Revista Española de Enfermedades Digestivas

pH metría en esófago proximal

Valores normales en pHmetría esofágica ambulatoria a dos niveles en España

Aim: upper oesophageal pH monitoring may play a significant role in the study of extra-oesophageal GERD, but limited normal data are available to date. Our aim was to develop a large series of normal values of proximal oesophageal acidification. Methods: 155 healthy volunteers (74 male) participated in a multi-centre national study including oesophageal manometry and 24 hours oesophageal pH monitoring using two electrodes individually located 5 cm above the LOS and 3 cm below the UOS. Results: 130 participants with normal manometry completed all the study. Twelve of them were excluded for inadequate pH tests. Twenty-seven subjects had abnormal conventional pH. The remaining 91 subjects (37 M; 18-72 yrs age range) formed the reference group for normality. At the level of the upper oesophagus, the 95th percentile of the total number of reflux events was 30, after eliminating the meal periods 22, and after eliminating also the pseudo-reflux events 18. Duration of the longest episodes was 5, 4 and 4 min, respectively (3.5 min in upright and 0.5 min in supine). The upper limit for the percentage of acid exposure time was 1.35, 1.05 and 0.95%, respectively. No reflux events were recorded in the upper oesophagus in 8 cases. Conclusion: this is the largest series of normal values of proximal oesophageal reflux that confirm the existence of acid reflux at that level in healthy subjects, in small quantity and unrelated to age or gender. Our data support the convenience of excluding pseudo-reflux events and meal periods from analysis.

Objetivo: la pHmetría con electrodo proximal puede jugar un papel importante en el estudio de las manifestaciones extraesofágicas de la ERGE, pero no existen series amplias que permitan establecer los valores de referencia con fiabilidad. Métodos: se incluyeron 155 voluntarios sanos (74 H) en un estudio multicéntrico a nivel nacional con manometría esofágica y pHmetría de 24 horas con dos electrodos individuales a 5 cm por encima del borde superior del EEI y a 3 cm por debajo del borde inferior del EES. Resultados: completaron todos los estudios 130 sujetos. Se desestimaron 12 por pHmetrías deficientes y 27 por presentar una pHmetría patológica en el esófago distal. Los 91 voluntarios restantes -37 H; media de edad: 28,5 años (rango 18-72)- constituyeron el grupo de referencia para valores de normalidad. A nivel del esófago superior el percentil 95 del número total de episodios fue 30, al eliminar los periodos de ingesta 22, y al eliminar además los seudo-reflujos 18. Los valores para la duración del episodio más largo fueron 5, 4 y 4 min (3,5 min en bipedestación y 0,5 min en decúbito), respectivamente. El límite superior para el % de tiempo de exposición ácida fue de 1,35, 1,05 y 0,95%, igual respectivamente. No se registraron episodios de reflujo en el esófago superior en 8 casos (17 al eliminar el periodo de ingesta o los seudo-reflujos). Conclusión: esta es la serie más amplia de valores normales de reflujo en el esófago proximal, con datos de referencia a nivel de la población española que confirman la existencia de reflujo ácido a ese nivel en sujetos sanos, de escasa cuantía y sin relación con la edad o sexo. Nuestros resultados apoyan la conveniencia de eliminar los seudo-reflujos y periodos de ingesta en el análisis.

Utilidad de la ecoendoscopia en la estadificiación preoperatoria del cáncer gástrico: rentabilidad diagnóstica e impacto terapéutico

Objectives: to evaluate the diagnostic yield of endoscopic ultrasonography in loco-regional staging of gastric cancer in our medium and to determine the impact of this technique on later therapeutic management. Material and methods: this is a retrospective study carried out on patients histologically diagnosed with gastric adenocarcinoma who had been referred for endoscopic ultrasonographic examination. The technique results were compared with those obtained from surgical samples and/or from exploratory laparoscopy-laparotomy. We compared the initial therapeutic decision based on conventional diagnostic techniques with the final therapeutic management based on the endoscopic ultrasonography results. Results: forty-six patients with gastric adenocarcinoma were included in the study (a reference exploration was available in 36 cases). Diagnostic precision was 70% in stage T, while in stages T1, T2, T3 y T4 was 100, 38, 82, and 100%, respectively. The sensitivity and specificity to differentiate T1-2 from T3-4 was 94 and 85%, respectively. We could not identify factors associated with obtaining a correct diagnosis in staging T. Diagnostic precision was 72% for stage N (N0: 58%; Nx 88%). The presence of free perigastric fluid was identified in 7 cases; the presence of peritoneal carcinomatosis was later confirmed in 5 of these. The result of endoscopic ultrasonography led to a modification in the subsequent therapeutic management in 13 patients (28%). Conclusions: endoscopic ultrasonography is a useful technique for loco-regional staging of gastric adenocarcinoma, which may have important implications in the therapeutic management of these patients.

