Revista Española de Enfermedades Digestivas

Argon gas in the management of radiation proctitis: effective and safe for everyone?

Esophageal multichannel intraluminal impedance and pH-testing in the study of apparent life threatening episode incidents in infants

Introduction: The conventional 24-hour pH monitoring is the gold standard for the diagnosis of gastro-esophageal reflux (GER), a possible cause of Apparent Life Threatening Episodes (ALTE). However, multichannel intraluminal impedance (MII) may provide advantages. Objectives: Comparison of the results of MII and pH monitoring in patients undergoing MII-pH monitoring in the 3-year study period because of having suffered from ALTE. Material and methods: Prospective study of MII-pH monitoring performed in our unit to infants < 12 months of age admitted for ALTE for a 3-year period. Results: Thirty nine patients studied. 2,692 pH monitoring episodes, with median of 24 (IQ: 15-44) episodes/patient, 1.30 (IQ: 0.80-2.60) reflux/hour, 1 (IQ: 0-4) reflux episode > 5 min per patient and clearance of 1.20 (IQ: 0.70-2.20) min/reflux. With pH monitoring analysis, 14 children (35.9 %) could have been diagnosed as GER (8 mild, 4 moderate and 2 severe) based on the classical criteria. MII identified a total of 8,895 events; only 3,219 among them were refluxes, with a median of 75 (IQ: 54-111) per patient, 1.30 (IQ: 1.3-2.6) episodes/hour). With MII-pH monitoring combination there were 21.60 (SD 15.21) acid reflux episodes, 67.33 weekly acid (SD 32.09) and 3.34 (SD 7.23) non-acid, being finally diagnosed 33 patients as GER. Conclusions: The association of pH monitoring and MII provides additional information that improves GER diagnostic performance without posing any additional risk to the infant patient. The non-acid/weekly acid refluxes, not detected by pH monitoring, account for a high percentage of episodes, this may have diagnostic and therapeutic significance, especially in infants. Further studies are needed to assess the normality of MMI in pediatric patients.

Introducción: la pHmetría convencional de 24 horas constituye el patrón de oro para el diagnóstico de episodios de riesgo vital aparente (ALTE). La impedanciometría intraluminal multicanal (IIM) puede aportar ventajas en el lactante. Objetivos: comparación de los resultados de IIM y pHmetría en los pacientes sometidos a IIM-pHmetría en el periodo de estudio por causa de estudio de ALTE. Material y métodos: estudio retrospectivo de IIM-pHmetrías realizadas en nuestro servicio a lactantes < 12 meses de edad ingresados por ALTE durante tres años. Resultados: 39 pacientes estudiados. La pHmetría registró 2.692 reflujos, con medianas de 24 (IQ: 15-44) reflujos/paciente, índice de reflujo de 1,30 (IQ: 0,80-2,60) reflujos/hora, 1 (IQ: 0-4) episodio de reflujo > 5 min por paciente y aclaramiento de 1,20 (IQ: 0,70-2,20) min/reflujo. Por pHmetría 14 niños (35,9 %) fueron diagnosticados de RGE. Mediante IIM se registraron 8.895 eventos; 3.219 fueron reflujos, con mediana de 75 (IQ: 54-111) reflujos/paciente, 1,30 (IQ: 1,3-2,6) reflujos/hora. Mediante IIM-pHmetría, la media de reflujos ácidos por paciente fue de 21,60 (DE 15,21), débilmente ácidos 67,33 (DE 32,09) y no ácidos 3,34 (DE 7,23), pudiéndose diagnosticar finalmente a 33 pacientes de RGE. Conclusiones: la asociación de IMM y pHmetría proporciona información adicional que mejora el rendimiento diagnóstico, sin suponer ningún riesgo adicional para el paciente. Los reflujos no ácidos/débilmente ácidos, los cuales no son detectados mediante pHmetría, suponen un porcentaje elevado, sobre todo en lactantes; esto tiene gran importancia diagnóstica en el estudio del ALTE. Aún son necesarios estudios para valorar la normalidad en IIM en pacientes pediátricos.

Is argon plasma coagulation an effective and safe treatment option for patients with chronic radiation proctitis after high doses of radiotherapy?

