Scielo RSS <![CDATA[Revista Española de Enfermedades Digestivas]]> http://scielo.isciii.es/rss.php?pid=1130-010820160004&lang=pt vol. 108 num. 4 lang. pt <![CDATA[SciELO Logo]]> http://scielo.isciii.es/img/en/fbpelogp.gif http://scielo.isciii.es <![CDATA[<b>Questionnaires for the diagnosis of gastroesophageal reflux disease</b>: <b>are they really useful for a diagnostic goal?</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Sensitivity and specificity of the Gastrointestinal Short Form Questionnaire in diagnosis of gastroesophageal reflux disease</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400002&lng=pt&nrm=iso&tlng=pt Introduction: Gastrointestinal Short Form Questionnaire (GSFQ) is a questionnaire for gastroesophageal reflux disease (GERD) diagnosis, with a version in Spanish language, not yet compared to an objective test. Aims: To establish GSFQ diagnostic performance against 24-hour pH monitoring carried out in two tertiary care hospitals. Methods: Consecutive adult patients with typical GERD symptoms (heartburn, regurgitation) referred for pH monitoring fulfilled the GSFQ (score range 0-30, proportional to probability of GERD). Diagnosis of GERD was established when acid exposure time in distal esophagus was superior to 4.5% or symptom association probability was greater than 95%. Receiver-operator characteristic (ROC) curves were calculated and best cut-off score determined, with corresponding sensitivity, specificity and likelihood ratios (LR) (95% confidence interval for each). Results: One hundred and fifty-two patients were included (59.9% women, age 47.9 ± 13.9; 97.4% heartburn; 71.3% regurgitation). pH monitoring was abnormal in 65.8%. Mean GSFQ score was 11.2 ± 6. Area under ROC was 56.5% (47.0-65.9%). Optimal cut-off score was 13 or greater: sensitivity 40% (30.3-50.3%), specificity 71.2% (56.9-82.9%), positive LR 1.39 (0.85-2.26) and negative LR 0.84 (0.67-1.07). Exclusion of questions 1 and 3 of the original GSFQ, easily interpreted as referred to dyspepsia and not GERD, improved only marginally the diagnostic performance: AUROC 59.1%. Conclusion: The GSFQ does not predict results of pH monitoring in patients with typical symptoms in a tertiary care setting.<hr/>Introducción: el Cuestionario Gastrointestinal Corto (GSFQ) es un cuestionario diseñado para el diagnóstico de enfermedad por reflujo gastroesofágico (ERGE), con versión en español. No ha sido comparado con una prueba diagnóstica objetiva. Objetivos: determinar el poder diagnóstico del GSFQ usando como referencia la pH-metría de 24 horas en dos hospitales de tercer nivel. Métodos: pacientes adultos consecutivos con síntomas típicos de ERGE (pirosis, regurgitación), a los que se solicita pH-metría, rellenaron el GSFQ (rango puntuación 0-30, proporcional a probabilidad de ERGE). Se estableció el diagnóstico de ERGE cuando la exposición ácida del esófago distal fue superior a 4,5% o cuando la probabilidad de asociación sintomática fue superior al 95%. Se calcularon curvas ROC (receiver operator characteristic) y se determinó el mejor punto de corte, con sus correspondientes sensibilidad, especificidad y ratios de probabilidad (LR) (intervalo de confianza del 95% para cada determinación). Resultados: se incluyeron 152 pacientes (59,9% mujeres; edad 47,9 ± 13,9; 97,4% pirosis; 71,3% regurgitación). La pH-metría fue patológica en el 65,8%. La puntuación media del GSFQ fue 11,2 ± 6. El área bajo la curva ROC fue 56,5% (47-65,9%). El punto de corte óptimo fue 13 o mayor: sensibilidad 40% (30,3-50,3%), especificidad 71,2% (56,9-82,9%), LR positiva 1,39 (0,85-2,26) y LR negativa 0,84 (0,67-1,07). Excluir las preguntas 1 y 3 del GSFQ, referidas a síntomas parecidos a los de la dispepsia, mejoró sólo marginalmente el poder diagnóstico (AUROC 59,1%). Conclusión: el GSFQ no predice los resultados de la pH-metría en pacientes con síntomas típicos de ERGE en un entorno de hospital terciario. <![CDATA[<b>Health-related quality of life and determinant factors in celiac disease</b>: <b>a population-based analysis of adult patients in Spain</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400003&lng=pt&nrm=iso&tlng=pt Background: Celiac disease (CD) has a negative impact on the health-related quality of life (HRQL) of affected patients. Although HRQL and its determinants have been examined in Spanish CD patients specifically recruited in hospital