Revista Española de Enfermedades Digestivas

Target population for the screening of human papillomavirus (HPV) and anal carcinoma precursor lesions: Results from a pilot study in HIV-infected males with sexual risk factors

Preliminary results of a screening program for anal cancer and its precursors for HIV-infected men who have sex with men in Vigo-Spain

Background and aims: Men who have sex with men (MSM) infected with human immunodeficiency virus (HIV) have the highest risk of developing anal cancer (AC). The objective of this study was to describe our screening implementation program in this population, and report the prevalence of human papillomavirus (HPV) anal infection, and cytological and histological findings in a Spanish medium-size community (Vigo, Spain). Method: Prospective cohort analysis of 240 HIV-infected MSM. Cellular anal sample and high risk HPV (HR-HPV)-tests were performed to study cytological changes and HPV genotyping. High resolution anoscopy (HRA) was performed in 209 patients. Results were analyzed with respect to epidemiological, clinical and analytical factors. Results: Of 209 patients selected for HRA, the prevalence of HR-HPV anal infection, cytological and histological alterations was 85.6%, 47.5%, and 39.8%, respectively. Sensitivity and specificity for ≥ ASCUS (atypia of squamous cells of undetermined significance) cytology in relation to histological alterations were 61% and 85%, (OR: 8.7; IC 95%: 4.4-17.2), respectively. Observed concordance between high-grade squamous intraepithelial lesion (HSIL) cytology and HSIL anal intraepithelial neoplasia types 2 and 3 (AIN-2/3) histology was 64% (OR: 11.4; IC 95%: 3.6-36.7). One patient with HSIL cytology presented a prevalent anal squamous carcinoma. Conclusions: HRA was feasible with similar results to relevant groups. There was a high prevalence of anal HR-HPV infection, and cytological and histological alterations.

Antecedentes y objetivos: los hombres VIH que tienen sexo con hombres (VIH-HSH) presentan la mayor incidencia de cáncer anal (CA). El estudio tiene como objetivo conocer la prevalencia de la infección anal por virus del papiloma humano de alto riesgo (VPH-AR) y de los hallazgos citológicos e histológicos, así como la implementación de un programa de cribado en el contexto de una ciudad media española, Vigo (España). Método: análisis prospectivo de una cohorte de 264 hombres (VIH-HSH). A los pacientes se les realizó una citología anal y genotipado de VPH-AR para el estudio de la prevalencia de alteraciones citológicas y de la infección VPH-AR. A 209 se les realizó una anoscopia de alta resolución (AAR). Los resultados se relacionaron con variables epidemiológicas, clínicas y analíticas. Resultados: de los 209 pacientes seleccionados, la prevalencia de VPH-AR, alteraciones citológicas e histológicas anales fue de 85,6%, 47,5% y 39,3% respectivamente. La sensibilidad y especificidad para la citología ≥ ASCUS (atipia de células escamosas de significado indeterminado) respecto a las alteraciones histológicas fue de 61% y 85% (OR: 8,7; IC95%: 4,4-17,2), respectivamente. La concordancia observada entre la citología HSIL (lesión escamosa intraepitelial de alto grado) e histología HSIL (AIN-2/3, neoplasia intraepitelial tipo 2 y 3) fue del 64%,(OR: 11,4; IC95%: 3,5-36,7). Un paciente con citología HSIL presentó cáncer escamoso anal prevalente. Conclusiones: la AAR resultó factible y con resultados similares a los de grupos relevantes. Gran prevalencia de la infección anal por VPH-AR y de alteraciones citológicas e histológicas.

Coping with celiac disease: how heavy is the burden for caregivers?

