed to the consumption of ibuprofen in recent years.
To describe the demographic, clinical and analytical characteristics, prognosis, causality and frequency of ibuprofen-induced hepatotoxicity in our area.
We analyzed the cases of ibuprofen-induced idiosyncratic hepatotoxicity included in the Spanish Liver Toxicity Registry (REH).
From the 740 cases diagnosed with hepatotoxicity between April 1994 and July 2010 found in the REH, 24 (3.2%) of them were ibuprofen-induced cases of hepatoxicity (average age 52, range 18-83, 50% women), becoming the third more frequently associated drug with hepatotoxicity behind amoxicillin-clavulanate and flutamide. The average latency time was 95 days (range 2-1768 days), and the average dose, 1200 mg/day (range 400-1800 mg). The type of injury was hepatocellular in 46% of cases, cholestatic in 29% and mixed in 25%. 17% of patients had fever, and 4% rash. 63% of the cases required hospitalization. 71% of the cases developed jaundice, 8 of them with hepatocellular damage, thus fulfilling the "Hy's law." One of the latter cases had fulminant liver failure, requiring liver transplantation. A second patient died of fulminant liver failure.
Ibuprofen-induced hepatotoxicity has proved to be relatively common in our area, and potentially serious and in some cases it may have fatal consequences. Therefore, this potential adverse effect should be taken into account when prescribing this drug.
Matas Cobos, A.; González Artacho, C.; Martos Ruíz, V.; Espinosa Aguilar, M.; de Teresa Galván, J.
VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. GRANADA
The immune system destroys neoplastic cells caused by somatic mutations or oncogenic viruses. Decreased surveillance by the immune system can cause an uncontrolled growth of neoplastic cells. The use of immunosuppressive medication in transplant patients is associated with an increased risk of malignant tumors.
To study the incidence of de novo tumors in patients with liver transplant from 2002 to July 2011.
Observational descriptive study to analyze patients with liver transplant between 2002 and 2011 diagnosed with a de novo tumor. Results analyzed using SPSS-15 statistical software.
From 227 transplant patients, 19 (8.37%) developed de novo tumors after transplantation: 15 men and 4 women. The average age was 51.5 +8. The most frequent diseases were alcoholic cirrhosis (37%) followed by hepatitis C virus infection associated with hepatocarcinoma (37%). 68.4% of patients were receiving immunosuppressive therapy with tacrolimus and mycophenolate mofetil and the rest with calcineurin inhibitors. Tumors were: 6 cases of skin cancer (31.2%), 4 lung cancer (20.8%), 4 lymphomas (20.85), 1 colorectal cancer (5.2%), 2 ENT (10.4%), 1 esophagus cancer (5.2%) and 1 prostate cancer (5.2%). 9 patients died (none of them died due to skin cancer).
The most common tumor in transplant patients was skin cancer, with a 100% survival. The frequency of other malignant neoplasms depended on several factors: time elapsed from transplantation, or immunosuppression intensity and duration. Lymphomas were the second most common malignant neoplasms.
Bellido Muñoz, F.; Giráldez Gallego, Á.; Araujo Míguez, Á.; Pascasio Acevedo, J.; Sousa Martín, J.
VIRGEN DEL ROCIO UNIVERSITY HOSPITALS. HEPATOLOGY UNIT. GASTROENTEROLOGY SERVICE. SEVILLE.
Key words Transient elastography, recurrent hepatitis C, liver transplantation.
To carry out a prospective study on changes in liver stiffness (LS) by transient elastography (TE) in a prospective series of cases of patients with recurrent hepatitis C after liver transplantation (LT), one group of patients left to develop in a natural way (group A) and the other group of patients under antiviral treatment (group B).
17 TE were performed for 31 months on 11 patients with recurrent hepatitis C after liver transplantation. The matched results from two TEs were evaluated in the same patient in order to identify changes in LS in groups A (13 cases) and B (4 cases). We recorded the following variables: 1) at the time of inclusion: age, sex, genotype, time elapsed since LT and basal fibrosis, 2) during follow-up: time between the two TEs (baseline and monitoring) and results of both.
