Revista Española de Enfermedades Digestivas

Ionizing radiation in Crohn's disease

Ionizing radiation in patients with Crohn’s disease: Estimation and associated factors

Introduction: exposure to ionizing radiation is associated with an increased risk of developing tumors. Patients with Crohn's disease (CD) usually require multiple imaging tests using this type of radiation. Objectives: the objectives of this study were to estimate the total dose of ionizing radiation received by patients with Crohn's disease during their course and to identify the factors associated with higher radiation doses. Methods: two hundred thirty-five CD patients diagnosed between 1972 and 2010 were included. The effective dose (ED) received by each patient was calculated retrospectively based on the number of gastrointestinal transit studies and computed tomography scans performed. Considering recent epidemiological studies, an ED greater than or equal to 50 mSv was used as the cut-off point for increased risk of developing cancer. Results: the mean ED received per patient was 33.4 mSv (95% CI 29.3-37.5). A total of 49 (20.8%) patients received an ED ≥ 50 mSv. The following factors were identified as independent predictors associated with an ED ≥ 50 mSv: Age older than 40 years, need for surgery, age under 16 years at diagnosis and disease duration over 8 years. Conclusions: a substantial proportion of patients with Crohn's disease receive high doses of potentially carcinogenic ionizing radiation. Identification of the most susceptible patients to receive high doses of radiation, monitoring of effective doses received and the use of imaging techniques that do not require ionizing radiation (MR enterography, abdominal ultrasound) could contribute in reducing patients' exposure to potentially carcinogenic ionizing radiation.

Introducción: la exposición a radiación ionizante se asocia a un mayor riesgo de desarrollar tumores. Los pacientes con enfermedad de Crohn requieren habitualmente múltiples pruebas de imagen que utilizan este tipo de radiación. Objetivos: los objetivos de este estudio son estimar la dosis total de radiación ionizante recibida por pacientes con enfermedad de Crohn a lo largo de su evolución e identificar los factores asociados a dosis de radiación más altas. Métodos: se incluyeron 235 pacientes con enfermedad de Crohn diagnosticados entre 1972 y 2010. Se calculó retrospectivamente la dosis efectiva (DE) recibida por cada paciente, teniendo en cuenta los tránsitos gastrointestinales y las tomografías computarizadas que se habían realizado. Basados en estudios epidemiológicos previos, se consideró un valor umbral de DE ≥ 50 mSv de mayor riesgo de desarrollar cáncer. Resultados: la media de DE recibida por paciente fue 33,4 mSv (IC 95% 29,3-37,5). Un total de 49 (20,8%) pacientes recibió una DE ≥ 50 mSv. Se identificaron como factores predictivos independientes asociados a una DE ≥ 50 mSv: edad mayor de 40 años, necesidad de cirugía, edad al diagnóstico menor 16 años y tiempo de evolución mayor de 8 años. Conclusiones: un porcentaje considerable de pacientes con enfermedad de Crohn recibe dosis elevadas de radiación ionizante potencialmente carcinogénicas. La identificación de los pacientes mas susceptibles a recibir dosis altas de radiación, la monitorización de la dosis efectiva recibida y la utilización de pruebas de imagen que no utilizan radiación ionizante (enterorresonancia, ecografía abdominal), podrían contribuir a reducir la exposición a la radiaciones ionizantes potencialmente carcinogénicas.

Endoscopic mucosal resection for proximal superficial lesions: efficacy and safety study in 59 consecutive resections

Introduction: endoscopic mucosal resection is an accepted technique for the treatment of proximal gastrointestinal tract superficial lesions. Objectives: to evaluate the efficacy and safety of this procedure in the proximal gastrointestinal tract. Material and methods: forty one consecutive patients (23 males and 18 females, mean age of 61 ± 11.5 years) were included in our study. Fifty nine resections were performed in these patients in 69 sessions. Lesions treated consisted of elevated lesions with high grade dysplasia in the context of Barrett's esophagus (group A), high grade dysplasia appearing in random biopsies taken during the follow-up of Barrett's esophagus (group B) and superficial gastroduodenal lesions (group C). Snare resection after submucosal injection, band ligator-assisted or cap-assisted mucosal resection were the chosen techniques. Results: we resected 7 elevated lesions with high grade dysplasia in the context of Barrett's esophagus, 6 complete Barrett's esophagus with high grade dysplasia in 16 sequential sessions and 46 gastroduodenal superficial lesions (10 adenomas, 9 gastric superficial carcinomas, 18 carcinoid tumours and 9 lesions of different histological nature). Resections in the two first groups were complete in 100% of the cases, and in 97.9% of the cases in group C. Complications included 2 cases of limited deferred bleeding (groups A and B) and another two cases of stenosis with little clinical relevance in Group B. Conclusions: a) endoscopic mucosal resection is an efficient technique for the treatment of proximal gastrointestinal tract superficial lesions; b) it is a safe procedure with a low percentage of complications, which can generally be managed endoscopically; and c) in contrast with other ablative techniques, endoscopic mucosal resection offers the possibility of a pathologic analysis of the samples.