Objetivos: valorar la rentabilidad diagnóstica de la ecoendoscopia en la estadificación locorregional del cáncer gástrico en nuestro medio y determinar el impacto de la técnica sobre el manejo terapéutico posterior. Material y métodos: estudio retrospectivo realizado en pacientes diagnosticados histológicamente de adenocarcinoma gástrico que habían sido remitidos para la realización de ecoendoscopia. Se comparó el resultado de la técnica con el estudio final obtenido en la pieza operatoria y/o laparoscopia-laparotomía exploradora. Se comparó la decisión terapéutica inicial basada en los resultados de las técnicas diagnósticas convencionales, con el manejo terapéutico final basado en el resultado de la ecoendoscopia. Resultados: se incluyeron en el estudio 46 pacientes con adenocarcinoma gástrico (en 36 de los cuales se disponía de exploración de referencia). La precisión diagnóstica fue del 70% para el estadIo T, y para T1, T2, T3 y T4 del 100, 38, 82 y 100%, respectivamente. La sensibilidad y especificidad para diferenciar el estadio T1-2 del T3-4 fue del 94 y 85% respectivamente. No se identificaron factores relacionados con la obtención de un diagnóstico correcto en la estadificación T. La precisión diagnóstica fue del 72% para el estadio N (N0: 58%; Nx 88%). En 7 pacientes se identificó la presencia de líquido libre perigástrico, en 5 de los cuales se confirmó posteriormente la existencia de carcinomatosis peritoneal. En 13 pacientes (28%) del resultado de la ecoendoscopia se derivó una modificación en el manejo terapéutico posterior. Conclusiones: la ecoendoscopia es una técnica útil en la estadificación locorregional del adenocarcinoma gástrico, lo que puede tener importantes implicaciones en el manejo terapéutico de estos pacientes.

Tratamiento con Montelukast (antagonista cisteinílico del receptor de leucotrienos) en un modelo de alergia alimentaria: cambios en la población linfocítica de la mucosa renal

Objective: the aim is to determine immunopathological modifications in rectal mucosa from rabbits after local challenge in ovalbumin (OVA) sensitized animals previously treated with montelukast. Material and methods: experimental design: thirty two rabbits divided into four groups: G1: normal; G2: subcutaneously OVA sensitized; G3: sensitized, locally OVA challenged and sampled 4 hours after challenge; and G4: sensitized, locally OVA challenged and treated 4 hours before challenge with montelukast (0.15 mg/kg). Specific anti-OVA IgE levels were evaluated by passive cutaneous anaphylaxis test (PCA). In each group 200 high microscopical power fields (HPF) were counted. Results were expressed as arithmetic mean and SE. Anti -CD4, CD5, µ chain monoclonal antibodies were used. Avidin biotin horseradish peroxidase system was used. Results: CD 4: G1: 8.3 ± 0.06; G2: 13.4 ± 0.08, G3: 8.25 ± 0.06, G4: 11.8 ± 0.02. CD 5: G1: 7.3 ± 0.05; G2: 9.4 ± 0.05, G3: 11.3 ± 0.06, G4: 8.1 ± 0.06. μ chain: G1: 10.4 ± 0.06; G2: 3.8 ± 0.02, G3: 6.0 ± 0.10, G4: 2.2 ± 0.10. In all cases, experimental groups (G3 vs. G4) presented statistical significant differences (p < 0.05). CD4+, CD5+ cells and μ chain+ decrease in experimental group (G4), probably due to lymphocyte migration inhibition to challenged mucosa. μ chain+ cell decrease could be based on B cell activation and expression of different surface immunoglobulins. Cells expressing μ chain decreased in G2 and G3 likely due to activation of B cells and subsequent expression of other immunoglobulin chains in cell surface. Conclusions: we conclude that obtained data are important to elucidate immunopathology of local anaphylactic reaction in rectal mucosa from systemic sensitized animals after treatment with montelukast.

Evaluación de la fibrosis hepática en pacientes con hepatopatía crónica C mediante elastografía transitoria: implicaciones para determinar la eficacia del tratamiento antiviral

