Revista Española de Enfermedades Digestivas

Intensificación del tratamiento de mantenimiento con infliximab de la colitis ulcerosa

Frecuencia, factores predictores y consecuencias de la intensificación del tratamiento de mantenimiento con infliximab en la colitis ulcerosa

Introduction: Infliximab (IFX) therapy intensification in ulcerative colitis (UC) is more common than established in pivotal studies. Objectives: To establish the frequency and form of intensification for UC in clinical practice, as well as predictors, and to compare outcomes between intensified and non-intensified treatment. Methods: A retrospective study of 10 hospitals and 144 patients with response to infliximab (IFX) induction. Predictive variables for intensification were analyzed using a Cox regression analysis. Outcome, loss of response to IFX, and colectomy were compared between intensified and non-intensified therapy. Results: Follow-up time from induction to data collection: 38 months [interquartile range (IQR), 20-62]. Time on IFX therapy: 24 months (IQR, 10-44). In all, 37% of patients required intensification. Interval was shortened for 36 patients, dose was increased for 7, and 10 subjects received both. Concurrent thiopurine immunosuppressants (IMM) and IFX initiation was an independent predictor of intensification [Hazard ratio, 0.034; p, 0.006; CI, 0.003-0.371]. In patients on intensified therapy IFX discontinuation for loss of response (30.4% vs. 10.2%; p, 0.002), steroid reintroduction (35% vs. 18%; p, 0.018), and colectomy (22% vs. 6.4%; p, 0.011) were more common. Of patients on intensification, 17% returned to receiving 5 mg/kg every 8 weeks. Conclusions: Intensification is common and occasionally reversible. IMM initiation at the time of induction with IFX predicts non-intensification. Intensification, while effective, is associated with poorer outcome.

Introducción: la intensificación del tratamiento con infliximab (IFX) en la colitis ulcerosa (CU) es más frecuente de lo establecido en estudios pivotales. Objetivos: establecer la frecuencia y forma con la que intensificamos en CU en práctica clínica, los factores predictores y comparar la evolución entre los pacientes con tratamiento intensificado y no intensificado. Métodos: estudio retrospectivo de 10 hospitales y 144 pacientes con respuesta a la inducción con IFX. Se analizaron variables predictoras de la intensificación con análisis de regresión de Cox. Se comparó la evolución, pérdida de respuesta a IFX y colectomía según tratamiento intensificado o no intensificado. Resultados: tiempo de seguimiento desde la inducción hasta la recogida de datos: 38 meses [rango intercuartil (RIC) 20-62]. Tiempo de tratamiento con IFX: 24 meses (RIC, 10-44). El 37% de los pacientes requirió intensificación. Se acortó el intervalo en 36pacientes, se aumentó la dosis en 7, ambas en 10. La intro-ducción simultánea de inmunosupresores tiopurínicos (INM) e IFX predijo la intensificación de forma independiente [Hazard ratio (HR) 0,034 p 0,006 IC 0,003-0,371]. En los pacientes con tratamiento intensificado fue más frecuente la suspensión de IFX por pérdida de respuesta (30,4% vs. 10,2% p 0,002), la reintroducción de corticoides (35% vs. 18%, p 0,018) y la colectomía (22% vs. 6,4% p 0,011). El 17% de los pacientes intensificados volvió a recibir 5mg/kg cada 8 semanas. Conclusiones: la intensificación es frecuente y en ocasiones reversible. La introducción del INM en el momento de la inducción con IFX predice la no intensificación. La intensificación, aunque eficaz, se asocia a una peor evolución.

