Revista Española de Enfermedades Digestivas

Tratamiento de la infección por Helicobacter pylori: ¿pequeños remedios para grandes males?

Rentabilidad diagnóstica de la citología por cepillado de las estenosis biliares durante la CPRE

Aim: to evaluate the diagnostic yield of brush cytology for biliary strictures detected on ERCP when a systematic approach is used. Patients and methods: data on 62 consecutive patients with a biliary stricture on ERCP were collected. Cytological samples were processed immediately after brushing in the endoscopy room, and all were analyzed by the same pathologist. For the statistical analysis specimens were classified as positive, negative, suspicious for malignancy (presence of atypias), and unsatisfactory for evaluation. Final diagnosis was based on either histopathologic (surgery or biopsies by other techniques) or clinical/radiographic diagnosis. Results: a total of 71 cytological specimens were included. Definite diagnosis was malignancy in 49 samples, and benign stricture in 22. Three samples were excluded because of insufficient material or processing artifacts. The sensitivity of biliary brushing was 62% (95% CI 0.47-0.77), specificity was 100%, positive predictive value was 100%, and negative predictive value was 58% (95% CI 0.43-0.75). When suspicious samples were included as malignant, sensitivity was 67% (95% CI 0.54-0.81) without changes in the remaining parameters. Eight patients underwent more than one ERCP. Repeated brush cytology exams in these patients yielded a definitive diagnosis in every case. Conclusions: brush cytology has intermediate sensitivity with a high specificity. A systematic approach with a dedicated pathologist and the inclusion of significant atypias as malignant results improves sensitivity. Due to its simplicity brush cytology should be performed in all cases of biliary strictures detected on ERCP, and in case of repeated ERCPs additional cytology brushings are recommended.

Objetivo: evaluar la rentabilidad de la citología por cepillado de las estenosis biliares diagnosticadas por CPRE cuando se aplica una metodología sistemática. Pacientes y métodos: se recogieron muestras de 62 pacientes consecutivos con estenosis biliares diagnosticadas mediante CPRE. Las muestras citológicas eran procesadas en la sala de endoscopias inmediatamente a su obtención y analizadas por el mismo patólogo. Para el análisis estadístico se clasificaron los casos como positivos o negativos para malignidad, sospechosos (presencia de atipias) y no válidos. Los patrones de referencia fueron el estudio de las piezas quirúrgicas, biopsias por otros métodos, o la evolución clínica y/o radiológica compatible. Resultados: fueron incluidas un total de 71 citologías. El diagnóstico fue malignidad en 49 casos, benignidad en 22 casos, y 3 muestras fueron excluidas por material insuficiente o artefactos de procesamiento. La sensibilidad de la técnica fue del 62% (IC 95% 0,47-0,77), la especificidad del 100%, el valor predictivo positivo del 100% y el valor predictivo negativo del 58% (IC 95% 0,43-0,75). Al incluir las citologías sospechosas como malignas la sensibilidad fue del 67% (IC 95% 0,54-0,81) sin modificarse el resto de parámetros. En ocho pacientes fueron necesarias nuevas CPRE durante las cuales se repitieron las tomas citológicas, llegando a un diagnóstico de certeza en todos ellos. Conclusiones: la citología biliar presenta una sensibilidad intermedia con elevada especificidad. Una metodología sistemática con un patólogo dedicado y la inclusión de las citologías con atipias celulares como malignas mejora la sensibilidad de la técnica. Dada su sencillez creemos que debe de realizarse en todos los casos de estenosis biliar observada durante una CPRE, incluyendo la repetición de las tomas citológicas siempre que sea necesario practicar más de una CPRE en el mismo paciente.

