Revista Española de Enfermedades Digestivas

ERCP in a low-volume hospital: Arguments "for" and "against" this type of practice

Efficacy and safety of ERCP in a low-volume hospital

Background and aims: there is little scientific evidence on the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) performed in low-volume hospitals; however, in our country, it is growing up its implementation. The objectives of our study were to evaluate the efficacy and safety of this technique performed by two endoscopists with basic training in a center of this nature and analyze the learning curve in the first procedures. Patients and methods: single-center retrospective study of the first 200 ERCP performed in our hospital (analyzing the evolution between the first 100 and 100 following procedures), comparing them with the quality standards proposed in the literature. Results: from February 2009 to April 2011, we performed 200 ERCP in 169 patients, and the most common indications were: Choledocholithiasis (77 %), tumors (14.5 %) and other conditions (8.5 %). The cannulation rate rose from 85 % in the first 100 ERCP to 89 % in the next 100 procedures, clinical success from 81 % to 87 %, decreasing the post-ERCP acute pancreatitis rate from 11 % to 4 %, upper gastrointestinal bleeding (UGIB) from 3 % to 2 % and acute cholangitis from 4 % to 1 %. There was a death from a massive UGIB in a cirrhotic patient in the first group of patients and a case of biliary perforation resolved by surgery in the second one. Conclusions: the results obtained after performing 200 procedures support the ability to practice ERCP in low-volume hospitals obtaining levels of efficacy and safety in accordance with published quality standards.

Introducción y objetivos: existe poca evidencia científica sobre los resultados de la CPRE realizada en hospitales con bajo volumen, sin embargo su puesta en marcha en nuestro medio es creciente. Los objetivos de nuestro estudio son evaluar la eficacia y seguridad de dicha técnica realizada por dos endoscopistas biliares noveles en un centro de estas características y analizar la curva de aprendizaje en los primeros procedimientos. Pacientes y métodos: estudio retrospectivo de las primeras 200 CPRE practicadas en nuestro hospital, analizando la progresión entre los 100 primeros procedimientos y los 100 segundos, comparándolos con los estándares de calidad propuestos en la literatura. Resultados: desde febrero de 2009 hasta abril de 2011 se realizaron 200 procedimientos a 169 pacientes con las siguientes indicaciones: coledocolitiasis (77 %), neoplasias (14,5 %) y otras patologías (8,5 %). La tasa de canulación ascendió del 85 % en las 100 primeras CPRE al 89 % en las siguientes, el éxito clínico del 81 % al 87 %, disminuyendo la tasa de pancreatitis aguda post-CPRE del 11 al 4 %, la de hemorragia digestiva alta del 3 al 2 % y la de colangitis aguda del 4 al 1 %. Hubo un éxitus secundario a una hemorragia digestiva alta en una paciente cirrótica en el primer grupo y un caso de perforación biliar resuelto mediante cirugía en el segundo. Conclusiones: los resultados obtenidos tras la realización de 200 procedimientos apoyan la posibilidad de practicar CPRE en hospitales con bajo volumen consiguiendo niveles de eficacia y seguridad acorde con los estándares de calidad publicados.

Primary lymphoma of the colon

Background: primary colorectal lymphoma is a very rare disease, representing less than 0.5 % of all primary colorectal neoplasms. The gastrointestinal tract is the most frequently involved site of all extranodal lymphomas, the most common type of that is non-Hodgkin's lymphoma. Early diagnosis is often difficult because of unspecific symptoms. Therapeutic approaches have classically included radical resection, chemotherapy and radiotherapy. Materials and methods: we present our experience in the management of primary colorectal lymphomas over a 17-year period (1994-20011). Results: in this period 7 cases of primary colorectal lymphoma were diagnosed in our institution. Abdominal pain and change in bowel habit were the most frequent symptoms. Five patients underwent emergency surgery because of bleeding or bowel obstruction. All primary intestinal lymphomas studied were of the B-cell phenotype. Patients were followed up for a median of 59 months (range 1-180). Three of them are alive with no evidence of recurrence. Conclusion: combination treatment with chemotherapy and surgery can obtain good remission rate. Surgery can resolve complications such bleeding or intestinal perforation that are implicated in lymphoma mortality.