The average age was 56.8 +/- 7.9; the men/women ratio was 10:1. 10 patients were genotype 1b. The median time from LT to baseline TE was 28 months (range: 6-142) and mean time between the two TE was 11.3 +/- 4.5 months. In group A there was an increase of LS in 10/13 cases (77%) while in group B there was a decrease in 3 of the 4 cases (75%). The magnitude of these changes was low, probably related to the short time between the two scans.
LS decreased in 75% of cases of recurrent hepatitis C undergoing specific treatment and increased in the same proportion of cases left to develop naturally. These results are consistent with the literature regarding the natural histological progression and regression of fibrosis in treated patients. This dynamic aspect is an advantage of the TE, allowing it to become a useful complement to biopsy.
Figueruela López, B.1; Suárez García, E.1; Aparcero López, R.1; Maraver Zamora, M.1; Morillo Verdugo, R.2; Hoyas Pablos, E.1; Romero Gómez, M.1
1NUESTRA SEÑORA DE VALME HOSPITAL, GENERAL AND DIGESTIVE SURGERY SERVICE; 2NUESTRA SEÑORA DE VALME HOSPITAL, PHARMACOLOGY UNIT. SEVILLE.
Treatment of chronic hepatitis B (CHB) with nucleoside/nucleotide analogs (NA) inhibits viral replication to prevent histological progression, to prevent the occurrence of complications, to reduce the need for liver transplantation and to improve survival.
Assess the response and long-term prognosis in a cohort of patients with CHB treated with NA. Methodology Retrospective analysis of a patients' database with CHB treated with NA before 2007. Liver and kidney laboratory tests were carried out and baseline HBV DNA levels were measured every 3-6 months. Virologic breakthrough (VB), no response and negative HBV DNA were defined according to accepted criteria (EASL). Kidney damage was considered when creatinine ≥ 1.5 mg/dl or creatinine clearance ≤ 50 ml/m
52 patients (73% men), whose average age was 46.8 (22-76) and 79% had HBeAg-negative. A biopsy was performed in 32 patients: 54% of them had portal inflammation ≥ 2 and 37% of them had fibrosis ≥ 2. 22 patients had cirrhosis. The mean baseline ALT was 145 IU/l and the mean baseline HBV DNA was 2176411 IU/ml. Patients were treated with lamivudine (28 patiens), adefovir (17 patients) and a combination of both (7 patients). The median follow-up was 82.7 months (5-123). 26 patients developed VB and 73% of them mutations. 11 continued with the same treatment and it was changed in 41 (55% due to VB, 19% due to cost-effectiveness, 13% due to renal impairment and 11% because they did not respond to treatment). At the end of the follow-up period 28 patients were being treated with tenofovir (14 in monotherapy and 14 in combination with other medicine), 12 with adefovir (6 in monotherapy and 6 in combination with other medicine), 7 with entecavir, 2 with lamivudine and 3 were without treatment. HBV DNA was negative in 87% of patients (100% of those who were still being treated). 5/11 HBeAg (+) seroconverted. HBsAg became negative in 10% of patients, all HBeAg at baseline (-) (3 patients developed antiHBs). 29% of the patients treated with adefovir showed renal damage. Fibrosis improvements were observed with respect to the baseline biopsy (1.27 vs 2.07; p = 0.009) in 15 patients who underwent elastography. From the patients with cirrhosis, 18% had decompensation, 18% developed hepatocellular carcinoma and 9% were transplanted. The overall actuarial survival was 88%. 3 patients died due to complications in the liver and 3 more due to non-hepatic tumors.
CHB treatment with nucleoside/nucleotide analogs in our cohort achieved viral load to become negative in all patients on the long-term, eliminating the infection in 12% of HBeAg negative patients, improving fibrosis and achieving a high survival rate.
Romo, G.; Martínez, E.; Viñolo, C.; Estévez, M.; Gallardo, F.; Jordán, T.; Gallego, F.
PONIENTE HOSPITAL, GASTROENTEROLOGY SERVICE.
