Revista Española de Enfermedades Digestivas

Clostridium difficile infection in inflammatory bowel disease

**Risk factors for Clostridium difficile diarrhea in patients with inflammatory bowel disease**

Background: Despite the growing incidence of Clostridium difficile diarrhea (CCD) in patients with inflammatory bowel disease (IBD), little is known about the associated risk factors. Method: A retrospective study comparing cases of CCD in patients with IBD to IBD carriers who did not develop CCD. A comparison was also made with patients who developed CCD but did not suffer IBD. Results: Three cases (20 %) with IBD and CCD had received antibiotics during the previous three months versus none of the controls (IBD without CCD, p = 0.22). Ten cases (67 %) received treatment with proton pump inhibitors (PPIs) versus 2 (13 %) in the control group (IBD without CCD, p = 0.001). Seven cases underwent colonoscopy and pseudomembranes were seen in one (14 %). Fourteen (93 %) patients demonstrated a favourable response to metronidazole. Patients with IBD and CCD presented with younger age (36 ± 10 years), a higher degree of community-acquired infection (13 patients, 87 %), immunosuppressive treatment (7 patients, 47 %) and less patients had received previous antibiotic treatment (3 patients, 20 %) than those with CCD without IBD. The proportion of patients who received treatment with PPIs was similar (66 % and 80 %, respectively p = 0.266). Conclusions: CCD in IBD carriers affects younger patients, the majority are community acquired (less nosocomial) and it is more related to previous treatment with PPIs than with the antibiotic treatment. Clinical evolution is also favourable.

Introducción: a pesar de la incidencia creciente de diarrea por Clostridium difficile (DCD) en pacientes con enfermedad inflamatoria intestinal (EII) disponemos de un conocimiento limitado de factores de riesgo. Método: estudio retrospectivo comparando casos de DCD en pacientes con EEI con pacientes portadores de EEI que no desarrollaron DCD. También se realizó una comparación con pacientes que desarrollaron DCD, pero que no padecían EII. Resultados: tres casos (20 %) con EII y DCD habían recibido antibióticos durante los tres meses previos frente a ninguno de los controles (EEI sin DCD, p = 0,22). Diez casos (67 %) estaban recibiendo tratamiento con un inhibidor de la bomba de protones (IBP) frente a dos (13 %) entre los controles (EEI sin DCD, p = 0,001). Se visualizaron pseudomembranas en uno (14 %) de los siete casos en los que se hizo colonoscopia. Hubo respuesta favorable a metronidazol en 14 pacientes (93 %). Los pacientes con EEI y DCD presentaron menor edad (36 ± 10 años), mayor grado de adquisición comunitaria de la infección (13 pacientes, 87 %) y tratamiento inmunosupresor (7 pacientes, 47 %) junto a menos pacientes con tratamiento antibiótico previo (3 pacientes, 20 %) que los pacientes con DCD pero sin EII. La proporción de pacientes que recibían tratamiento con un IBP era similar (66 % y 80 %, respectivamente; p = 0,266). Conclusiones: los casos de DCD en portadores de EEI se caracterizan por afectar a pacientes más jóvenes, mayoritaria adquisición comunitaria (y menor nosocomial), guardar más relación con el tratamiento previo con IBP que con el tratamiento antibiótico y presentar evolución clínica favorable.

Association of NAFLD with subclinical atherosclerosis and coronary-artery disease: meta-analysis