settings, these aspects of CD have not been assessed among the general Spanish population. Methods: An observational, cross-sectional study of a non-randomized, representative sample of adult celiac patients throughout all of Spain's Autonomous Regions. Subjects were recruited through celiac patient associations. A Spanish version of the self-administered Celiac Disease-Quality of Life (CD-QOL) questionnaire was used. Determinant factors of HRQL were assessed with the aid of multivariate analysis to control for confounding factors. Results: We analyzed the responses provided by 1,230 patients, 1,092 (89.2%) of whom were women. The overall mean value for the CD-QOL index was 56.3 ± 18.27 points. The dimension that obtained the most points was dysphoria, with 81.3 ± 19.56 points, followed by limitations with 52.3 ± 23.43 points; health problems, with 51.6 ± 26.08 points, and inadequate treatment, with 36.1 ± 21.18 points. Patient age and sex, along with time to diagnosis, and length of time on a gluten-free diet were all independent determinant factors of certain dimensions of HRQL: women aged 31 to 40 expressed poorer HRQL while time to diagnosis and length of time on a gluten-free diet were determinant factors for better HRQL scores. Conclusions: The HRQL level of adult Spanish celiac subjects is moderate, improving with the length of time patients remain on a gluten-free diet. <![CDATA[<b>Endoluminal calprotectin measurement in assessment of pouchitis and a new index of disease activity</b>: <b>a pilot study</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400004&lng=pt&nrm=iso&tlng=pt Pouchitis is the most common complication following proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis (UC). To provide a standardized definition of pouchitis clinical, endoscopic and histological markers were grouped and weighted in the pouch disease activity index (PDAI). However, the delay in the assessment of the final score due to the time requested for histological analysis remains the main obstacle to the index implementation in clinical practice so that the use of modified-PDAI (mPDAI) with exclusion of histologic subscore has been proposed. We tested the ability of calprotectin measurement in the pouch endoluminal content to mimic the histologic score as defined in the PDAI, the index that we adopted as gold standard for pouchitis diagnosis. Calprotectin was measured by ELISA in the pouch endoluminal content collected during endoscopy in 40 consecutive patients with J-pouch. In each patient PDAI and mPDAI were calculated and 15% of patients were erroneously classified by mPDAI. ROC analysis of calprotectin values vs. acute histological subscore ≥ 3 identified different calprotectin cut-off values with corresponding sensitivity and specificity allowing the definition and scoring of different range of calprotectin subscores. We incorporated the calprotectin score in the mPDAI obtaining a new score that shows the same specificity as PDAI for diagnosis of pouchitis and higher sensitivity when compared with mPDAI. The use of the proposed new score, once validated in a larger series of patients, might be useful in the early management of patients with symptoms of pouchitis. <![CDATA[<b>Endoscopic incision for the treatment of refractory esophageal anastomotic strictures</b>: <b>outcomes of 13 cases with a minimum follow-up of 12 months</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400005&lng=pt&nrm=iso&tlng=pt Background and aim: Endoscopic incision is an alternative method for refractory esophageal strictures; however, little is known about its long-term efficacy. The aim of the study is to assess the long-term outcomes of endoscopic incision for treating refractory esophageal anastomotic strictures. Methods: Between September 2011 and September 2014, 13 patients with refractory esophageal anastomotic strictures were treated with endoscopic incision. Their clinical data were retrospectively collected to evaluate the efficacy and safety of the technique. Results: All the 13 patients underwent the procedure successfully with median operation duration of 15 minutes. A total of 27 sessions were necessary to maintain lumen patency until September 2015, and 7 patients needed retreatment. The symptoms relieved in all the cases, and the median dysphagia score decreased from 4 to 1 during a median follow-up of 24 months. The median