Introducción: la resección endoscópica mucosa es una técnica aceptada en el tratamiento de lesiones superficiales del tracto digestivo. Objetivos: evaluar la eficacia y seguridad de dicho procedimiento en el tracto digestivo superior. Material y métodos: se incluyeron en nuestro estudio 41 pacientes consecutivos (23 hombres y 18 mujeres, edad media de 60,6 años) a los que se les realizaron 59 resecciones en 69 sesiones. Se trataron las siguientes patologías: lesiones sobreelevadas con displasia de alto grado sobre esófago de Barrett (grupo A), displasia de alto grado en biopsias aleatorias del seguimiento de esófago de Barrett (grupo B) y lesiones superficiales gastroduodenales (grupo C). Las técnicas utilizadas fueron la resección con asa tras inyección submucosa, la asistida por bandas o por capuchón. Resultados: se resecaron 7 lesiones sobreelevadas con displasia de alto grado sobre esófago de Barrett, 6 esófagos de Barrett con displasia de alto grado de forma completa en 16 sesiones secuenciales de resección mucosa y 46 lesiones superficiales gastroduodenales (10 adenomas, 9 carcinomas gástricos superficiales, 18 carcinoides y 9 lesiones de diferente estirpe). Las resecciones se realizaron con éxito en el 100% de los dos primeros grupos y en el 97,9% del grupo C. Como complicaciones tuvimos 2 sangrados diferidos autolimitados (grupos A y B) y dos casos de estenosis con escasa relevancia clínica en el grupo B. Conclusiones: a) la resección endoscópica mucosa es una técnica eficaz en el tratamiento de lesiones superficiales del tracto digestivo superior; b) se trata de un procedimiento seguro, con un porcentaje de complicaciones muy bajo y que generalmente pueden ser manejadas de forma endoscópica; y c) al contrario que otras técnicas ablativas, permite el estudio anatomopatológico de las muestras.

Efficacy of adalimumab for the treatment of extraintestinal manifestations of Crohn's disease

Background and aims: Crohn's disease (CD) is commonly associated with inflammatory processes located in organs and systems others than the gut, which are known as extraintestinal manifestations (EIM) of the disease. The aim of this study was to assess the effectiveness of adalimumab (ADA) for the treatment of EIM in patients with CD. Methods: forty two consecutive CD patients with at least one EIM were prospectively included in a open-label study. Patients received ADA (160 mg at week zero, 80 mg at week two and 40 mg every other week) over six months and the effectiveness and safety of ADA for EIMs were assessed. The influence of gender, age, smoking habits, family history of inflammatory bowel disease, phenotype and previous anti-TNF treatment on EIM resolution was also investigated. Results: at month six, 76.2% of the patients showed remission or response in CD (33.3% remission and 42.9% any response). EIM showed a parallel course with CD in most cases, and showed remission or response in 66.7% of patients (38.1% remission and 28.5% any response). Patients with any response of their EIM condition were younger than those with no response (p = 0.04). No relationship was found between sex, tobacco, family history of IBD, phenotype and previous treatment with anti-TNF, and EIM resolution. Conclusions: adalimumab is effective in reducing EIM of CD. Age but not tobacco, CD phenotype and anti-TNF-naïve status appears to influence the response.