Background: Recent studies have associated non-alcoholic fatty liver disease (NAFLD) with increased risk of cardiovascular disease, using tests of subclinical atherosclerosis. Aim: To evaluate the influence of NAFLD on subclinical atherosclerosis and coronary artery disease (CAD). Methods: We reviewed Pubmed and EMBASE. According to inclusion and exclusion criteria, we selected 14 studies and were classified in two groups. Ten studies aimed the presence of subclinical atherosclerosis and four studies the presence of coronary artery disease. To assess subclinical atherosclerosis, we selected studies with pathological carotid intima-media thickness (CIMT) and with presence of carotid plaques. We considered coronary artery disease when patients showed at least 50 % stenosis at one or more major coronary arteries. NAFLD was assessed by ultrasound (US) and liver biopsy. Results: NAFLD showed a higher prevalence of pathological CIMT [35.1 % (351/999) vs. 21.8 % (207/948); p < 0.0001], with OR 2.04 (95 % CI: 1.65-2.51). Similarly, the presence of carotid plaques was higher in NAFLD diagnosed by US [34.2 % (101/295) vs. 12.9 % (51/394); p < 0.0001] [OR 2.82 (95 % CI: 1.87-4.27)] and diagnosed by liver biopsy [64.8 % (70/108) vs. 31.3 % (59/188); p < 0.0001] [OR 4.41 (95 % CI: 2.63-7.40)]. On the other hand, four studies assessed CAD in patients underwent coronary angiogram. Subjects with NAFLD showed 80.4 % (492/612) of CAD, while it was detected in 60.7 % (356/586) (p < 0.0001) in patients without NAFLD. Therefore, NAFLD was associated with a remarkably higher likelihood of CAD, using random effects model [OR 3.31 (95 % CI: 2.21-4.95)] or fixed effects model [OR 3.13 (95 % CI: 2.36-4.16)]. Conclusions: NAFLD increases the risk of subclinical atherosclerosis and coronary artery disease. The right management of these patients could modify the natural history both liver and cardiovascular disease.

Ischemic etiopathogenesis as the possible origin of post-double baloon enteroscopy pancreatitis: a porcine model study

The aim is to evaluate the pancreatic vascular-ischemic effects related to double balloon enteroscopy in the porcine model as a possible etiopathogenesis of post-enteroscopic pancreatitis. For this reason we carry out two independent experiments in a porcine animal model. In the first arm protocol (group I), 10 animals underwent 90 minutes of oral enteroscopy with 7 days follow-up. The levels of amylase, lipase and C-reactive protein were measured at T0 basal-T1 -90 min, T2-24, T3-7 days. Also we perform upper gastrointestinal endoscopy in a control group. At 7 days, the animals of experimental protocol-I had their pancreases removed for a pathological and immunohistochemical study to evaluate vascular epithelial growth factor (VEGF) expression. The second experimental protocol in this study aims to evaluate possible changes in vascular topography due to the double balloon enteroscopy (DBE). Group-II (10 animals) underwent oral enteroscopy and selective angiography of the cranial mesenteric artery and celiac trunk. None of the group I or control group animals presented pancreatitis, although the biochemical results for group-I showed increases in the levels of amylase, lipase and C reactive protein at 24 hours. The microscopic study for group-I showed pancreatic necrotic foci and positive VEGF expression, though these changes were not expressed in the control group. These foci were found in 50 % of the group I animals and in relation to the total of the parenchyma were quantified at 6 % of the pancreas. The results for group-II showed that the enteroscopy caused mobilization of the mesenteric vascular axis, with signs of both intestinal and pancreatic hypoperfusion. The conclusions of this study are that, after enteroscopy in the porcine model, pancreatic necrotic foci are produced, in addition to ischemic phenomena causing VEGF expression. This could be related to episodes of visceral hypoperfusion caused by vascular alterations on a topographic level. This can be related to the possible ischemic etiopathogenesis described for post-enteroscopic pancreatitis.

Evaluation of bariatric surgery patients at the emergency department of a tertiary referral hospital

Objective: To describe the profile of the bariatric surgery patients that were admitted to the Emergency Department (ED). Method: A retrospective review of the reasons why bariatric surgery patients go to our ED. We analyzed the first 30 days after the surgery. We evaluated the number and indications of admissions, the examinations ordered, and final diagnosis and destination of the patients. Results: From January 2010 to July 2012, 320 patients underwent bariatric surgery at our Institution. Fifty three patients (16.6 %) were admitted to the ED at leas t once. We found 58 admissions (1.1 admissions by patient). Patients who had duodenal switch and Roux-en-Y gastric bypass were the most representative (74 %). The main indications for admission were abdominal pain (50 %), and problems related to the surgical wounds (22.4 %). Blood test was the most performed examination (75.9 %). The most frequent final diagnosis was unspecific abdominal pain in 27 cases (46.6 %), and complications of the surgical wound in 10 patients (17.2 %). Nineteen patients (35.84 %) were admitted to the surgical ward from the ED, and 5 of them required surgical revision (9.4 %). Multivariate analyses showed that the type of surgery was the only predictor variable for the ED admission. Conclusions: Attending ED after bariatric surgery is not common, and less than a third of the patients required hospital admission. Just a small percentage of the examinations showed any pathological value. Readmission rate is very low. Surgical procedure is the only predictor for ED admission.