Strongyloidiasis is an endemic infection in tropical and subtropical regions, which can manifested exceptionally in its disseminated form as cholestatic hepatitis. We present the case of a 37 year old man, born in Gambia, resident in Spain for 5 years, with no remarkable personal or family history who was admitted because of 2 weeks history of painless cholestatic jaundice. From the results of the laboratory tests, the following could be noted: GOT: 108 U/L, GPT 87 U/L, GGT 160 U/L, FA 540 U/L, BT 15.2 mg/dl (BD: 7 mg/dl) and eosinophilia. The imaging tests ruled out an extrahepatic cause of cholestasis. Other causes of cholestatic hepatitis (alcohol, drugs, hepatotropic virus, etc.) were also ruled out by directed anamnesis and laboratory tests. Given these findings, a liver biopsy was performed showing a portal tract inflammatory infiltrate (lymphocytes, histiocytes, neutrophils and eosinophils) and canalicular cholestasis in the perivenular region which suggested toxic hepatitis versus systemic infectious process. Given the geographic area where the patient was born, specific serology tests were performed with positive findings for: strongyloides stercoralis (SS), schistosoma and Rickettsia conorii. A duodenal aspirate finally confirmed the presence of SS, so that cyclic treatment was started with Ivermectin and Albendazole, solving the pathology. This case represents a rare cause of cholestatic hepatitis caused by the parasite SS invasion of the intrahepatic bile canaliculi, which, although rare, must be taken into account in areas of high immigration concentration.
Peña Ojeda, J.; Monrobel Lancho, A.; Chicano Gallardo, M.; Pérez de Luque, D.
MONTILLA HOSPITAL. ALTO GUADALQUIVIR HOSPITAL.
To describe the initial experience and the usefulness of double-balloon enteroscopy (DBE) in a regional hospital.
Analysis of consecutive procedures performed between May 2008 and June 2011 using the double-balloon enteroscopy Fujinon EN-450P5 model.
14 procedures performed in 12 patients, 6 men and 6 women whose average age was 51 (23-77). The symptoms were: * Persistent iron deficiency anemia of unknown origin in 5 cases (45%). * Suspected inflammatory bowel disease (IBD) affecting the small bowel in 4 cases (36%). * Abdominal pain in 1 case. * Persistent vitamin B12 deficiency in 1 case. * Lower gastrointestinal bleeding of unknown cause in 1 case. DBE was performed in 9 patients through the anus, 1 orally and by both routes in 2 cases. The chosen path depended on the clinical suspicions and/or alterations in previous tests. The maximum distance reached orally was 250 cm, reaching the first sections of the proximal ileum in all cases. Through the anal route it was possible to pass the ileocecal valve in all patients, in 6 it was possible to reach the medium ileum being 150 cm the maximum distance examined from the ileocecal valve. Pathological changes were found in 7 patients: 4 were diagnosed with ileal Crohn's disease, 1 had a submucosal tumor in the ileum and 2 had an ulcerated stenosis in the ileum. DBE did not detect lesions in the other 5 patients: 3 of them had anemia and 2 of them maintained a chronic use of NSAIDs, 1 had started treatment for high suspicion of Crohn's disease that was considered in remission at the time of testing and in 1 of them DBE ruled out the injuries suggested by the previous imaging techniques (scintigraphy). No patient suffered any complications.
DBE is a safe and reliable way to explore the small bowel. In selected patients it has a high diagnostic yield and it constitutes the ultimate test to confirm a suspected diagnosis of previously undetected lesions or ruling out definitively the existence of a suspected pathology observed in the radiological tests.
Matas Cobos, A.; González Artacho, C.; Ojeda Hinojosa, M.; Espinosa Aguilar, M.; de Teresa Galván, J.
Fulminant liver failure (FLF) is a rare entity with diverse etiology and a high mortality rate ranging from 70% to 90%. Transplant is the only curative treatment, but it is a radical treatment option with high risk, and implies a permanent immunosuppressive therapy.
Analyze the incidence of FLF in our unit from April 2002 to July 2011.
