Búsqueda de un sistema de priorización de la esófago-gastro-duodenoscopia en pacientes con síntomas de enfermedad por reflujo gastroesofágico y en otras situaciones clínicas

Analizamos 907 enfermos remitidos para realización de una endoscopia digestiva alta para, basándonos en la delimitación de aquellos con ERGE, estudiar elementos de priorización. Ninguno de los factores de riesgo considerados condicionó mayor presencia de ERGE salvo la hernia de hiato. La endoscopia detectó lesiones relevantes en la mitad de los casos, especialmente cuando existían síntomas de alarma y en enfermos sin ERGE clínica, por lo que la subdivisión de los pacientes según estas dos características ayudaría a establecer un orden de prioridades. El empleo de IBPs no condicionó la relevancia de los hallazgos endoscópicos. La edad > a los 50 años en enfermos sin ERGE y el sexo masculino en el total de los casos, así como el consumo de alcohol, la cirugía previa, la presencia de disfagia y sospecha clínica de neoplasia deberían ser aspectos a considerar a la hora de fijar el momento de la endoscopia.Departamento de Medicina, Dermatología y Toxicologí

Zenker diverticulum. Report of two atypical cases and review of surgical alternatives

[ES]Introducción y objetivo: El divertículo de Zenker es una protrusión o hernia de la mucosa faríngea posterior en la unión faringoesofágica. El mecanismo etiopatogénico parece ser la relajación insuficiente del músculo cricofaríngeo. Es el divertículo esofágico más común y los síntomas predominantes son disfagia y aspiración. El tratamiento quirúrgico está indicado en pacientes sintomáticos. Existen diversas alternativas. Descripción del caso: Presentamos dos casos clínicos atípicos de divertículo de Zenker. El primero es un paciente de 56 años de edad que presenta un divertículo de Zenker asociado a un carcinoma de tiroides en el cual se lleva a cabo una tiroidectomía total y la exéresis del divertículo. El segundo caso es un paciente de 64 años pluripatológico intervenido en otro centro de un divertículo de Zenker mediante abordaje endoscópico, remitido a nuestro servicio por disnea, enfisema, neumomediastino y absceso cervicomediastínico a los 3 días de dicha intervención. Se realiza traqueotomía temporal y cervicotomía y evoluciona favorablemente. Discusión: El divertículo de Zenker es una patología rara con una prevalencia menor al 0,1%. Se disponen de varias alternativas quirúrgicas, tanto por cirugía abierta como por procedimientos endoscópicos. No hay casos descritos asociados a neoplasias tiroideas. Aunque las complicaciones postoperatorias son raras pueden ser muy graves. Conclusiones: El divertículo de Zenker es una patología infrecuente cuyo tratamiento quirúrgico no está exento de complicaciones. Hay varias alternativas terapéuticas, desde la cirugía abierta hasta la endoscopia rígida o flexible. Todos los abordajes han sido bien demostrados en manos experimentadas y ninguno en es claramente superior a los demás. [EN] Introduction and objective: Zenker`s diverticulum is a protusion or hernation of the posterior pharyngeal mucosa in the pharyngoesophageal junction. The etiopathogenic mechanism appears to be insufficient relaxation of the cricopharyngeal muscle. It`s the most common esophageal diverticulum and the predominant symptoms are dysphagia and aspiration. Surgical treatment is indicated in symptomatic patients. There are several alternatives. Case description: We present two atypical clinical cases of Zenker diverticulum. The first is a 56 yo patient diagnosed of Zenker´s diverticulum associated with thyroid carcinoma wich is performed a total thyroidectomy and excision of the diverticulum. The second case is a 64 yo pluripathological patient intervened in another center of Zenker`s diverticulum by endoscopic approach, wich is referred to our department with dyspnea, emphysema, pneumomediastinum and cervical abscess at 3 days of this intervention. Temporary tracheotomy and cervicotomy is performed and progressing favorably. Discussion: Zenker`s diverticulum is a rare pathology with a prevalence less than 0,1%. There are various surgical options both open surgery and the endoscopic procedures. There are no reported cases associated with thyroid neoplasms. Postoperative complications are rare and severe. Conclusions: Zenker`s diverticulum is a uncommon pathology and the surgical treatment is not without complications. There are various treatment options wich include open surgery and the rigid and flexible endoscopy. All approaches have been well proven in experienced hands and none is clearly superior to others