diameter of stricture was enlarged from 4 mm to 12 mm. As a short-term effect, dysphagia symptoms improved in 100% (13/13), 84.6% (11/13) and 76.9% (10/13) of the patients one, three and six months after a single treatment. As long-term effect, the dysphagia improved in 61.5% (8/13), 63.6% (7/11) and 60% (6/10) of the patients 12, 18 and 24 months after a single treatment. Conclusions: The efficacy of endoscopic incision is favorable in the short term. However, retreatment is needed to maintain the long-term lumen patency for parts of the patients. <![CDATA[<b>Endoscopic sleeve gastroplasty (the Apollo method)</b>: <b>a new approach to obesity management</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400006&lng=pt&nrm=iso&tlng=pt Background: Many obese patients cannot lose weight or reject conventional obesity management. Endoscopic sleeve gastroplasty (the Apollo method) is a pioneering coadjuvant, interventionist technique for the integral management of obesity. Objectives: The goals of this study were to report safety and efficacy results obtained at 6 months in patients undergoing endoscopic sleeve gastroplasty. Material and methods: A prospective study was performed in 55 patients (13 males, 42 females) who were subjected to the Apollo technique; mean age was 43.5 years (range 25-60) and mean BMI was 37.7 kg/m² (range 30-48). All received multidisciplinary follow-up for weight loss. Weight changes and presence of complications were assessed. Through the endoscope a triangular pattern suture is performed consisting of approximately 3-6 transmural (mucosa to serosa) stitches, using a cinch device to bring them nearer and form a plication. Results: A total of 6-8 plications are used to provide a tubular or sleeve-shaped restriction to the gastric cavity. No major complications developed and patients were discharged at 24 hours following the procedure. Endoscopic and radiographic follow-up at 6 months post-procedure showed a well preserved tubular form to the stomach. After 6 months patients had lost 18.9 kg and 55.3% of excess weight. Conclusions: Endoscopic sleeve gastroplasty, together with dietary and psycho-behavioral changes, is a safe, effective technique in the coadjuvant management of obese patients.<hr/>Introducción: muchos pacientes obesos no son capaces de perder peso o rechazan los tratamientos convencionales de la obesidad. La gastroplastia endoscópica en manga (método Apollo) es una técnica intervencionista pionera coadyuvante para el tratamiento integral de la obesidad. Objetivos: los objetivos de este estudio son comunicar resultados de seguridad y eficacia a 6 meses de pacientes intervenidos de gastroplastia endoscópica en manga. Material y métodos: se realizó un estudio prospectivo de intervención sobre 55 pacientes (13 hombres, 42 mujeres) sometidos a método Apollo, con edad media de 43,5 años (rango 25-60) e índice de masa corporal (IMC) medio de 37,7 kg/m² (rango 30-48), y a seguimiento multidisciplinar para perder peso. Se evaluaron cambios ponderales y presencia de complicaciones. A través de un endoscopio se realizó un patrón de sutura triangular, consistente en aproximadamente 3-6 puntos transmurales (de mucosa a serosa) que, mediante un sistema de cinchado, aproxima los puntos para formar una plicatura. Resultados: en total se realizaron entre 6-8 plicaturas para crear la restricción tubular o en manga de la cavidad gástrica. No existieron complicaciones mayores y los pacientes fueron dados de alta 24 horas después de la intervención. Los controles endoscópicos y radiográficos a los 6 meses postprocedimiento mostraron conservación de la forma tubular gástrica. Los pacientes con 6 meses de evolución perdieron 18,9 kg y un 55,3% de porcentaje de exceso de peso. Conclusiones: la gastroplastia endoscópica en manga, junto a la intervención dietética y modificación psicoconductual en pacientes obesos, es una técnica segura y eficaz en el tratamiento coadyuvante de la obesidad. <![CDATA[<b>Proton-pump inhibitors adverse effects</b>: <b>a review of the evidence and position statement by the Sociedad Española de Patología Digestiva</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400007&lng=pt&nrm=iso&tlng=pt Introduction: In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. Objective: The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. Material and methods: A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. Results: Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. Conclusions: PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.