Observational retrospective study including those patients who had a fulminant liver failure in the period under study. Data were analyzed with SPSS-15.0 statistical software. Results 8 (3.52%, 4 men and 4 women) out of the 227 patients with liver transplant in our unit, underwent it due to fulminant liver failure. Their average age was 30 (the youngest was 20 and the oldest was 49). Causes of FLF: 1 patient due to intake of paracetamol (12.5%), 3 patients due to ecstasy consumption (37.5%), 1 due to viral infection (12.5%) and in 3 patients the cause was not determined (37.55). 3 of the 8 patients died (37.5%). The death causes were: intraoperative death, late stenosis of the hepatic artery and cholangiocarcinoma.
Liver transplantation is currently the treatment of choice for acute liver failure patients who have poor prognosis. The most common cause of FLF in our unit is ecstasy consumption. The survival rate of patients transplanted for ALF is lower than that in patients transplanted for chronic diseases because of the urgency and the clinical status of the recipient.
Navarrete, N.1; Troncoso, S.1; Muñoz, M.1; Sánchez-ángulo, J.2; García, I.1; Fernández, C.1; Blanco, M.1; López-cepero, J.1 1JEREZ DE LA FRONTERA GENERAL HOSPITAL, GENERAL AND DIGESTIVE SURGERY SERVICE; 2JEREZ DE LA FRONTERA GENERAL HOSPITAL, CRITICAL-CARE UNIT AND EMERGENCY SERVICES;
Clinical pathways (CP) are multidisciplinary and sequential care plans applied to patients with a given disease which has a predictable clinical course. Our unit developed and implemented the CP for the management of UGIB.
In order to do it a multidisciplinary working group was set up which in first place conducted a search of literature supporting the development of the CP, in order to adapt it later to our work environment. Evaluation indicators were also agreed. After months of implementation, the data were analyzed retrospectively by reviewing medical records. Results From April 2010 to January 2011, the general and digestive surgery service treated a total of 57 patients with UGIB without portal hypertension, 9 of whom were early discharged and 56 patients were performed oral endoscopy within 24 hours. 22 cases of UGIB secondary to portal hypertension were treated, all them being admitted to hospital. Oral endoscopy was performed in 19 patients within 12 hours and 20 of them received prophylactic antibiotics since the moment their diagnosis was confirmed. In 2009 we had a 74 day potential gain in patients with UGIB while in 2010, 7 hospital stays were not necessary; on the whole, a positive variation of 81 hospital stays saved. Conclusions UGIB is a condition that benefits from CPs as they enable to match resources to needs, avoiding variability and working supported by scientific evidence.
García Caparros, C.; Ruiz Cuesta, P.; García Sánchez, V.; Iglesias Flores, E.; Jurado García, J.; Marín Pedrosa, S.; Gómez Camacho, F.
Inflammatory bowel disease (IBD) can affect patients between 60 and 80. This population group has special characteristics that may make them more susceptible to develop complications related with the disease and treatments. There are few data that allow us nowadays to know the severity of the disease in this population group. Aim of this study To determine the severity of IBD in older-aged patients.
Methods and Approach
Retrospective, observational, case-control study. We identified all patients diagnosed with IBD who were older than 60 (case patients) and those who were between 20-40 (control patients) using the ENEIDA database. Two controls were taken randomly for each case. The disease was defined as severe or complicated in patients who presented within three years after diagnosis: stenosing or fistulizing disease in the case of CD, complications such as abdominal abscesses, toxic megacolon, severe bleeding or perforation, need for immunomodulators or biological treatment, and mortality.
220 patients were included in the study: 72 case patients (77.8% with UC and 22.2% with CD whose average age was 74±6.1, range 62-91) and 148 control patients (54.7% with UC and 45.3% with CD whose average age was 31.8±5, range 22-40). 153 of the total patients had an uncomplicated disease (59 case patients and 94 control patients) and 67 patients had a complicated disease (13 case patients and 54 control patients). Control patients had a complicated disease with a significance level of p = 0.005, above all by the presence of fistulizing CD (p = 0.024) and the need for immunomodulators or biological treatment (p = 0.0103). From the group of patients with a complicated disease, the most frequent complication was the presence of severe bleeding (p = 0.023).
Older-aged patients diagnosed with IBD did not have a more severe form of the disease than young patients during the first years after diagnosis, although they have more bleeding-related complications.
Grilo Bensusan, I.; Gomez Delgado, E.; Ruz Segura, I.