Background: Celiac disease (CD) is the most common chronic enteropathy demanding a lifelong gluten-free diet. Objective: The aim of the study was to identify and estimate the subjective burden of caregivers of celiac patients. Methods: A cross-sectional observational study was conducted during the regional meeting of the Italian Society for the Celiac Disease in April 2014. A written self-administered anonymous questionnaire enquired into caregivers' demographic profile, natural history of patients' disease and caregivers' self-reported degree of burden at the onset of symptoms (T0), at CD diagnosis (T1) and during follow-up (T2). Fifty-five caregivers completed the questionnaire (69% females, 47 ± 13 years old, 73% first-degree relatives). Results: The presence of warning symptoms, such as abdominal pain, chronic diarrhea and weight loss was responsible for higher levels of concern. A statistically significant reduction of concern in the follow-up was demonstrated by the comparison of visual analogue scales (VAS) values from T0 to T2 and from T1 to T2 (6.8 ± 3.1 vs 4.2 ± 2.9 and 7.0 ± 2.5 vs 4.2 ± 2.9, respectively; p < 0.001), mirroring the reduction of distress among newly diagnosed individuals. A global impact of gluten-free diet and CD on quality of life was reported in VASs (6.7 ± 2.4). Family (5.4 ± 3.1), social (5.6 ± 2.9) and economic (4.5 ± 3.4) domains were the most associated. Conclusion: The assessment of caregivers' subjective burden should be considered as an essential step in the evaluation of celiac patients, needing a specific investigation and support.

Usefulness of an intra-gastric balloon before bariatric surgery

Introduction: There are only few reports regarding the use of intragastric-balloons (IGB®) to achieve weight loss and subsequently decrease surgical complications. In this study, we try to assess whether presurgery weight loss using IGB decreases the postsurgical mortality after bariatric surgery. Material and methods: This is a prospective case-control study. We matched 1:1 by gender, age (± 10 y-o) and type of surgery (sleeve resection [LSG] or gastric bypass [LGBP]), matching cases (A) and controls (H, from a historic cohort). Morbidly obese patients with an indication for bariatric surgery were included in the study. Cases (A) were recruited from an ongoing clinical trial, and the controls (H) came from a historic cohort prior to the start of the clinic trial. The presurgical weight loss in group A was reached by IGB combined with diet, versus only diet in group H. Results: We included 58 patients, 65.5% women, 69% LGBP/31% LSG. The mean age of group A was 42 and 43.4 years old for group H. ASA III of 24.1% group A vs 58.6% group H, p = 0.012. The mean total weight loss (TWL) before surgery was greater in group A (16.2 kg, SD 9.75) than in group H (1.2 kg, SD 6.4), p < 0.0001. The % of EWL before surgery was 23.5 (SD 11.6) in group A vs 2.4 (SD 8) in group H, p < 0.001. Hospital stay was seven days for group A, and eight days for group H, p = 0.285. The rate of unsuccessful IGB treatment to accomplish the scheduled weight loss was 34.5%. The balloon morbidity was 17.2% (6.9% severe). All in all, morbidity (due to bariatric surgery and IGB) was 41% in both groups. Postsurgical morbidity moderate-severe was 20.3% in group A (6.9% severe) and 27.3% in group H (17.2% severe) without statistical significance. One patient died in group H (mortality rate, 3.44%). Conclusion: Preoperative IGB treatment in morbid obesity has not been found to be effective at decreasing postsurgical morbidity LSG and LGBP, despite the fact that it acheives a greater weight loss than diet and exercise.