<hr/>Introducción: en los últimos años, numerosos artículos relacionan el uso de los inhibidores de la bomba de protones (IBP) con posibles efectos adversos serios que han creado cierta alarma social. Objetivo: el objetivo de este trabajo es revisar la literatura de cara a elaborar un documento institucional de posicionamiento de la Sociedad Española de Patología Digestiva (SEPD) sobre la seguridad de los IBP a largo plazo. Material y métodos: se ha realizado una revisión exhaustiva de la literatura orientada a la presentación de conclusiones tras una valoración crítica sobre los siguientes temas: a) indicaciones actuales de los IBP; b) déficit de vitamina B12 y alteraciones neurológicas; c) déficit de magnesio; d) fracturas óseas; e) infecciones entéricas y neumonías; f) interacción con los derivados de las tienopiridinas; y e) complicaciones en pacientes cirróticos. Resultados: las indicaciones actuales de los IBP no han variado en los últimos años y están bien establecidas. No se recomienda la realización de un cribado generalizado de los niveles de vitamina B12 en todos los pacientes tratados de forma crónica con estos medicamentos; sin embargo, sí parece necesario controlar los niveles de magnesio al inicio del tratamiento y monitorizarlos en pacientes con toma de otros fármacos que puedan inducir hipomagnesemia. Existe mayor riesgo de fracturas óseas, aunque no se puede concluir que esta asociación sea causal. La asociación IBP e infección por Clostridium difficile es débil o moderada y el riesgo de neumonía es bajo. En pacientes con riesgo cardiovascular y tratados con derivados de las tienopiridinas -dada la ausencia de evidencias definitivas en relación a posibles interacciones medicamentosas- parece que lo prudente sea sopesar adecuadamente los riesgos gastrointestinales y los riesgos cardiovasculares de cada paciente; cuando el riesgo gastrointestinal sea moderado/alto, debemos ejercer una acción terapéutica de prevención efectiva utilizando un IBP. En cirróticos descompensados deben ser indicados con cautela. Conclusiones: los IBP son fármacos seguros y los beneficios de su empleo, tanto a corto como a largo plazo superan los posibles efectos secundarios, siempre que la indicación, dosis y duración sean las adecuadas. <![CDATA[<b>Successive breaks in biliary stents</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400008&lng=pt&nrm=iso&tlng=pt Introduction: In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. Objective: The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. Material and methods: A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. Results: Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. Conclusions: PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.<hr/>Introducción: en los últimos años, numerosos artículos relacionan el uso de los inhibidores de la bomba de protones (IBP) con posibles efectos adversos serios que han creado cierta alarma social. Objetivo: el objetivo de este trabajo es revisar la literatura de cara a elaborar un documento institucional de posicionamiento de la Sociedad Española de Patología Digestiva (SEPD) sobre la seguridad de los IBP a largo plazo. Material y métodos: se ha realizado una revisión exhaustiva de la literatura orientada a la presentación de conclusiones tras una valoración crítica sobre los siguientes temas: a) indicaciones actuales de los IBP; b) déficit de vitamina B12 y alteraciones neurológicas; c) déficit de magnesio; d) fracturas óseas; e) infecciones entéricas y neumonías; f) interacción con los derivados de las tienopiridinas; y e) complicaciones en pacientes cirróticos. Resultados: las indicaciones actuales de los IBP no han variado en los últimos años y están bien establecidas. No se recomienda la realización de un cribado generalizado de los niveles de vitamina B12 en todos los pacientes tratados de forma crónica con estos medicamentos; sin embargo, sí parece necesario controlar los niveles de magnesio al inicio del tratamiento y monitorizarlos en pacientes con toma de otros fármacos que puedan inducir hipomagnesemia. Existe mayor riesgo de fracturas óseas, aunque no se puede concluir que esta asociación sea causal. La asociación IBP e infección por Clostridium difficile