ECIJA HOSPITAL. APES. BAJO GUADALQUIVIR. GASTROENTEROLOGY SERVICE.
Presenting a model of organization of the consultation for dyspepsia in a single act (SA). To analyze the appropriateness of the referral, the use of resources and usefulness of training to improve referral.
Descriptive prospective study of patients with dyspepsia referred to SA consultation between January and July 2011. Conducting a training session in each health center between February and March.
5 weekly consultation appointments were offered through the Diraya appointment system and there were 3 appointments that day 3 for endoscopy in SA. 117/135 (87.3%) patients were treated. 41 (57%) out of the 71 appointments for endoscopy were treated. Referral was successful in 41/117 (35%) patients without differences between the health centers (p = 0.9). There were differences between the months before and after training (14.3 vs. 41.6%) (p = 0.008). Of all patients referred, 65 (55%) had dyspepsia, their average age was 41 (27 to 55.5) and most patients were women, 43 (66.2%). The main cause of wrong referral among dyspeptic patients was the lack of criteria for endoscopy 15 (65.2%).It was not possible to perform endoscopy in 8 patients for non-fasting. The most frequent diagnosis was functional dyspepsia in 33 cases (50.8%).
Appropriate referral was low in the SA consultation model for dyspepsia in our area, mainly due to the appointment of patients without dyspepsia. Training can improve this referral, although other organizational models could be used.
Rincón Gatica, A.; Marquez Galisteo, C.; de La Cruz Martinez, M.; Leo Carnerero, E.; Sousa Martin, J.; Trigo Salado, C.
VIRGEN DEL ROCIO UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE.
To analyze the characteristics of cases of groove pancreatitis from our unit. This is a special type of chronic pancreatitis characterized by focal inflammation at the area level pancreaticoduodenal groove secondarily affecting the duodenum.
Descriptive and retrospective study of 11 cases of diagnosed groove pancreatitis in our unit.
We analyzed a series of 11 cases, 10 men (90.9%) and 1 woman with an average age of 49 (range 37-78). The etiology was alcohol in all men and idiopathic in the woman. Amylase determinations at admission ranged from 86 to 1727 mU/ml. The radiological diagnosis was based on an abdominal CT scan with contrast in 5 cases (45%) and on an abdominal MRI in the remaining 6 (55%). Duodenal stenosis was found in 6 cases and 4 of them (36 %) required surgery (cephalic duodenopancreatectomy) correlating the findings of imaging techniques to the pathology study of surgical specimens.
Groove pancreatitis is not a very well known entity although there are descriptions from the 70's. It should be considered in the differential diagnosis of masses in tumors of the pancreatic head and in duodenal stenosis. Initial treatment should be conservative reserving surgery (cephalic duodenopancreatectomy) when symptoms persist or when there are complications such as duodenal or bile duct obstruction.
Ojeda Hinojosa, M.; Martos-ruiz, V.; Matas Cobos, A.; González Artacho, C.; de Teresa Galvan, J.
VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE
To evaluate the efficacy and complications of performing endoscopic dilation of symptomatic intestinal stenosis in patients with IBD.
Until 2011 we have performed in our service fourteen endoscopic dilations in patients with IBD. The features analyzed were the following: type of IBD (Crohn's disease = 85.5%, UC = 14.8%), median time from the diagnosis of the disease to dilation (10.5 years), location (surgical anastomosis to be noted, accounting for 56.2 % of indications), type of dilator (rigid + penumatic = 14.8%; pneumatic = 85.8%), complications (perforation = 7.1%, bleeding = 7.1% , failure of the technique = 14.2%), median time to relapse (9.5 months), average number of dilatations per patient (1.78), and treatment at the time of dilation (mesalazine = 78.5%; azathioprine = 64.2%, mercaptopurine = 7.1%; infliximab = 7.1%, adalimumab = 7.1 %). Mean follow-up was 39 months.
- High percentage of relapses after performing the procedure (57.1%), most of them (75%) undergoing surgery later. This figure is higher than previously reported in the literature, something that could be related to the poor performance of the technique in these patients.
- We consider, however, that it is a valid option in certain cases, such as patients at high surgical risk or patients who had already undergone several intestinal operations.
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