Introducción: existen pocos estudios que analicen la utilidad del balón intragástrico (BIG) preoperatorio para disminuir la morbilidad relacionada con la cirugía bariátrica. En este estudio evaluamos si el adelgazamiento prequirúrgico mediante BIG disminuye la morbimortalidad tras la cirugía de la obesidad mórbida. Material y métodos: estudio caso-control emparejado 1:1 por sexo, edad y cirugía bariátrica (bypass gástrico/gastrectomía vertical). Se incluyeron pacientes con obesidad mórbida candidatos a cirugía bariátrica, siendo los casos A reclutados de un ensayo clínico en marcha y los controles H, pacientes operados previo al inicio del ensayo. El adelgazamiento prequirúrgico en el grupo A fue mediante BIG vs. dieta exclusivamente en H. Resultados: se incluyen 58 pacientes: 65,5% mujeres, 69% bypass y 31% gastrectomía vertical. La edad fue de 42 años en el grupo A y 43 en el H. Encontramos un 34,5% de fracasos terapéuticos del BIG. ASA III: 24,1% en A vs. 58,6% en H (p = 0,012). La pérdida de peso medio corporal (PPCT) antes de cirugía fue de 16,2 kg (desviación estándar [DE] 9,75) en el grupo A frente a 1,2 kg (DE 6,4) en el grupo H, p < 0,0001. El porcentaje de exceso de pérdida de peso (EPP) antes de la cirugía fue del 23,5% (DE 11,6) en el grupo A vs. 2,4 (DE 8) en el grupo H (p < 0,0001), y el porcentaje de exceso de índice de masa corporal perdida (EPIMC) fue del 34,6% (DE 24) en el grupo A vs. 0,98% (DE 12,4) en el grupo H (p < 0,0001). La estancia hospitalaria fue de siete días en el A y ocho en el H (p = 0,285). El tratamiento con BIG fracasó en el 34,5% de los pacientes. La morbilidad del BIG fue del 17,2% (6,9% grave). La morbilidad relacionada con la cirugía bariátrica/BIG fue del 41% en ambos grupos (p = 0,687); la morbilidad quirúrgica moderada-grave en el grupo A fue del 20,3% (dos pacientes, 6,9% grave) y del 27,3% en el H (cinco pacientes, 17,2% grave), sin diferencias significativas. Un paciente falleció en el grupo H (3,44%). Conclusión: el BIG preoperatorio no consigue disminuir la morbilidad postquirúrgica de la cirugía bariátrica, y tampoco la estancia ni la tasa de reoperaciones, sin olvidar su coste, pese a que el BIG consigue mayor adelgazamiento que la dieta y el aumento de actividad física.

Health-related quality of life in adults with irritable bowel syndrome in a Mexican specialist hospital: a cross-sectional study

Background: Evidence shows the negative impact of irritable bowel syndrome on the quality of life of patients who suffer from the condition as compared to the general population. Objective: The objective of this study was to determine the health-related quality of life in adults with irritable bowel syndrome who are receiving treatment at a specialist hospital. Material and methods: The study had a cross-sectional prospective design. The study included consecutive patients diagnosed with irritable bowel syndrome under the Rome III criteria and attending outpatient appointments. The SF-36 questionnaire was applied in its standard Spanish version and the results were compared with population reference scores in Mexico. Statistical analysis was performed with the Student's t test, analysis of variance and the Chi-squared test, considering a significance of 0.05%. Results: One hundred and fifty-four patients were included in the study, 137 (89%) women and 17 (11%) men, with an average age of 52.8 (SD 12.6). The constipation, diarrhea and mixed subtypes comprised 85 (55.2%), 27 (17.5%) and 42 (27.3%) patients, respectively. The quality of life of patients with irritable bowel syndrome vs the population reference scores in Mexico were 50 vs 79 for the physical health sub-scale and 59.1 vs 76.7 for the mental health sub-scale, respectively (p = 0.000). No significant difference was found in quality of life among the irritable bowel syndrome subtypes (p > 0.05). Conclusions: Health-related quality of life is lower in patients with irritable bowel syndrome in a population in the North East of Mexico compared to the data taken from a population reference study undertaken in the same country, enabling an inference in the female population and a cautious one from the results found in the small male sample studied. There was no significant difference found in the quality of life according to the clinical subtype of irritable bowel syndrome.