es débil o moderada y el riesgo de neumonía es bajo. En pacientes con riesgo cardiovascular y tratados con derivados de las tienopiridinas -dada la ausencia de evidencias definitivas en relación a posibles interacciones medicamentosas- parece que lo prudente sea sopesar adecuadamente los riesgos gastrointestinales y los riesgos cardiovasculares de cada paciente; cuando el riesgo gastrointestinal sea moderado/alto, debemos ejercer una acción terapéutica de prevención efectiva utilizando un IBP. En cirróticos descompensados deben ser indicados con cautela. Conclusiones: los IBP son fármacos seguros y los beneficios de su empleo, tanto a corto como a largo plazo superan los posibles efectos secundarios, siempre que la indicación, dosis y duración sean las adecuadas. <![CDATA[<b>Mechanical intestinal obstruction secondary to congenital diaphragmatic hernia in an adult</b>: <b>report of a case</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400009&lng=pt&nrm=iso&tlng=pt Introduction: In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. Objective: The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. Material and methods: A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. Results: Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. Conclusions: PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.<hr/>Introducción: en los últimos años, numerosos artículos relacionan el uso de los inhibidores de la bomba de protones (IBP) con posibles efectos adversos serios que han creado cierta alarma social. Objetivo: el objetivo de este trabajo es revisar la literatura de cara a elaborar un documento institucional de posicionamiento de la Sociedad Española de Patología Digestiva (SEPD) sobre la seguridad de los IBP a largo plazo. Material y métodos: se ha realizado una revisión exhaustiva de la literatura orientada a la presentación de conclusiones tras una valoración crítica sobre los siguientes temas: a) indicaciones actuales de los IBP; b) déficit de vitamina B12 y alteraciones neurológicas; c) déficit de magnesio; d) fracturas óseas; e) infecciones entéricas y neumonías; f) interacción con los derivados de las tienopiridinas; y e) complicaciones en pacientes cirróticos. Resultados: las indicaciones actuales de los IBP no han variado en los últimos años y están bien establecidas. No se recomienda la realización de un cribado generalizado de los niveles de vitamina B12 en todos los pacientes tratados de forma crónica con estos medicamentos; sin embargo, sí parece necesario controlar los niveles de magnesio al inicio del tratamiento y monitorizarlos en pacientes con toma de otros fármacos que puedan inducir hipomagnesemia. Existe mayor riesgo de fracturas óseas, aunque no se puede concluir que esta asociación sea causal. La asociación IBP e infección por Clostridium difficile es débil o moderada y el riesgo de neumonía es bajo. En pacientes con riesgo cardiovascular y tratados con derivados de las tienopiridinas -dada la ausencia de evidencias definitivas en relación a posibles interacciones medicamentosas- parece que lo prudente sea sopesar adecuadamente los riesgos gastrointestinales y los riesgos cardiovasculares de cada paciente; cuando el riesgo gastrointestinal sea moderado/alto, debemos ejercer una acción terapéutica de prevención efectiva utilizando un IBP. En cirróticos descompensados deben ser indicados con cautela. Conclusiones: los IBP son fármacos seguros y los beneficios de su empleo, tanto a corto como a largo plazo superan los posibles efectos secundarios, siempre que la indicación, dosis y duración sean las adecuadas. <![CDATA[<b>Unusual presentation of Gilbert disease with high levels of unconjugated bilirubin</b>: <b>report of two cases</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400010&lng=pt&nrm=iso&tlng=pt Gilbert's syndrome is a benign condition characterized by asymptomatic sporadic episodes of jaundice, due to a mild unconjugated hyperbilirubinemia caused by a deficiency in bilirubin glucoronidation. Under certain physiologic or pathologic events, bilirubin level rises but according to literature it does not reach out more than 3 mg/dl. We report 2 cases of Gilbert's syndrome, genetically tested, which presented with bilirubin levels above 6 mg/dl without any trigger or coexisting condition. In conclusion, bilirubin levels higher than 6 mg/dl in Gilbert syndrome are rare, hemolytic and