Outcome of endoscopic self-expandable metal stents in acute malignant colorectal obstruction at a tertiary center

Background: Malignant colorectal obstruction (MCRO) by advanced colonic cancer occurs in 8-13% of colonic cancer patients. Emergent surgery carries a high mortality and morbidity risk. Endoscopic self-expanding metal stents (SEMS) may be used in acute MCRO. Aim: Evaluate clinical outcome of SEMS in acute MCRO and efficacy of SEMS placement considering fluoroscopy guidance. Methods: Retrospective study of patients with acute MCRO that placed SEMS in a 3 years period. Results: SEMS were placed in 47 patients, followed-up for a median time of 150 days. The intent of stenting was bridge to definitive surgery in 40% of the patients (n = 19) and palliation in the remaining 60% (n = 28). The location of the tumor did not influence the presence of lymph node involvement (p = 0.764) nor metastasis (p = 0.885). Mortality rate at year 1 was 61%. Survival was significantly higher in patients submitted later to combination therapy compared to chemotherapy, surgery or symptomatic treatment (p < 0.001). Fluoroscopy was used in 57% of the procedures. Clinical success was 79%. A second SEMS was needed during the procedure in 6% of the patients. Rate of early and late complications was 11% and 5%, respectively. Fluoroscopy guidance did not influence the occurrence of immediate (p = 0.385), early (p = 0.950) or late complications (p = 0.057). Thirty-three percent of patients underwent surgery at a later stage, with neo-adjuvant therapy in 18%. Conclusions: SEMS provide a relative safe and successful treatment in a palliative or bridge-to-surgery indication. No significant differences were found in SEMS placement success, early complications or late complications considering fluoroscopy guidance.

Characteristics and pattern of recurrence after curative surgery in oesophageal cancer

Background and aim: Recurrence in oesophageal cancer continues to remain high after curative surgery. The aim of this study was to determine the presence of recurrence after curative surgery during follow-up, and the associated variables. Methods: A retrospective and prospective follow-up study in patients with an anatomical-pathological diagnosis of oesophageal cancer who underwent curative surgery (n = 57) in the health district of A Coruña (Spain) during the period 2003-2008. The calculation of recurrence-free survival was made using a competing risks survival analysis. Results: Out of the 57 patients included in the study, 87.7% were men with a mean age of 61.4 ± 10.3 years. The median follow-up period was 18.5 months, during which 28 recurrences were detected (50.9%). Patients with dysphagia on diagnosis of the disease, as well as patients in stages III-IV, have a higher probability of recurrence during the follow-up period. The median disease-free interval was 8.5 months. After one year of follow up, 57.1% of the recurrences were diagnosed and 82.1% after 2 years of follow-up. The median post-recurrence survival rate was 4.7 months. After adjusting for a multivariate regression model, the variable with an independent effect for predicting recurrence is the TNM classification (HR = 8.49). Conclusions: The majority of the recurrences will be developed during the 2 years after surgery, with a very poor prognosis. The predictor variable for recurrence is the TMN classification.

Contribution of KIR (killer immunoglobulin-like receptor) genes, HLA class I ligands, and KIR/HLA class I ligand combinations on the genetic predisposition to celiac disease and coexisting celiac disease and type 1 diabetes mellitus

Backgound and aim: There are some common genetic features between celiac disease (CD) and diabetes mellitus type 1 (DM). However, the genetic risk factors have not been fully clarified for CD and the co-occurrence of CD and DM. KIR (killer immunoglobulin-like receptor) genes regulate the cytolitic activity of NK-cells and T lymphocytes. The aim of this study is to evaluate the contribution of KIR genes, KIR ligands, and combinations of KIR/KIR ligands on the genetic predisposition to CD and co-occurrence of CD and DM. Material and methods: Forty six patients with CD (n = 46), 20 patients with CD+DM (n = 20), and 60 healthy controls (n = 60) were included in this study. KIR genes and KIR ligands were investigated with PCR-ssOP and PCR-ssP in all subjects, respectively. Results: This study showed that while the telomeric KIR genes (2DS5 and 3DS1), and combinations of 3DS1+HLA-BBw4-Thr- and 3DS1+HLA-BBw4-Iso- (p < 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively) were observed more frequently in patients with CD than in controls, the 2DS5, 3DS1 KIR genes, C1 ligand, and combinations of 3DS1+HLA-BBw4-Thr- and 3DS1+HLA-BBw4-Iso- (p = 0.002, p = 0.004, p = 0.036, p < 0.001, and p = 0.007, respectively) were observed more frequently in patients with CD+DM than in controls. Conclusions: The results of this study indicated that some KIR genes, KIR ligands, and KIR/KIR ligand interactions may be responsible for a predisposition to CD and the coexistence of CD and DM. For development of coexisting CD and DM, the 2DS5 and 3DS1 genes, C1 ligand, and combinations of 3DS1+HLA-BBw4-Thr- and 3DS1+HLA-BBw4-Iso- were found to be risk factors.