Background: the efficacy of combination therapy with peginterferon plus ribavirin to eradicate viral infection in patients with chronic hepatitis C (CHC) is well established; moreover, it is able to arrest or even reverse liver fibrosis. Aims: to analyze the measurements of hepatic stiffness as an index of liver fibrosis using transient elastography (TE) in patients who underwent a sustained virological response (SVR) during long-term follow-up; comparing the changes in the severity of fibrosis with non-responders patients. Material and methods: after hepatic fibrosis was studied in three patients with CHC who underwent a SVR during long-term follow up, a prospective study was initiated in 24 patients with CHC who received combination therapy to compare the evolution of fibrosis in those with SVR and those who were non-responders. The genotype of hepatitis C virus (HCV) and the degree of viremia were determined. METAVIR scoring system was used for liver fibrosis. Hepatic stiffness was measured by TE. Results: of the initial three patients pre-treatment liver biopsies revealed active disease and fibrosis (stage 3) in two and mild fibrosis (stage 1) in one. After several years of follow up serum AST/ALT levels were normal and HCV RNA was undetectable in each case; in contrast to the baseline histological assessments of fibrosis, values for hepatic stiffness (3.4-6.9 KPa) were compatible with an absence of any appreciable hepatic fibrosis. In the prospective study, 8 patients underwent a SVR and 16 were non-responders. TE indicated that the severity of hepatic fibrosis in the SVR group improved in 7 (88%) patients, whereas in the non-responder it improved in only 4 (25%) (p < 0.05). The difference between development of severe fibrosis (F ≥ 3) in responders and non-responders was not significant (p = 0.23), possibly due to the small sample size. Conclusions: regression of hepatic fibrosis appears to be common in patients with CHC who undergo a SVR. TE is a simple non-invasive technique that enables multiple assessments of the severity of hepatic fibrosis to be made efficiently during long-term follow-up of patients with CHC who receive combination antiviral therapy.

Resección endoscópica de cáncer colorrectal temprano como único tratamiento

Colonoscopic screening in developed countries allows detection and resection of a great number of early colorectal cancers. There is a strong controversy to decide when endoscopic treatment is enough or when surgical resection is necessary. To this contributes the diverse names to define the lesions, the wide number of classifications and the different criteria of each author. We perform an extense literature review, aiming to clarify concepts and unify criteria that can be used as a guide for the treatment of early colorectal cancer. We conclude that in early colorectal cancer arising in pedunculated polyps (0-Ip), mucosal endoscopic resection would be indicated as only treatment in Haggitt levels 1, 2 and 3, tumors smaller than 2 cm, well- or moderately differentiated, without vascular or lymphatic affection, with submucosal infiltration lower than 1 µm from the muscularis mucosae and maximal submucosal width lower than 4 µm, and undergoing en bloc resection. In sessile polyps (0-Is) or non-polypoideal elevated (0-IIa) or plain (0-IIb) lesions, recommendations will be similar, without applicability of Haggitt levels.

El screening mediante colonoscopia que se realiza en países occidentales ha permitido la detección y resección de un número elevado de tumores colorrectales en estadio temprano. Existe una gran controversia a la hora de decidir cuándo el tratamiento endoscópico es suficiente y cuándo debe realizarse la resección quirúrgica. A ello contribuye la gran diversidad en la nomenclatura para definir estas lesiones, la amplia variedad de clasificaciones de las mismas y los diferentes criterios que tiene cada autor. Mediante una revisión extensa de la literatura, pretendemos aclarar conceptos, enlazar los datos de las diferentes clasificaciones y unificar unos criterios que sirvan de guía para el tratamiento del cáncer colorrectal temprano. Tras ello, llegamos a la conclusión de que en el cáncer colorrectal temprano que aparece en pólipos pedunculados (0-Ip), estaría indicada la resección endoscópica como único tratamiento en los niveles 1, 2 y 3 de Haggitt, tumores menores de 2 cm de diámetro, en tumores bien o moderadamente diferenciados, sin afectación vascular ni linfática, con infiltración de la submucosa menor de 1 µm desde la muscularis mucosae y anchura máxima en la submucosa menor de 4 µm y resecados en bloque. En las lesiones polipoideas sésiles (0-Is) y no polipoideas elevadas (0-IIa) o planas (0-IIb) las recomendaciones serían las mismas descritas anteriormente, no siendo aplicables los niveles de Haggitt.

Erosiones duodenales: un hallazgo endoscópico infrecuente en la enfermedad celiaca

Cuerpo extraño intragástrico: una causa poco frecuente de dolor abdominal

Metástasis agudas fulminantes de cáncer de colon tras el trasplante renal

We report a 52-year-old male with no family history of colonic cancer, who was found to have advanced colonic cancer with metastases two months post renal transplantation. With this case, we highlight the possibility of acute fulminant cancer metastases within short period after renal transplantation and the importance of periodic colorectal cancer screening pre-transplant. To our knowledge, this case is not yet reported in the literature, especially with such presentation of acute fulminant colonic cancer metastases post renal transplantation.

Prótesis descompresiva cólica

Síndrome de Angelman y enfermedades celiacas

Hemorragia digestiva alta aguda por una complicación rara de la úlcera péptica: doble píloro

Hemoperitoneo por rotura hepática en gestante con síndrome HELLP

Colitis eosinofílica

Kikuchi-Fujimoto, localización atípica como tumoración abdominal

Rotura esplénica durante colangiopancreato-grafía retrógrada endoscópica