Eficacia de una triple terapia con un inhibidor de la bomba de protones, levofloxacino y amoxicilina, como primer tratamiento, en la erradicación de Helicobacter pylori

Background: triple therapy including a proton pump inhibitor, clarithromycin, and amoxicillin (PPI-CA) is the first-choice treatment used for H. pylori eradication. The efficacy of this treatment is declining of late, and alternative therapies are currently under evaluation. Objectives: to evaluate the efficacy, safety and compliance of a triple therapy with a PPI, amoxicillin and levofloxacin (PPI-LA) - replacing clarithromycin - for the eradication of H. pylori. Methods: the study included 135 patients (65% women), mean age 53 years, with dyspeptic symptoms and H. pylori infection proven by a positive urease rapid test, histological analysis, or C13-urea breath test. Diagnosis: non-investigated dyspepsia 48.9%, functional dyspepsia 36.3%, and ulcerative dyspepsia 14.8%. Treatment was indicated with a proton pump inhibitor at usual doses, amoxicillin 1 g, and levofloxacin 500 mg, administered jointly during breakfast and dinner for 10 days. We studied the performance of this triple therapy and its effects using a questionnaire, and effectiveness by the negativity of the C13-urea breath test after 6-8 weeks after treatment discontinuation. Per protocol, we compared the effectiveness of PPI-LA with a control group of 270 patients treated with PPI-CA for 10 days. Results: 130 patients (96.2%) could complete the treatment and follow-up protocol. Effectiveness (intention to treat) was 71.8% (97/135) and 74.6% (per protocol) (97/130). Sixteen patients (11.8%) had well-tolerated adverse effects, except for 5 subjects (3.7%) who dropped out. PPI-CA was effective (per protocol) in 204 patients out of 270 (75.5%) in the control group. Conclusions: triple therapy with a PPI, amoxicillin and levofloxacin for 10 days is a well-tolerated treatment that is easy to comply with; however it has low efficiency - less than 80% - and is not recommended as a first-choice treatment for H. pylori eradication. Similar results were obtained with the classic triple therapy using a PPI, clarithromycin and amoxicillin.

Introducción: la triple terapia con un inhibidor de la bomba de protones, claritromicina y amoxicilina (IBP-CA) es el tratamiento de primera elección más utilizado en la erradicación de H. pylori. La eficacia de este tratamiento está disminuyendo en los últimos años y se están valorando otras alternativas terapéuticas. Objetivos:valorar la eficacia, cumplimiento y seguridad de una triple terapia con un IBP, amoxicilina y levofloxacino, sustituyendo a la claritromicina, en la erradicación de H. pylori. Métodos: periodo de estudio: 2007-2008. Se incluyen 135 pacientes (65% mujeres), edad media de 53 años, con síntomas dispépticos e infección por H. pylori, constatada por positividad del test rápido de la ureasa, histología o prueba del aliento con urea-C13. Diagnósticos: dispepsia no investigada: 48,9%, dispepsia funcional: 36,3% y dispepsia ulcerosa: 14,8%. Se indica tratamiento con un inhibidor de la bomba de protones, a dosis habitual, amoxicilina 1 g y levofloxacino 500 mg (IBP-LA), administrados de forma conjunta en desayuno y cena, durante 10 días. Se valora el cumplimiento de la triple terapia y sus efectos adversos mediante interrogatorio y su eficacia mediante la negatividad de la prueba del aliento con urea-C13 practicada a las 6-8 semanas del término del tratamiento. Se compara la eficacia, por protocolo, del tratamiento con IBP-LA con la observada en un grupo control de 270 pacientes tratados con IBP-CA durante 10 días en los años 2006-2007. Resultados: 130/135 pacientes (96,2) del grupo de estudio completaron el tratamiento y el protocolo del seguimiento. La eficacia por intención de tratar fue del 71,8% (97/135) y por protocolo del 74,6% (97/130). Dieciséis pacientes (11,8%) presentaron efectos adversos bien tolerados, excepto en 5 pacientes (3.7%) que motivan el abandono del tratamiento. El tratamiento con IBP-CA resultó eficaz, por protocolo, en 204/270 (75,5%) pacientes del grupo control. Conclusiones: la triple terapia con un IBP, amoxicilina y levofloxacino durante 10 días es un tratamiento bien tolerado, con fácil cumplimiento, pero con una baja eficacia, inferior al 80%, similar a la obtenida con la triple terapia clásica con un IBP, claritromicina y amoxicilina, no siendo un tratamiento de primera elección recomendable, en nuestra área sanitaria, en la erradicación de H. pylori.