Natural history of irritable bowel syndrome

Producción CientíficaIBS). The aim of this study was to investigate the presence of chronic functional digestive symptoms in childhood, interviewing adult patients diagnosed with IBS, in an attempt to establish a relationship between them. METHODS: By means of a questionnaire, the history of colic, chronic diarrhea, functional abdominal pain, constipation and migraine in childhood, was analyzed in patients diagnosed with IBS according to the current Rome III criteria, and in control patients without known chronic digestive disorders. Fisher's exact test was used for comparison of frequencies. RESULTS: The IBS study group was made up of 40 patients (24 women; average age, 33.03 years), and the control group by 40 adults (22 women; average age, 29.62 years). IBS-diagnosed adults spoke about a significantly higher prevalence of chronic diarrhea (32.5/7.5%; odds ratio [OR], 7.01; 95% confidence interval [CI]: 26.84-1.80), and FAP (37.5/15%; OR, 4.30; 95%CI: 12.67-1.43) in their childhood, than the control group. There were no differences in the presence of other childhood functional symptoms. Interestingly, the present patients, when asked about the onset of symptoms that led to the diagnosis of IBS, referred to them mostly beginning in adulthood, not linking their current diagnosis of IBS with their background in childhood. In a proportion of adults with IBS the natural history of their symptoms probably began during their childhood.(IBS). The aim of this study was to investigate the presence of chronic functional digestive symptoms in childhood, interviewing adult patients diagnosed with IBS, in an attempt to establish a relationship between them. By means of a questionnaire, the history of colic, chronic diarrhea, functional abdominal pain, constipation and migraine in childhood, was analyzed in patients diagnosed with IBS according to the current Rome III criteria, and in control patients without known chronic digestive disorders. Fisher's exact test was used for comparison of frequencies. The IBS study group was made up of 40 patients (24 women; average age, 33.03 years), and the control group by 40 adults (22 women; average age, 29.62 years). IBS-diagnosed adults spoke about a significantly higher prevalence of chronic diarrhea (32.5/7.5%; odds ratio [OR], 7.01; 95% confidence interval [CI]: 26.84-1.80), and FAP (37.5/15%; OR, 4.30; 95%CI: 12.67-1.43) in their childhood, than the control group. There were no differences in the presence of other childhood functional symptoms. Interestingly, the present patients, when asked about the onset of symptoms that led to the diagnosis of IBS, referred to them mostly beginning in adulthood, not linking their current diagnosis of IBS with their background in childhood. In a proportion of adults with IBS the natural history of their symptoms probably began during their childhood

Accuracy of urea breath test performed immediately after emergency endoscopy in peptic ulcer bleeding

Producción CientíficaThe aim of this work is to investigate the accuracy of the urea breath test (UBT) performed immediately after emergency endoscopy in peptic ulcer bleeding (PUB). METHODS: Urea breath test was carried out right after emergency endoscopy in patients with PUB. The accuracy of this early UBT was compared to a delayed one after hospital discharge that was considered the gold standard. Clinical and epidemiological factors were analyzed in order to study their influence on the accuracy of the early UBT. RESULTS: Early UBT was collected without any complication and good acceptance from all the 74 patients included. In 53 of the patients (71.6%), a delayed UBT was obtained. Comparing concordance between the two tests we have calculated an accuracy of 83% for the early UBT. Sensibility and specificity were 86.36 and 66%, respectively, with a positive predictive value of 92.68% and negative predictive value of 50% (Kappa index = 0.468; p = 0.0005; CI: 95%). We found no influence of epidemiological factors, clinical presentation, drugs, times to gastroscopy, Forrest classification, endoscopic therapy, hemoglobin, and urea levels over the accuracy of early UBT. CONCLUSIONS: Urea breath test carried out right after emergency endoscopy in PUB is an effective, safe, and easy-to-perform procedure. The accuracy of the test is not modified by clinical or epidemiological factors, ulcer stage, or by the type of therapy applied. However, we have found a low negative predictive value for early UBT, so a delayed test is mandatory for all negative cases