Introduction: In severe cases refractory to medical treatment, APC appears to be the preferred alternative to control persistent rectal bleeding of patients with chronic radiation proctitis. Although successful outcomes have been demonstrated in patients previously treated with moderate doses of radiotherapy, there is reluctance towards its indication due to the concern of severe adverse events in patients treated with high doses of radiation. Objectives: The aim of this study was to assess the efficacy and toxicity of APC in the management of bleeding radiation-induced proctitis in patients treated with high doses of radiation for prostate cancer. Methods and materials: Data from 30 patients were treated with APC due to chronic radiation proctitis, were reviewed retrospectively. All cases had prostate cancer and 9 of them (30 %) underwent previous radical prostatectomy. The median dose of conformal 3D External Beam Radiotherapy (EBRT) delivered was 74 Gy (range 46-76). Median rectal D1cc and D2cc was 72.5 and 72.4 Gy respectively. Median rectal V70, V60 and V40 was 12, 39.5 and 80 %. Cardiovascular and digestive disease, diabetes, smoking behaviour, lowest haemoglobin and transfusion requirements were recorded. Indications for treatment with APC were anemia and persistent bleeding despite medical treatment. Argon gas flow was set at 1.8 l/min with an electrical power setting of 50 W. Results: Median age of all patients was 69.6 years. The median lowest haemoglobin level was 9.6 g/dL. Median time between completion of radiotherapy and first session of APC was 13 months. Ninety-four therapeutic sessions were performed (median 3 sessions). Median time follow-up was 14.5 months (range 2-61). Complete response with resolved rectal bleeding was achieved in 23 patients (77 %), partial response in 5 (16 %) and no control in 2 (6 %). No patients required transfusion following therapy. Two patients developed long-term (> 6 weeks) grade 2 rectal ulceration and grade 2 rectal incontinence, respectively. Conclusions: The argon plasma coagulation is an effective and safe management option in patients with medically refractory rectal bleeding after high doses of radiation for prostate cancer.

Liver regeneration - The best kept secret: A model of tissue injury response

Liver regeneration (LR) is one of the most amazing tissue injury response. Given its therapeutic significance has been deeply studied in the last decades. LR is an extraordinary complex process, strictly regulated, which accomplishes the characteristics of the most evolutionary biologic systems (robustness) and explains the difficulties of reshaping it with therapeutic goals. TH reproduces the physiological tissue damage response pattern, with a first phase of priming of the hepatocytes -cell-cycle transition G0-G1-, and a second phase of proliferation -cell-cycle S/M phases- which ends with the liver mass recovering. This process has been related with the tissue injury response regulators as: complement system, platelets, inflammatory cytokines (TNF-α, IL-1β, IL-6), growth factors (HGF, EGF, VGF) and anti-inflammatory factors (IL-10, TGF-β). Given its complexity and strict regulation, illustrates the unique alternative to liver failure is liver transplantation. The recent induced pluripotential cells (iPS) description and the mesenchymal stem cell (CD133+) plastic capability have aroused new prospects in the cellular therapy field. Those works have assured the cooperation between mesenchymal and epithelial cells. Herein, we review the physiologic mechanisms of liver regeneration.

La regeneración hepática (RH) representa una de las formas más extraordinarias de respuesta al daño tisular. Debido a sus implicaciones terapéuticas, ha sido motivo de un interés extraordinario en las últimas décadas. La RH es un proceso muy complejo y estrictamente regulado que cumple las características de los sistemas biológicos más evolucionados (robustness) y que explica la dificultad de interferir en ella con usos terapéuticos. La RH reproduce el modelo fisiológico de respuesta al daño con una fase primera de preparación o "cebado" de los hepatocitos -transición G0-G1 del ciclo celular- y una fase ulterior de proliferación -fases S/M del ciclo- que termina con la recuperación de la masa hepática. Dicho proceso se ha relacionado con los mediadores de la respuesta biológica al daño tisular: hormonas, sistema del complemento, plaquetas, citocinas proinflamatorias (TNF-α, IL-1β, IL-6), factores de crecimiento (HGF, EGF, VGF, etc.) y factores antiinflamatorios (Il-10, TGF-β). Debido a su complejidad y a su estricta regulación, se explica que todavía hoy la única alternativa a la insuficiencia hepática sea el trasplante hepático. La identificación reciente de las células pluripotenciales inducidas (iPS) y la capacidad plástica de las células madre mesenquimales (CD133+) ha suscitado nuevas expectativas a la terapia celular regenerativa. Dichos trabajos han confirmado la cooperación entre las células mesenquimales y epiteliales. En el presente trabajo se describen los mecanismos fisiológicos de la regeneración hepática.