Introducción: el linfoma primario de colon y recto es una patología poco prevalente, representa tan solo el 0,5 % de todas las neoplasias primarias de colon y recto. El tracto gastrointestinal es el lugar donde asientan la gran mayoría de los linfomas extranodales, siendo el más frecuente el tipo linfoma no-Hodking. El diagnóstico precoz es siempre difícil debido a que la sintomatología es muy poco específica. Los algoritmos terapéuticos han incluido clásicamente la resección radical, el tratamiento con quimioterapia y con radioterapia. Materiales y métodos: presentamos nuestra experiencia en el manejo de los linfomas primarios de colon en un periodo de 17 años (1994-2011). Resultados: en dicho periodo en nuestro centro fueron diagnosticaron 7 casos de linfoma primario de colon. El dolor abdominal y los cambios en el ritmo deposicional fueron los síntomas más frecuentes. Cinco pacientes requirieron tratamiento quirúrgico urgente debido a hemorragia digestiva u obstrucción intestinal. El estudio anatomopatológico reveló que todos los linfomas tenían el fenotipo de tipo B. Los pacientes tuvieron un seguimiento medio de 59 meses (rango 1-180). Tres de ellos siguen vivos sin evidencia de recidiva. Conclusión: el tratamiento combinado con quimioterapia y cirugía puede obtener buenos resultados de remisión. La cirugía puede resolver complicaciones como la hemorragia o la perforación intestinal, ambas directamente relacionadas con la mortalidad por linfoma.

Diagnostic accuracy of lugol chromoendoscopy in the oesophagus in patients with head and neck cancer

Background and aim: patients with head and neck squamous cell malignancies have a higher risk of oesophageal squamous cell carcinomas. Lugol chromoendoscopy in oesophagus is a simple technique with a high diagnostic yield in premalignant lesions. The objective was to analyze its diagnostic accuracy in dysplasia and carcinoma of the oesophagus in high-risk patients. Methods: prospective study from April/2008 to January/2012 using lugol chromoendoscopy with biopsies of suspicious lugol voiding areas ≥ 5 mm. Patients with head and neck malignancies were included, except the ones with iodine allergy, oesophageal varices and contra-indications to standard endoscopy. The reference method was histopathology. Results: 89 patients were enrolled (mean age 62.8 ± 13.3 years, 87 % men). Primary tumour was located in oropharynx in 37 (41.6 %), in oral cavity in 29 (32.6 %) and in the larynx in 23 (25.8 %) cases. 40.4 % patients had previous treatments and 87 % reported alcohol or tobacco addition. All exams performed without anaesthesia or complications. Nine suspicious lugol voiding areas were observed and biopsied. Histopathological analysis revealed high-grade dysplasia in 2 (2.2 %) and inflammation or normal findings in the others. The sensitivity and specificity for detecting high-grade dysplasia were 100 % and 92 % (95 % CI: 87-97), respectively. Diagnostic accuracy of the test was 92 % (95 % CI: 86-98). Conclusion: lugol staining of the oesophagus during endoscopy seems to be a feasible, safe and justified procedure in high-risk population as it enhances the detection of premalignant lesions.

Factors related to length of hospital admission in mild interstitial acute pancreatitis

Objectives: to describe the clinical practice and the factors associated with length of hospital stay in mild acute pancreatitis. Methods: we present a retrospective observational study that includes a series of patients admitted to our hospital between January 2007 and December 2009 due to mild acute pancreatitis. Baseline data, treatments and examinations were collected. Variables associated with the length of hospital were determined using a Cox proportional hazards model. Results: 232 patients were included (median age 74.3 years, bedside index for severity in acute pancreatitis score 1, comorbidity Charlson score 1, 52.6 % male). 75.9 % were admitted to the gastroenterology department. Oral diet was reintroduced at 3 (0-11) days and 28 patients (12 %) were intolerant to oral re-feeding. Abdominal ultrasound, a magnetic resonance cholangiopancreatography, endoscopic ultrasound, a computed tomographic scan, and endoscopic retrograde cholangiopancreatography were performed in 92.2, 34.5, 9.5, 28.4 and 14.7 % of admissions, respectively. The length of hospital stay was 8 (1-31) days. The variables independently associated with length of admission were: Charlson index ≥ 2 (hazard ratio-HR-1.4, 95 % confidence interval-CI- 1.06-1.84; p: 0.017), admission in gastroenterology department (HR 0.67, 95 % CI 0.49 to 0.93; p: 0.016), fasting period ≥ 3 days (HR 1.37, 95 % CI 1.05-1.78; p: 0.02), intolerance to oral re-feeding (HR 1.8, 95 % CI 1.17-2.77; p: 0.007), performance of computed tomographic scan (HR 2.05, 95 % CI 1.49-2.82; p < 0.001), magnetic resonance cholangiopancreatography (HR 1.87, 95 % CI 1.42-2.49; p < 0.001) and endoscopic retrograde cholangiopancreatography (HR 2.23, 95 % CI 1.51-3.3; p < 0.001). Conclusions: the variables associated with length of hospital stay were comorbidity, department in charge, fasting period, food intolerance and complementary explorations.