Long-Term Real-World Effectiveness and Safety of Ustekinumab in Crohn’s Disease Patients: The SUSTAIN Study

Background Large real-world-evidence studies are required to confirm the durability of response, effectiveness, and safety of ustekinumab in Crohn’s disease (CD) patients in real-world clinical practice. Methods A retrospective, multicentre study was conducted in Spain in patients with active CD who had received ≥1 intravenous dose of ustekinumab for ≥6 months. Primary outcome was ustekinumab retention rate; secondary outcomes were to identify predictive factors for drug retention, short-term remission (week 16), loss of response and predictive factors for short-term efficacy and loss of response, and ustekinumab safety. Results A total of 463 patients were included. Mean baseline Harvey-Bradshaw Index was 8.4. A total of 447 (96.5%) patients had received prior biologic therapy, 141 (30.5%) of whom had received ≥3 agents. In addition, 35.2% received concomitant immunosuppressants, and 47.1% had ≥1 abdominal surgery. At week 16, 56% had remission, 70% had response, and 26.1% required dose escalation or intensification; of these, 24.8% did not subsequently reduce dose. After a median follow-up of 15 months, 356 (77%) patients continued treatment. The incidence rate of ustekinumab discontinuation was 18% per patient-year of follow-up. Previous intestinal surgery and concomitant steroid treatment were associated with higher risk of ustekinumab discontinuation, while a maintenance schedule every 12 weeks had a lower risk; neither concomitant immunosuppressants nor the number of previous biologics were associated with ustekinumab discontinuation risk. Fifty adverse events were reported in 39 (8.4%) patients; 4 of them were severe (2 infections, 1 malignancy, and 1 fever). Conclusions Ustekinumab is effective and safe as short- and long-term treatment in a refractory cohort of CD patients in real-world clinical practice

Using Interpretable Machine Learning to Identify Baseline Predictive Factors of Remission and Drug Durability in Crohn’s Disease Patients on Ustekinumab

Ustekinumab has shown efficacy in Crohn's Disease (CD) patients. To identify patient profiles of those who benefit the most from this treatment would help to position this drug in the therapeutic paradigm of CD and generate hypotheses for future trials. The objective of this analysis was to determine whether baseline patient characteristics are predictive of remission and the drug durability of ustekinumab, and whether its positioning with respect to prior use of biologics has a significant effect after correcting for disease severity and phenotype at baseline using interpretable machine learning. Patients' data from SUSTAIN, a retrospective multicenter single-arm cohort study, were used. Disease phenotype, baseline laboratory data, and prior treatment characteristics were documented. Clinical remission was defined as the Harvey Bradshaw Index <= 4 and was tracked longitudinally. Drug durability was defined as the time until a patient discontinued treatment. A total of 439 participants from 60 centers were included and a total of 20 baseline covariates considered. Less exposure to previous biologics had a positive effect on remission, even after controlling for baseline disease severity using a non-linear, additive, multivariable model. Additionally, age, body mass index, and fecal calprotectin at baseline were found to be statistically significant as independent negative risk factors for both remission and drug survival, with further risk factors identified for remission

Hepatocolic fistula managed with a novel Padlock® device for endoscopic closure

Recent advances in endoscopic therapeutics allow conditions such as fistulas of the digestive system to be treated endoscopically. These cases were recently managed with surgery. The Padlock® system includes a nitinol clip that was recently introduced for endoscopic therapy. There are few reports with regard to its use in the daily clinical practice. We report a case of a colonic fistula that was endoscopically managed with this novel over-the-scope nitinol clip system