Objetivo: describir el perfil de consulta en el servicio de Urgencias de pacientes intervenidos de cirugía bariátrica (CB). Método: análisis retrospectivo de las consultas al servicio de Urgencias de pacientes intervenidos de CB. Se analizan las visitas realizadas en los primeros 30 días tras el alta. Se evalúan número y motivos de consulta/reconsulta, exploraciones complementarias realizadas, diagnóstico clínico establecido y destino de los pacientes. Resultados: entre enero de 2010 y julio de 2012 se intervinieron de 320 pacientes de CB, 53 enfermos (16,6 %) consultaron al menos una vez en Urgencias. Se registraron 58 consultas (1,1 visitas/paciente). Los pacientes intervenidos de cruce duodenal y bypass gástrico representaron el 74 %. Los motivos de consulta más frecuentes fueron dolor abdominal (50 %) y problemas relacionados con la herida quirúrgica (22,4 %). La analítica sanguínea fue la exploración complementaria más solicitada (75,9 %). El diagnóstico más frecuente fue dolor abdominal inespecífico en 27 casos (46,6 %), y problemas de herida quirúrgica en 10 casos (17,2 %). Diecinueve pacientes (35,84 %) requirieron ingreso hospitalario desde Urgencias y 5 de ellos precisaron reintervención quirúrgica (9,4 %). El análisis multivariante muestra que la única variable en relación a las visitas a Urgencias es el tipo de cirugía. Conclusiones: las visitas a Urgencias de pacientes intervenidos de cirugía bariátrica son poco frecuentes, menos de un tercio de ellos precisan ingreso hospitalario. Las exploraciones complementarias sólo mostraron resultados patológicos en un pequeño porcentaje de los casos. La tasa de reconsultas es baja. La técnica quirúrgica es el único predictor de consulta en Urgencias.

Proton pump inhibitor-responsive esophageal eosinophilia: a historical perspective on a novel and evolving entity

Eosinophilic esophagitis (EoE) is an emerging chronic esophageal disease, first described in 1993, with a steadily increasing incidence and prevalence in western countries. Over the 80's and early 90's, dense esophageal eosinophilia was mostly associated gastroesophageal reflux disease (GERD). For the next 15 years, EoE and GERD were rigidly considered separate entities: Esophageal eosinophilia with pathological acid exposure on pH monitoring or response to proton pump inhibitor (PPI) therapy was GERD, whereas normal pH monitoring or absence of response to PPIs was EoE. Updated guidelines in 2011 described a novel phenotype, proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE), referring to patients who appear to have EoE clinically, but who achieve complete remission after PPI therapy. Currently, PPI-REE must be formally excluded before diagnosing EoE, since 30-40 % of patients with suspected EoE are eventually diagnosed with PPI-REE. Interestingly, PPI-REE and EoE remain undistinguishable based on clinical, endoscopic, and histological findings, pH monitoring, and measurement of tissue markers and cytokines related to eosinophilic inflammation. This review article aims to revisit the relatively novel concept of PPI-REE from a historical perspective, given the strong belief that only GERD, as an acid peptic disorder, could respond to the acid suppressing ability of PPI therapy, is becoming outdated. Evolving evidence suggests that PPI-REE is genetically and phenotypically undistinguishable from EoE and PPI therapy alone can almost completely reverse allergic inflammation. As such, PPI-REE might constitute a subphenotype of EoE and PPI therapy may be the first therapeutic step and diet/ steroids may represent step up therapy. Possibly, the term PPI-REE will be soon replaced by PPI-responsive EoE. The mechanism as to why some patients respond to PPI therapy (PPI-REE) while others do not (EoE), remains to be elucidated.