Manejo de la intolerancia a la lactosa entre los médicos de atención primaria y su correlación con la de los especialistas en digestivo: encuesta nacional SEPD-SEMG

Introduction and aims: The understanding of lactose intolerance (LI) is limited in some professional settings. Sociedad Española de Patología Digestiva (SEPD) and Sociedad Española de Medicina General (SEMG) have developed a survey in order to: a) Analyze primary care physicians (PCPs) knowledge and clinical management; and b) to compare results with those of a previous survey of Spanish gastroenterologists (GEs). Material and methods: An online questionnaire was sent to SEMG members with 27 items on various issues: Demographics, occupational characteristics, outlook on LI, diagnostic tests, treatment, and follow-up. Results were compared to those from a survey of GEs. Results: A total of 456 PCPs responded, versus 477 GEs. PCPs had an older mean age and longer professional experience. Level of understanding of LI was similar, albeit a higher proportion of PCPs lacked epidemiological awareness (p < 0.01). GEs tended to consider LI a "minor" condition (71.3 vs. 40.1%; p > 0.001), and LI symptoms as overlapping those of irritable bowel syndrome (93.5 vs. 88.2%; p = 0.005), although symptoms perceived as suspicious of LI were similar in both groups. Dietary recommendations were recognized as the primary therapeutic approach. Conclusion: This study reveals the outlook of PCPs on LI, and allows comparison with that of GEs, as a basis for the development of strategies aimed at improving LI understanding, approach and management in our setting.

Introducción y objetivos: el conocimiento sobre la intolerancia a la lactosa (IL) es limitado en algunos ámbitos profesionales. La Sociedad Española de Patología Digestiva (SEPD) y la Sociedad Española de Medicina General (SEMG) han elaborado una encuesta con los objetivos de: a) analizar el nivel de conocimiento y de manejo clínico de los médicos de atención primaria (MAP); y b) comparar sus resultados con los de la encuesta ya realizada entre los gastroenterólogos españoles (GE). Material y métodos: se envió un cuestionario online a los socios de la SEMG, con 27 preguntas sobre distintas cuestiones: demografía y características laborales, actitud frente a la IL, métodos de diagnóstico, tratamiento y seguimiento. Los resultados fueron comparados con los de la encuesta a GE. Resultados: se recopilaron 456 respuestas de MAP, que se compararon con las proporcionadas por 477 GE. Los MAP presentaron una edad media y experiencia profesional mayor. El nivel de conocimiento sobre IL fue parecido, si bien una mayor proporción de MAP desconocía la epidemiología del problema (p < 0,01). Los GE tendieron a considerar a la IL una patología "menor" (71,3 vs. 40,1%; p > 0,001), y a sus síntomas superponibles a los del síndrome del intestino irritable (93,5 vs. 88,2%; p = 0,005), si bien los síntomas reconocidos como sospechosos de IL fueron similares entre ambos grupos. Las recomendaciones dietéticas fueron reconocidas como la principal medida terapéutica. Conclusión: este estudio permite conocer la actuación de los MAP ante la IL y compararla con la de los GE, como base para el desarrollo estrategias para mejorar el conocimiento, actitud y tratamiento de la IL en nuestro medio.