Vaccination of patients with inflammatory bowel disease: Practical recommendations

Patients with inflammatory bowel disease (IBD) have a greater risk of infection associated with the endogenous immunosuppression brought about by their underlying disease as well as the exogenous immunosuppression resulting from their therapies. In the last few years guidelines and consensus papers have been issued on the indication of vaccines for these patients as primary prevention of infection. However, vaccine coverage is low, likely because the risk for infection and both safety and efficacy concerns regarding vaccines are scarcely perceived in such cases. The available scientific evidence shows that immunization is safe for most preparations, and bears no association with an increased risk for disease activity. This paper reviews the available scientific literature, and provides recommendations on the vaccination of adults with IBD.

Los pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de infecciones, asociado tanto a la inmunosupresión endógena condicionada por su enfermedad de base, como a la exógena generada por los tratamientos que reciben. En los últimos años se han publicado guías y documentos de consenso sobre indicaciones de vacunación en estos pacientes, como medida de prevención primaria de infecciones. Sin embargo, las coberturas vacunales alcanzadas son bajas, probablemente por la falta de percepción del riesgo de infección y las dudas sobre la seguridad y eficacia de las vacunas en estos casos. La evidencia científica disponible muestra que la inmunización es segura para la mayoría de preparados y no se asocia a un incremento del riesgo de actividad de la enfermedad. En este documento se revisa la literatura científica disponible y se presentan unas recomendaciones de vacunación para pacientes adultos con EII.

Trichotillomania and trichophagia: The causes of Rapunzel syndrome

Abdominal pain and intestinal malrotation in adults

An endoscopic technique for treating symptomatic distal jejunum obstruction by leaving the overtube in place

Double balloon enteroscopy has a limitation for positioning an enteral stent in the distal jejunum through its long, narrow biopsy channel. When the distal end of its overtube is left in place close to the neoplasia with the enteroscope removed, if we push an enteral stent introduction system, it tends to form loops so the technique cannot be performed with this instrument. However, the double balloon colonoscope has a shorter overtube length and using the same push-and-pull technique we can reach the distal jejunum with this instrument by inserting the delivery stent system without loops through its overtube. We present a patient with neoplastic obstruction in the distal jejunum with resolution of his symptoms after positioning an enteral stent.

Cholangitis and multiple liver abscesses after percutaneous ethanol injection (PEI) for recurrent hepatocellular carcinoma (HCC)

Percutaneous ablation procedures are minimally invasive treatments for unresectable early stage hepatocellular carcinoma (HCC). These techniques are usually safe, but rare and even fatal complications have been described. We present a fatal result after percutaneous ethanol injection (PEI) for the treatment of a recurrent HCC in a non-cirrhotic liver, with subsequent development of diffuse cholangitis and multiple liver abscesses. Although percutaneous drainage and intensive antibiotic treatment were employed, the patient finally died. We discuss about the etiology and the physiopathology of this rare complication in which the therapeutic options are limited and usually unsuccessful.

Percutaneous liver biopsy

Computed tomography angiography (CTA) in the diagnosis of an infrequent cause of gastrointestinal bleeding

Severe perianal disease degenerated to adenocarcinoma: Is close monitoring of long-term perianal disease necessary?

Gastric outlet obstruction after the insertion of a fully filled intragastric balloon

Gastrointestinal stromal tumor associated with a different malignant neoplasia

Severe colitis due to indomethacin suppository