**Low co-existence rates of Lactobacillus spp. and Helicobacter pylori detected in gastric biopsies from patients with gastrointestinal symptoms**

Background: bacterial diversity of the stomach includes various species. Among them, Helicobacter pylori, a microorganism which has been associated to gastric diseases, is frequently isolated in this habitat. In addition, Lactobacillus spp., a genus including probiotic strains, has also been documented in this habitat. The co-existence of these two species in the stomach of symptomatic patient needs to be elucidated. Aims: our goal was to establish if Lactobacillus spp. and H. pylori co-exist in the stomach mucosa of symptomatic patients. Methods: gastric biopsies (antrum and/or the body) from 427 Chilean patients with gastrointestinal discomfort were analyzed. The H. pylori infection and/or Lactobacillus spp. colonization status was determined for each patient by standard culture techniques, and statistical correlations between the presence of those species and the age, gender, or the severity of the gastric disease were also established. Results: only 6.1% of the samples presented co-existence of Lactobacillus spp. and H. pylori. This former species was isolated in 42.6% of the patients as unique species, while Lactobacillus spp. was isolated as single species in 19.4% of the individuals. Chronic non-atrophic gastritis was prevalent in Lactobacillus spp. non colonized individuals, while chronic non-atrophic and chronic atrophic gastritis diagnosis was similar in Lactobacillus spp. harbouring individuals (p < 0.001). The presence of Lactobacillus spp. significantly increased with age (p = 0.005), independently of gender. Conclusion: the negative Pearson correlation between Lactobacillus spp. and H. pylori(r = -0.112, p = 0.020) indicates that the co-existence of both species is low in human gastric mucosa of symptomatic patients.

Nutritional treatment in inflammatory bowel disease: An update

Background and aims: enteral (EN) and parenteral (TPN) nutrition exert variable therapeutic effects on the induction and maintenance of remission in inflammatory bowel disease (IBD). This review aims to provide an updated discussion on the complex relationship between diet and IBD. Methods: medline, Cochrane and Scopus database searches were conducted. Sources cited in the articles obtained were also searched to identify other potential sources of information. Results: nutritional status is significantly compromised in IBD patients, especially those with Crohn's disease (CD). Apart from restoring malnourishment, dietary components contribute to modulate intestinal immune responses. Nutritional treatment is divided into support therapy and primary therapy to induce and maintain remission through TPN and EN. EN is considered a first-line therapy in children with active CD whereas it is usually used in adult CD patients when corticosteroid therapy is not possible. TPN has limited effects on IBD. En formula composition, in terms of carbohydrates, nitrogen source and bioactive molecules supplementation, differentially influence on IBD treatment outcomes. Other dietary components, such as poorly absorbed short-chain carbohydrate, polyols, and exogenous microparticles, also participate in the etiopathogenesis of IBD. Finally, new approaches to understanding the complex relationship between IBD and diet are provided by nutrigenenomic. Conclusion: further long-term, well-powered studies are required to accurately assess the usefulness of nutrition in treating IBD. In future research, the potential role of nutrient-gene interaction in drug trials and specific dietary formula compositions should be investigated in order to incorporate new knowledge about the etiopathology of IBD into nutritional intervention.

Endoscopic closure of duodenal perforation with an over-the-scope clip during endoscopic ultrasound-guided cholangiopancreatography

Multiple lymphomatous polyposis of intestine as presentation of mantle cell lymphoma

Evaluation of the oncogenic risk of diffuse gastric polyposis: A case report

Benign polyps of the stomach undergo malignant transformation at a rate correlating to the histological type and size of the proliferative lesion. We report a case of a 50-year-old Caucasian woman, affected by a diffuse gastric polyposis of both hyperplastic and adenomatous type. At endoscopy polyps were more than 1,000, scattered over the entire gastric cavity. The patient underwent total gastrectomy. The perilesional gastric mucosa was characterized by the presence of either atrophic or metaplastic areas and by a mild dysplasia. A single tubulo-villous adenomatous polyp was also present in the ascending tract of the colon. The absence of both high-grade dysplastic lesions and outbreaks of neoplastic transformation well correlated with the histochemical and molecular features, confirming the highly proliferative pattern of the polyps in the lack of signs of malignant progression.

Hemodinamyc study of the liver

Pseudomembranous colitis and bacteremia in an immunocompetent patient associated with a rare specie of Clostridium (C. ramosum)

Spontaneous hemoperitoneum due to rupture of short gastric artery after vomiting

Signet ring cell adenocarcinoma of the ampulla of Vater: A rare pathology

Therapeutic options in pancreatic pseudoaneurysms

Jejunal diverticular perforation due to gallstone ileus

Hepatocellular carcinoma in non-cirrhotic liver

In memoriam. Adolfo Benages Martínez (1942-2012)