Introducción: existe evidencia del impacto negativo del síndrome de intestino irritable (SII) en la calidad de vida de los pacientes que lo padecen en comparación con la población general. Objetivo: el objetivo de este estudio fue determinar la calidad de vida relacionada con la salud (CVRS) en adultos con SII en la consulta de un hospital de especialidades de México. Material y métodos: se realizó un diseño transversal y se incluyeron prospectivamente pacientes consecutivos con diagnóstico de SII con criterios de Roma III que acudieron a consulta externa. Se aplicó el cuestionario SF-36 en español versión estándar y sus resultados se compararon con puntuaciones referenciales poblacionales en México. En el análisis estadístico se utilizó t de Student, análisis de varianza y Chi cuadrado, y se consideró una significancia del 0,05%. Resultados: fueron estudiados 154 pacientes, 137 (89%) mujeres y 17 (11%) hombres; la edad media fue de 52,8 (DE 12,6) años. Los subtipos estreñimiento, diarrea y mixto fueron 85 (55,2%), 27 (17,5%) y 42 (27,3%) pacientes respectivamente. La calidad de vida de pacientes con SII vs. puntuaciones referenciales poblacionales en México fueron: subescala salud física 50 vs. 79 y subescala salud mental 59,1 vs. 76,7, respectivamente (p = 0,000). No existió diferencia significativa en la calidad de vida entre los subtipos de SII (p > 0,05). Conclusiones: la CVRS es menor en pacientes con SII en una población al noroeste de México con respecto a datos de un estudio de referencia poblacional realizado en el mismo país, pudiendo realizar inferencia a población de mujeres pero con cautela en los resultados por la muestra pequeña estudiada en hombres. No existió diferencia significativa en la calidad de vida según el subtipo clínico de SII.

Endoscopic colostomy with percutaneous colopexy: an animal feasibility study

Background: Indications for colostomy in colorectal diseases are obstruction of the large bowel, such as in cancer, diverticular disease in the acute phase, post-radiotherapy enteritis, complex perirectal fistulas, anorectal trauma and severe anal incontinence. Some critically ill patients cannot tolerate an exploratory laparotomy, and laparoscopic assisted colostomy also requires general anesthesia. Objective: To evaluate the feasibility, safety and efficacy of performing colostomy assisted by colonoscopy and percutaneous colopexy. Materials and methods: Five pigs underwent endoscopic assisted colostomy with percutaneous colopexy. Animals were evaluated in post-operative days 1, 2, 5 and 7 for feeding acceptance and colostomy characteristics. On day 7 full colonoscopy was performed on animals followed by exploratory laparotomy. Results: Average procedure time was 27 minutes (21-54 min). Postoperative mobility and feeding of animals were immediate after anesthesia recovery. Position of the colostomy, edges color, appearance of periostomal area, as well as its function was satisfactory in four animals. Retraction of colostomy was present in one pig. The colonoscopy and laparotomy control on the seventh day were considered as normal. A bladder perforation that was successfully repaired through the colostomy incision occurred in one pig. The main limitation of this study is its experimental nature. Conclusion: Endoscopic assisted colostomy with percutaneous colopexy proves to be a safe and effective method with low morbidity for performing colostomy in experimental animals, with possible clinical application in humans.

Onsite evaluation of endoscopic ultrasound fine needle aspiration: the endosonographer, the cytotechnologist and the cytopathologist

Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has become an essential tool in the management of multiple diseases. Its accuracy is related to different aspects of the technique, one of the most important being the experience and interaction of the endosonographer and pathologist. Certain studies over the past years have highlighted the importance of having rapid on-site evaluation (ROSE) of samples obtained at the time of EUS-FNA. We have reviewed the role of ROSE, performed by the same endosonographer, a cytotechnologist and an expert cytopathologist. The available data suggest that ROSE (either by the endosonographer, the cytotechnologist, or the cytopathologist) improves sample adequacy and diagnostic yield, with the best option to have ROSE performed by an expert cytopathologist. However, if non-ROSE accuracy is already very high, any improvement is harder to achieve.