Respuesta Th17 y autofagia: principales vías implicadas en enfermedad inflamatoria intestinal por los estudios de asociación de genoma completo: nuevos factores implicados en la susceptibilidad a enfermedad inflamatoria intestinal

Inflammatory bowel disease (IBD) is an entity that mainly includes ulcerative colitis (UC) and Crohn's disease (CD). Improved health care, diet changes, and higher industrialization are associated with an increase in IBD prevalence. This supports the central role of environmental factors in the pathology of this disease. However, IBD also shows a relevant genetic component as shown by high heritability. Classic genetic studies showed relevant associations between IBD susceptibility and genes involved in the immune response. This is consistent with prior theories about IBD development. According to these, contact of the immune system with a high number of harmless antigens from the diet and the bacterial flora should originate tolerance while preserving response against pathogens. Failure to achieve this balance may originate the typical inflammatory response associated with IBD. Recently, genome-wide association studies (GWASs) have confirmed the implication of the immune system, particularly the Th17 immune response, previously associated to other autoimmune diseases, and of autophagy. In this paper, the mechanisms involved in these two relevant pathways and their potential role in the pathogenesis of IBD are reviewed.

La enfermedad inflamatoria intestinal (EII) es una entidad que engloba principalmente a la colitis ulcerosa (CU) y la enfermedad de Crohn (EC). Las mejoras sanitarias, cambios en la alimentación y una mayor industrialización se han asociado con mayor prevalencia de EII lo que demuestra la gran importancia de diferentes factores ambientales en la etiopatogenia de esta patología. Sin embargo, la EII presenta al mismo tiempo un importante componente genético según demuestra su alta heredabilidad. Los estudios genéticos clásicos mostraron asociaciones con genes implicados en la respuesta inmune, consecuentes con las teorías expuestas sobre el desarrollo de la enfermedad en las que el contacto del sistema inmune del sistema digestivo con gran número de antígenos inocuos de la flora y de la dieta debe originar tolerancia, manteniendo al mismo tiempo la respuesta frente a los patógenos. Un desequilibrio en este sistema originaría la respuesta inflamatoria típica de la EII. Recientemente, estudios de asociación de genoma completo (GWAS) han confirmado esta implicación del sistema inmune, particularmente de la respuesta inmune Th17, relacionada también con otras patologías autoinmunes. Otro proceso fuertemente implicado por estos estudios es el de la autofagia. En este artículo se revisan los mecanismos involucrados en estas dos vías y su posible relación con la patogenia de la EII.

Jejunal plasmablastic lymphoma presenting as obscure overt gastrointestinal bleeding: diagnosis by wireless capsule endoscopy

Obscure gastrointestinal bleeding in a patient with congenital hepatic fibrosis and Crohn's disease

Tumoración mesentérica secundaria a anisakiasis crónica

Intestinal anisakiasis is a rare parasitic disease and difficult to diagnose due to symptoms are not specific, so it is considered an underdiagnosed disease. The clinical suspicion with a correct diagnosis of anisakiasis allows the establishment of a correct treatment; in most cases, the resolution is possible with conservative treatment, avoiding unnecessary surgery to the preoperative differential diagnosis of acute abdomen. We report the case of a patient who required urgent surgery secondary to an exacerbation of chronic anisakiasis.

La anisakiasis intestinal es una enfermedad parasitaria rara y de difícil diagnóstico, ya que las manifestaciones clínicas son inespecíficas, por lo que se considera una enfermedad infradiagnosticada. La sospecha clínica junto a un correcto diagnóstico de la anisakiasis permite la instauración de un tratamiento correcto, ya que en la mayoría de los casos es posible la resolución del cuadro con tratamiento conservador, evitando cirugías innecesarias ante el diagnóstico diferencial preoperatorio de abdomen agudo. Presentamos el caso clínico de un paciente que precisó una intervención quirúrgica urgente secundaria a una reagudización de anisakiasis crónica.

Esteroides en enfermedad inflamatoria intestinal

Absceso hepático por Eikenella corrodens

Insuficiencia hepática aguda grave y tirotoxicosis: una asociación infrecuente

Pitavastatina: otra estatina a emplear y vigilar

Acute gastric dilatation in the context of bulimia nervosa

Varices estomales: una causa infrecuente de sangrado en pacientes con hipertensión portal

Leiomyosarcoma of the ascending colon: a rare tumor with poor prognosis