Sedation for gastrointestinal endoscopy: clinical practice guidelines of the Sociedad Española de Endoscopia Digestiva

Deep infiltrating rectosigmoid endometriosis: diagnostic keys

Cavernous hemangioma of small bowel: a rare cause of digestive hemorrhage

Insertion of self-expanding metal stent for treatment of malignant obstruction in a pregnant woman

Colorectal cancer (CRC) is the second most frequent cancer both in incidence and mortality in women, especially in those over 60 years of age. Diagnosis in women at gestational age is rare, so its incidence during pregnancy is low. However, an increase in its diagnosis is expected during the next years because of the raise in the average age of pregnancy. In most cases, the diagnosis is delayed because symptoms related to CRC can be attributed to pregnancy itself. Up to 30 % of CRC cases may present as an intestinal obstruction. In this situation, the main objective is to solve the clinical emergency in the safest way for mother and fetus, together with performing an accurate diagnostic approach to offer the best possible therapeutic management knowing the limitations and difficulties related to pregnancy. The self-expanding metallic stent (SEMS) can be particularly useful in colon obstruction in a pregnant patient with CRC because it allows solving the acute condition providing time to perform a more accurate staging study and to prepare the patient for surgery, thus reducing both post-surgical morbidity and mortality. We report on the case of a patient who early in the second trimester of pregnancy presented with an acute colonic obstruction due to CRC which was successfully managed with the placement of a self-expanding metal stent.

El cáncer colorrectal (CCR) es el segundo tumor tanto en incidencia como en mortalidad en mujeres, sobre todo en mayores de 60 años. El diagnóstico en mujeres en edad gestacional es infrecuente por lo que su incidencia durante el embarazo es baja. Sin embargo, es posible que debido al aumento de la edad media de las gestantes se observe en los próximos años un incremento en el diagnóstico de esta patología. En la mayoría de ocasiones el diagnóstico se retrasa debido a que la sintomatología derivada del CCR puede atribuirse al propio embarazo. Hasta en un 30 % de los casos el CCR puede debutar como una obstrucción intestinal. En este caso el objetivo principal es solucionar el cuadro agudo de la forma más segura posible para madre y feto y realizar una aproximación diagnóstica adecuada para plantear el mejor manejo terapéutico, con las limitaciones y dificultades que supone la gestación. La prótesis metálica autoexpandible puede ser particularmente útil en la obstrucción de colon por CCR en la paciente embarazada ya que permite solucionar el cuadro agudo y proporciona el tiempo necesario para el estudio de extensión y preparación para la cirugía, reduciendo la morbimortalidad derivada de la misma. Presentamos el caso de una paciente que al inicio del segundo trimestre de gestación presentó un cuadro obstructivo secundario a una neoplasia de sigma que se resolvió satisfactoriamente con la colocación de una prótesis autoexpandible metálica.

Down's syndrome and inflammatory bowel disease: is there a real link?

Down's syndrome (DS) is a genetic disease that has been associated with several immune and autoimmune diseases, including digestive and liver diseases, like celiac disease, autoimmune chronic hepatitis and sclerosing cholangitis. Despite in inflammatory bowel disease (IBD) pathogenesis, genetics and immune mechanism play an important role, the association among DS and IBD has been poorly studied. Data about IBD diagnosis in DS patients is very scarce with only some individual case-reports. We report three cases of DS patients diagnosed of IBD and we discuss the possible association of these two entities.

Type II intrapancreatic choledochal malignant cyst in adults: duodenopancreatectomy

A 62-year-old female patient was admitted for abdominal pain and vomiting. Imaging tests revealed a solid-cystic lesion at the head of the pancreas communicating with the distal bile duct. A Todani type II choledochal cyst was diagnosed with neoplastic degeneration after cytological diagnosis with endoscopic ultrasound-guided puncture. The patient was treated with a cephalic duodenopancreatectomy with curative intention.

Presentamos el caso de una paciente de 62 años que ingresó de urgencias por pancreatitis aguda leve. En las pruebas de imagen se observó una lesión sólido-quística en la cabeza de páncreas comunicante con la vía biliar distal, y se diagnosticó quiste de colédoco tipo II de Todani con degeneración neoplásica en su interior confirmada tras una biopsia por punción en una ecoendoscopia. La paciente fue tratada con una duodenopancreatectomía cefálica con intención curativa.

Gastrointestinal stromal tumor

New contributions to consensus on biosimilars

Colorrectal Kaposi's sarcoma

Recurrent acute pancreatitis as a long-term complication of congenital choledochal cyst surgery

Fever and acute cytomegalovirus hepatitis in Crohn's disease

Development of a duodenal gallstone ileus with gastric outlet obstruction in a patient with a huge duodenal diverticulum