Gallbladder perforation after closed thoracoabdominal trauma, diagnosed and treated by ERCP

A cause of porto-mesenteric pneumatosis not secondary to intestinal ischemia

Enteral stent for the treatment of a urinary fistula associated with a biological mesh following a Bricker-type procedure

A bronchobiliary fistula treated with cyanoacrylate glue in a patient with liver cirrhosis

Effectiveness of arterial embolization in recurrent bleeding due to duodenal ulcer during postoperative cardiac surgery

Intrauterine device in the rectal cavity

Coloduodenal and enterocutaneous fistula in twins with Crohn's disease

An unusual enterolith ileus

Debut of an unusual liver cirrhosis

Paraesophageal hernia and gastric volvulus: an uncommon etiology of vomiting and upper gastrointestinal bleeding

Meckel's diverticulum bleeding detected by capsule endoscopy

Hepatocellular carcinoma presenting with Budd-Chiari syndrome, right atrial thrombus and pulmonary emboli

Enteral feeding via jejunostomy as a cause of intestinal perforation and necrosis

Background: Jejunostomy for enteral feeding is excellent for patients who cannot manage oral intake, with a low complication rate. A Foley catheter, Ryle tube, Kerh tube or needle-catheter (Jejuno-Cath®) are commonly used. It is a safe procedure but it can lead to severe complications. Case report: We present two cases: firstly, an 80 year old male who was admitted to the Emergency Room with a bowel perforation secondary to Jejuno-Cath® for enteral feeding after a subtotal gastrectomy with Roux-en-Y reconstruction; and secondly, a 53 year old male who was admitted to the Emergency Room due to gastric perforation developing multiple complications, including bowel necrosis and enteral feeding impaction. Discussion: We have reviewed the recent literature with regard to this rare complication.

Introducción: la yeyunostomía de alimentación es una excelente manera de nutrir por vía enteral a pacientes que no pueden tolerar dieta oral con una tasa de complicaciones baja. Se utiliza comúnmente una sonda de Foley, tubo de Ryle, de Kerh o catéter con aguja (Jejuno-Cath®). Caso clínico: presentamos el caso de un paciente varón de 80 años que presentó una perforación intestinal como consecuencia de la nutrición a través de un yeyunocath en el postoperatorio de una gastrectomía subtotal con reconstrucción en Y de Roux, y de otro paciente varón de 53 años con perforación gástrica y múltiples complicaciones postoperatorias, entre ellas, necrosis de un segmento de intestino delgado por impactación de nutrición enteral. Discusión: revisamos la literatura existente sobre esta rara complicación.

Case of drug-induced acute pancreatitis produced by horsetail infusions

Introduction: The most frequent causes of acute pancreatitis are biliary stones, alcohol consumption, smoking and tumors. Some of them do not have any established cause, and they are catalogued as idiopathic pancreatitis. Case report: We report the case of a 56-year-old woman with a history of bilateral adrenalectomy on hormone replacement therapy with corticosteroids, who has recurrent episodes of mild acute pancreatitis with an etiologic study (laboratory and imaging tests) without significant findings. A drug-induced etiology was suspected, so corticosteroids were removed and antihypertensive treatment was modified, but the clinical manifestations persisted. Later regular consumption of horsetail infusions was detected, and after their suspension the patient became asymptomatic and has not presented new episodes. Discussion: The drug-induced acute pancreatitis is a strange cause of pancreatitis that is frequently underdiagnosed because of the difficulty to establish a relationship between the drugs and the pancreatitis. Lots of drugs have been related with acute pancreatitis, while the information available for herbal products is limited. They usually present like mild and recurrent episodes, without significant findings in both laboratory and imaging tests (abdominal ultrasound, abdominal computed tomography [CT], cholangiography and endoscopic ultrasound). It is important to detect the origin of this type of pancreatitis to prevent recurrence.