Resección endoscópica de la mucosa con un ligador multibanda para el tratamiento de la displasia de Barret de alto grado y el cáncer gástrico precoz

Aim: due to surgery's high mortality and morbidity, local therapeutic techniques are required for Barrett's high-grade dysplasia (BHGD) and early gastric cancer (EGC). Various techniques are available for endoscopic mucosal resection (EMR) in the GI tract. The "suck and cut" technique, which uses a transparent cap or modified multiband variceal ligator, is usually the most practiced method. A multiband ligator (ML) allows sequential resection without the need for submucosal injection and endoscope withdrawal. The objective of this study was to evaluate the efficacy and safety of EMR with a ML device in the treatment of Barrett's high-grade dysplasia and early gastric cancer. Patients and methods: prospective study. Eight consecutive patients (4 men; median age, 62 years; range 38-89 years) with BHGD (4) or EGC (4) were treated. EMR was performed with a multiband ligator in order to create a pseudopolyp and then permit snare polypectomy of flat mucosal lesions. The pseudopolyp was resected by using pure coagulating current. No submucosal saline injection was administered before resection. Results: a total of 8 consecutive patients were treated with the multiband ligator (ML) technique. Barrett's esophagus (BE): one patient with long BE received 3 EMR sessions. Three patients presented with short BE and received 1 EMR session each. The histology of the EMR specimens confirmed a moderately differentiated adenocarcinoma with submucosal infiltration (1 patient) and BHGD (3 patients). Early gastric cancer (EGC): 3 patients had EGC (type IIa) and 1 patient had high-grade dysplasia. EMR was accomplished in 1 session for each patient. The histology of EMR specimens confirmed a mucinous adenocarcinoma with submucosal infiltration (1 patient), EGC (2 patients), and HGD (1 patient). Complications (mild esophageal stenosis, minor bleeding) occurred in 2 patients. Conclusions: EMR has diagnostic and therapeutic implications, and represents a superior diagnostic modality as compared to traditional biopsy. By means of EMR the resected mucosa is pathologically examined, and the lesion may be appropriately treated. EMR-ML is a safe and effective technique for the treatment of superficial lesions of the digestive tract, and is accepted as an alternative to surgical therapy for non-invasive lesions. Long-term follow-up is needed to determine the clinical impact of this method.

Alteración del patrón hormonal regulatorio renal durante la ictericia obstructiva experimental

Objective: the alteration of hormones regulating sodium and water status is related to renal failure in obstructive jaundice (OJ). Experimental design: OJ was induced by common bile duct ligation. Samples were obtained from the control (SO) and OJ groups at 24 and 72 hours, and at 7 days. Different parameters related to biliary obstruction, liver and renal injury, and vasoactive mediators such as renin, aldosterone, endothelin-1 (ET-1) and prostaglandin E2 (PGE2) were studied. Results: bile duct ligation caused an increase in total bilirubin (p < 0.001) and alkaline phosphatase (AP) (p < 0.001). The SO and OJ groups had the same values for diuresis, renin, and creatinine clearance at 24 h. However, animals with OJ had a lower sodium concentration in urine than SO animals (p < 0.01), as well as an increase in aldosterone levels (p < 0.03). ANP levels were moderately increased during OJ but did not reach statistical significance when compared to the SO group. In contrast, OJ animals showed a rise in serum ET-1 concentration (p < 0.001) and increased PGE2 in urine (p < 0.001). Conclusions: biliary obstruction induced an increase in ET-1 release and PGE2 urine excretion. These hormones might play a role during the renal complications associated with renal disturbances that occur during OJ.