Inflammatory fibroid polyp of the appendix or Vanek's tumor

Acute abdomen for lymphangioma of the small bowel mesentery: a case report and review of the literature

Acute abdomen in patients with systemic lupus erythematosus and antiphospholipid syndrome: importance of early diagnosis and treatment

Systemic lupus erithematosus (SLE) is an autoimmune disease with multiorgan involvement caused principally by vasculitis of small vessels. The gastrointestinal tract is one of the most frequently affected by SLE, with abdominal pain as the most common symptom. An early diagnosis and treatment of lupus enteritis is essential to avoid complications like hemorrhage or perforation, with up to 50 % of mortality rate. However, differential diagnosis sometimes is difficult, especially with other types of gastrointestinal diseases as digestive involvement of antiphospholipid syndrome (APS), moreover when both entities may coexist. We describe the case of a patient with both diseases that was diagnosed with lupus enteritis and treated with steroid therapy; the patient had an excellent response.

El lupus eritematoso sistémico es una enfermedad autoinmune con afectación multivisceral causada principalmente por vasculitis de pequeño vaso. El tracto gastrointestinal es uno de los órganos más frecuentemente afectados, siendo el dolor abdominal el síntoma predominante. La enteritis lúpica requiere un diagnóstico y tratamiento precoces para evitar complicaciones como la hemorragia digestiva y la perforación intestinal, que pueden alcanzar una mortalidad de hasta el 50 %. Su diagnóstico a veces se ve dificultado por la presencia de otras patologías con afectación gastrointestinal similar como ocurre en el síndrome antifosfolípido. Presentamos el caso de una paciente con ambas enfermedades que fue diagnosticada de enteritis lúpica y tratada de forma conservadora con terapia corticoidea de choque. La paciente tuvo una respuesta excelente al tratamiento.

Eosinophilic cholecystitis: an infrequent cause of acute cholecystitis

Eosinophilic cholecystitis (EC) is a rare disease that is characterised by eosinophilic infiltration of the gallbladder. Its pathogenesis is unknown, although many hypotheses have been made. Clinical and laboratory manifestations do not differ from those of other causes of cholecystitis. Diagnosis is histological and usually performed after analysis of the surgical specimen. We report the case of a woman aged 24 years, with symptoms of fever, vomiting and pain in the right upper quadrant. When imaging tests revealed acalculous cholecystitis, an urgent cholecystectomy was performed. Histological examination of the surgical specimen revealed eosinophilic cholecystitis. No cause of the symptoms was found.

La colecistitis eosinofílica (CE) es una enfermedad rara caracterizada por una infiltración eosinófila de la vesícular biliar. Su etiopatogenia es desconocida, aunque se han postulado múltiples hipótesis. Las manifestaciones clínicas y de laboratorio no difieren de otras causas de colecistitis. El diagnóstico es histológico y suele realizarse tras el análisis de la pieza quirúrgica. Presentamos el caso de una mujer de 24 años, con clínica de fiebre, dolor en hipocondrio derecho y vómitos. Las pruebas de imagen evidenciaban una colecistitis alitiásica, tras lo cual se realizó una colecistectomía urgente. Los hallazgos histológicos de la pieza quirúrgica revelaban una colecistitis eosinofílica. En este caso, no se encontró causa que justificase el cuadro.

Gastric varices

Correlation between location of amyloid deposits and endoscopic and clinical manifestations in symptomatic gastrointestinal amyloidosis

**Liver abscess due to Klebsiella pneumoniae and its relation to colon lesions**

Vacuolar internal anal sphincter myophaty as a rare cause of proctalgia fugax and constipation

13 cm GIST in 19-year-old patient, is it the first manifestation of Carney triad?

Results of a nation-wide survey on hypolactasia: how is this condition diagnosed and managed in our setting?