Introducción: las causas más frecuentes de pancreatitis aguda son las litiasis biliares, el consumo de alcohol, el tabaquismo o los tumores. Hay un porcentaje de ellas que quedan sin causa establecida, catalogándose de pancreatitis idiopática. Caso clínico: presentamos el caso de una mujer de 56 años con antecedente de suprarrenalectomía bilateral de las glándulas suprarrenales en tratamiento hormonal sustitutivo con corticoides, que presenta episodios de pancreatitis aguda leve de repetición con estudio etiológico (analítico y pruebas de imagen) sin hallazgos. Se sospecha el origen tóxico, por lo que se retiran los corticoides y se modifica el tratamiento antihipertensivo, pero la clínica persiste. Posteriormente se detecta el consumo habitual de infusiones de cola de caballo. Tras su suspensión la paciente se queda asintomática y no vuelve a presentar nuevos episodios. Discusión: la pancreatitis aguda tóxica es una causa rara de pancreatitis que con cierta frecuencia queda sin diagnosticar por la dificultad de establecer una relación entre el agente tóxico y la pancreatitis. Los fármacos relacionados con las pancreatitis agudas son múltiples, mientras que la información disponible es escasa con los productos de herboristería. Se suelen presentar como episodios leves y recurrentes, sin objetivar la causa en el estudio tanto analítico como por pruebas complementarias (ecografía de abdomen, tomografía computarizada [TC] de abdomen, colangiopancreatografía por resonancia magnética [RMN] y ecoendoscopia). Es importante detectar el origen de estas pancreatitis para evitar su recurrencia.

Jejunal pseudodiverticulosis: three cases report

Jejunal pseudodiverticulosis is an uncommon entity. Pseudodiverticulum are usually asymptomatic and an incidental finding. They can have a less frequent acute onset with perforation, obstruction or bleeding and they could have high morbidity and mortality. We report three patients who debuted with an acute abdomen.

La pseudodiverticulosis yeyunal es una entidad infrecuente que cursa habitualmente de forma asintomática. Cuando produce sintomatología, en muchas ocasiones es como resultado de sus complicaciones (obstrucción, perforación o sangrado) y asocia una elevada morbimortalidad. Presentamos tres casos que debutaron como un cuadro de abdomen agudo.

Colonic obstruction secondary to sigmoid fecaloma endoscopically resolved with Coca-Cola^®

Background: Colonic obstruction is a relatively common condition in emergency care, with a mortality rate of up to 20%. In 90% of cases it results from colonic or rectal adenocarcinoma, volvulus, or stenosis secondary to diverticular disease. When fecal impaction is the underlying cause, the condition is usually managed conservatively, but may on occasion become complicated and even require surgical intervention. Based on the proven efficacy of Coca-Cola® to dissolve gastric phytobezoars, we report a case of colonic obstruction secondary to sigmoid fecaloma. Case report: A 58 years old woman arrived at the Emergency Room (ER) with persistent constipation for the last six days. An abdominal CT scan showed a large fecal mass at the sigmoid colon with retrograde dilated colonic loops. Cleansing enemas and oral lactulose were administered, which failed to resolve the clinical presentation, so we then proceeded to inject Coca-Cola® within the fecaloma using a sclerosing needle, and then washed the fecaloma surface also with Coca-Cola®. After a few minutes we started to fragment the fecalith, the consistency of which had been notably decreased. Discussion: The use of Coca-Cola® for gastric washes in the management of phytobezoars is well established. Since fecaliths are partly composed of these same substances than phytobezoars, the use of Coca-Cola® might well be warranted against them as in our patient, without surgery. Our case report is the second one published in the literature, in which Coca-Cola® helped solve colonic obstruction secondary to fecaloma.