other metabolism diseases must be ruled out, and genetic testing may be necessary in some cases. <![CDATA[<b>Primary peritonitis by <i>Streptococcus pyogenes</i></b>: <b>a condition as rare as it is aggressive</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400011&lng=pt&nrm=iso&tlng=pt Gilbert's syndrome is a benign condition characterized by asymptomatic sporadic episodes of jaundice, due to a mild unconjugated hyperbilirubinemia caused by a deficiency in bilirubin glucoronidation. Under certain physiologic or pathologic events, bilirubin level rises but according to literature it does not reach out more than 3 mg/dl. We report 2 cases of Gilbert's syndrome, genetically tested, which presented with bilirubin levels above 6 mg/dl without any trigger or coexisting condition. In conclusion, bilirubin levels higher than 6 mg/dl in Gilbert syndrome are rare, hemolytic and other metabolism diseases must be ruled out, and genetic testing may be necessary in some cases. <![CDATA[<b>Endobronchial metastases of colorectal cancer</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400012&lng=pt&nrm=iso&tlng=pt Gilbert's syndrome is a benign condition characterized by asymptomatic sporadic episodes of jaundice, due to a mild unconjugated hyperbilirubinemia caused by a deficiency in bilirubin glucoronidation. Under certain physiologic or pathologic events, bilirubin level rises but according to literature it does not reach out more than 3 mg/dl. We report 2 cases of Gilbert's syndrome, genetically tested, which presented with bilirubin levels above 6 mg/dl without any trigger or coexisting condition. In conclusion, bilirubin levels higher than 6 mg/dl in Gilbert syndrome are rare, hemolytic and other metabolism diseases must be ruled out, and genetic testing may be necessary in some cases. <![CDATA[<b>Diarrhea caused by multiparasitic infection</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400013&lng=pt&nrm=iso&tlng=pt Gilbert's syndrome is a benign condition characterized by asymptomatic sporadic episodes of jaundice, due to a mild unconjugated hyperbilirubinemia caused by a deficiency in bilirubin glucoronidation. Under certain physiologic or pathologic events, bilirubin level rises but according to literature it does not reach out more than 3 mg/dl. We report 2 cases of Gilbert's syndrome, genetically tested, which presented with bilirubin levels above 6 mg/dl without any trigger or coexisting condition. In conclusion, bilirubin levels higher than 6 mg/dl in Gilbert syndrome are rare, hemolytic and other metabolism diseases must be ruled out, and genetic testing may be necessary in some cases. <![CDATA[<b>Hiatal herniation following total gastrectomy</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400014&lng=pt&nrm=iso&tlng=pt Gilbert's syndrome is a benign condition characterized by asymptomatic sporadic episodes of jaundice, due to a mild unconjugated hyperbilirubinemia caused by a deficiency in bilirubin glucoronidation. Under certain physiologic or pathologic events, bilirubin level rises but according to literature it does not reach out more than 3 mg/dl. We report 2 cases of Gilbert's syndrome, genetically tested, which presented with bilirubin levels above 6 mg/dl without any trigger or coexisting condition. In conclusion, bilirubin levels higher than 6 mg/dl in Gilbert syndrome are rare, hemolytic and other metabolism diseases must be ruled out, and genetic testing may be necessary in some cases. <![CDATA[<b>Ulcerative colitis in a patient with common variable immunodeficiency</b>: <b>does the treatment differ from the routine?</b>]]> http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082016000400016&lng=pt&nrm=iso&tlng=pt Gilbert's syndrome is a benign condition characterized by asymptomatic sporadic episodes of jaundice, due to a mild unconjugated hyperbilirubinemia caused by a deficiency in bilirubin glucoronidation. Under certain physiologic or pathologic events, bilirubin level rises but according to literature it does not reach out more than 3 mg/dl. We report 2 cases of Gilbert's syndrome, genetically tested, which presented with bilirubin levels above 6 mg/dl without any trigger or coexisting condition. In conclusion, bilirubin levels higher than 6 mg/dl in Gilbert syndrome are rare, hemolytic and other metabolism diseases must be ruled out, and genetic testing may be necessary in some cases.