Patogénesis en cirrosis biliar primaria

Primary biliary cirrhosis (PBC) would develop when the immune system comes across a microorganism with proteins similar to those in the piruvate dehydrogenase complex E2 (PDC-E2), or a neoantigen resulting from a xenobiotic-modified autoantigen. This would lead to an innate immune response where TLRs would play a pivotal mediating role, which would give rise to a local microenvironment favoring an adaptive immune response. Such response would be particularly strong in individuals with selected genetic characteristics. The genetic characteristics underlying this predisposition remain unknown, but they likely entail small numbers of scarcely-active regulatory T cells. The AE2 anion exchanger, which is deficient in patients with PBC, may reduce the number and activity of regulatory T cells. NK cells are also pivotal in the preparation of an adaptive response, as they release a number of cytokines and chemokines that favor and recruit antigen-presenting cells to activate B and T cells - CD4+ Th1 and CD8+. An activation of the former would increase the production of IgM and anti-mitochondrial IgG and IgA antibodies against PDC-E2. An activation of CD8+ cells, also sensitive to PDC-2 as aberrantly expressed on the surface of BECs and SECs, would result in apoptosis for these epithelial cells, and in small bile-duct destruction. Immune response is likely inadequately suppressed because of the small numbers of scarcely-active regulatory T cells, the latter resulting from low genetic expression and activity of the AE2 transporter.

Dolor abdominal de 9 días de evolución

**Infección intestinal y biliar por Ascaris lumbricoides en endoscopia digestiva**

Angiosarcoma hepático: Presentación de dos casos

Hepatic angiosarcoma is a rare primary tumor of the liver with a mesenchymal origin. Diagnosis is difficult because clinical manifestations and imaging studies are inconclusive. In many cases a diagnosis is obtained during necropsy, not being apparent during the course of disease. It is associated with several risk factors, but these contribute to explaining only a few of all reported cases. When clinical manifestations begin progression is often fast, and possibilities for curative treatment are limited. We report two cases of hepatic angiosarcoma. In the first one, our patient had an insidious initial course, and then suddenly presented with hepatic failure followed by acute respiratory distress. A diagnosis was reached during necropsy. In the second case, we initiated the study of a chronic liver disease using fine-needle aspiration biopsy, which showed findings suggestive of hepatic angiosarcoma. In the following weeks the patient started on a torpid clinic course, and died from multiple organ failure.

El angiosarcoma hepático es una neoplasia de estirpe mesenquimal de baja frecuencia y difícil diagnóstico por su forma inespecífica de manifestarse clínica y radiológicamente. Tanto es así que muchos diagnósticos se obtienen mediante necropsia, no siendo posible poner de manifiesto la enfermedad durante su curso. Se asocia a diferentes agentes etiológicos, pero en la mayoría de los casos no es posible establecer una exposición concreta a ninguno de ellos. Cuando comienza a manifestarse, la evolución suele ser rápida y las opciones de tratamiento curativo son escasas. Presentamos en nuestro trabajo dos casos de angiosarcoma hepático. En el primero, el paciente sufre en principio una evolución insidiosa, presentando al fin, y de forma abrupta, un cuadro de insuficiencia hepática seguido de distrés respiratorio, falleciendo por este motivo. El diagnóstico se alcanza en la necropsia. En el segundo caso se inicia un estudio de hepatopatía en el cual se indica una PAAF. Esta es informada como hallazgos compatibles con angiosarcoma hepático. El paciente presenta en las semanas ulteriores una evolución tórpida, falleciendo en fracaso multiorgánico.

Quistes de páncreas

Visceral leishmaniasis diagnosed by duodenal biopsy

Papulomatosis bowenoide: Una neoplasia intraepitelial anal

Bronconeumonía secundaria a perforación en carcinoma epidermoide de esófago sobre acalasia

Perforación intestinal secundaria a tuberculosis intestinal

Neumomediastino y enfisema subcutáneo como raras complicaciones tras microcirugía endoscópica transanal

Necrosis de injerto hepático por síndrome de robo de la arteria gastroduodenal

Mucocele apendicular gigante: Implicaciones diagnósticas y terapéuticas

Nudo ileosigmoideo gangrenado