Introducción: la obstrucción colónica es una patología relativamente frecuente en el área de urgencias, con una mortalidad de hasta el 20%. En el 90% de los casos se debe a adenocarcinoma de colon o recto, vólvulo o estenosis secundaria a enfermedad diverticular. Respecto a la impactación de material fecal como causa de la misma es una entidad que suele manejarse forma conservadora, aunque en ocasiones puede complicarse y precisar incluso de intervención quirúrgica para su resolución. Basándonos en la efectividad demostrada de la Coca-Cola® para disolver fitobezoars gástricos planteamos su uso en un caso de obstrucción colónica secundaria a fecaloma de sigma. Caso clínico: se trata de una mujer de 58 años que acude a urgencias por cuadro de estreñimiento pertinaz de 6 días de evolución. En las pruebas radiológicas realizadas se demostró la presencia gran masa de material fecal impactada en colon sigmoides que condicionaba dilatación retrógrada de asas colónicas. Tras el fracaso de las medidas conservadoras con enemas de limpieza y lactulosa oral, se decidió desimpactar el fecaloma mediante colonoscopia valiéndonos de Coca-Cola®, que aplicamos con irrigaciones e inyección local. Esto disminuyó su consistencia y permitió la fragmentación con asa del fecaloma. Discusión: la Coca-Cola® ya se emplea para disolver fitobezoars gástricos. La composición similar de los fecalomas hace suponer que esta sea también efectiva como así fue en el caso de nuestra paciente, permitiendo no tener que intervenir a la paciente. Nuestro caso es el segundo publicado en el que la Coca-Cola® ayudó a la resolución de una obstrucción colónica secundaria a fecaloma.

Liver metastasis from neuroendocrine carcinoma after the use of the new direct-action antivirals against hepatitis C virus in a patient with past history of hepatocellular carcinoma

The use of the new direct-action antivirals against hepatitis C virus provides very high viral eradication rates. However, various recently published articles recommend caution with their use after the appearance of some cases of de novo tumors (originated in hepatic and extra-hepatic locations) and a possible shorter time period of recurrence of hepatocellular carcinomas previously treated with surgery or loco-regional therapies. The sudden drop of the number of natural killer cells secondary to the use of these new medicines has been suggested as one of the possible mechanisms responsible for this process. However, due to the controversy concerning this subject and the absence of long-term follow-up studies in clinical practice, caution is needed before definitive conclusions are settled. We present the case report of a patient diagnosed of chronic liver disease secondary to hepatitis C virus infection and a past history of hepatocellular carcinoma in complete remission after radiofrequency ablation. He was treated with the new direct-action antivirals reaching sustained viral response. Six months later, the patient was diagnosed with liver metastasis from a small-cell neuroendocrine tumor of unknown primary site.

El uso de los nuevos fármacos antivirales de acción directa frente al virus de la hepatitis C provee unas tasas muy elevadas de erradicación viral. No obstante, se están publicando de forma reciente artículos que defienden la precaución en su uso al documentarse algunos casos de tumores de novo tanto hepáticos como extrahepáticos, así como una mayor rapidez de aparición de recurrencias de hepatocarcinomas previamente tratados mediante cirugía o terapias locorregionales. El rápido descenso de las células natural killer con los tratamientos antivirales libres de interferón se ha propuesto como uno de los posibles mecanismos que podrían explicar este proceso, si bien, dada la controversia a este respecto y la ausencia de estudios a largo plazo en la práctica clínica, se requiere precaución antes de establecer conclusiones definitivas. Presentamos el caso clínico de un paciente con hepatopatía crónica por el virus de la hepatitis C y hepatocarcinoma en remisión completa tras tratamiento ablativo con radiofrecuencia que fue tratado con los nuevos antivirales de acción directa, consiguiendo respuesta virológica sostenida. Seis meses después el paciente fue diagnosticado de metástasis hepáticas de un carcinoma neuroendocrino de célula pequeña de tumor primario no conocido.

Diagnosis and management of patients with an intermediate probability of choledocholithiasis

Giant esophageal diverticulum as a new clinical indication for endoscopic gastrostomy

Laparoscopic treatment of hemorrhagic Meckel diverticulum after diagnosis with wireless capsule endoscopy and double-balloon enteroscopy

Hemobilia related to cystic artery pseudoaneurysm as a cause of acute pancreatitis

Invasive pulmonary aspergillosis in an immunocompromised patient with severe ulcerative colitis

A rare acute thoracic manifestation of a chronic digestive disease: pancreaticopleural fistula

Juan Rodés Teixidor (Barcelona, 1938-2017)

Thomas E. Starzl (Le Mars, Iowa, 1926-2017)