Revista Española de Enfermedades Digestivas

Gastroenterology: a historical specialty with a great future

Gastroenterology: evolution of specialty choice in recent years

Introduction: Gastroenterology is one of the medical specialties offered to residency training candidates each year. This project analyzes the data associated with the choice of a Gastroenterology residency program in recent years. Material and methods: Data related to specialty selection were obtained from official reports with regard to the allocation of residency places by the Spanish Ministry of Health, Social Services and Equality. Information was collected from various teaching centers via their training guides, the Spanish National Catalogue of Hospitals and the National Transplant Organization. Results: The median consecutive number involved in the choice of Gastroenterology training has decreased year after year, and this specialty is now positioned among the five most commonly selected residency programs in 2015. The median number of hospitals with a higher number of beds, adult liver transplantation activities and dedicated GI bleeding units is significantly lower. This is also true when centers are analyzed according to the presence of specific Gastroenterology on-call shifts for residents or their association with medical schools. Data from the past five years highlight Madrid, Aragón and the Basque Country as the autonomous communities where Gastroenterology is the most popular. Centers selected by candidates with the lowest median consecutive numbers from 2011-2015 included the university hospitals Ramón y Cajal, Santiago de Compostela and Gregorio Marañón. Conclusions: Gastroenterology has gradually escalated in the ranking of residency choices and is now one of the five most popular options. Potential residents prefer larger centers with complex-care patients and more research activity.

Introducción: Aparato Digestivo es una de las especialidades ofertadas a los opositores que acceden a la formación sanitaria especializada cada año. Este proyecto analiza los datos de elección de Aparato Digestivo en los últimos años. Material y métodos: los datos de la elección se han obtenido de la publicación oficial de los actos de asignación de plazas del Ministerio de Sanidad, Servicios Sociales e Igualdad. Se ha recabado información de los distintos centros docentes a través de sus guías formativas, el Catálogo Nacional de Hospitales y la Organización Nacional de Trasplantes. Resultados: la mediana de elección de número de orden para Aparato Digestivo ha descendido anualmente, situando la especialidad en 2015 entre las cinco más populares en la elección. La mediana de los hospitales con mayor número de camas, actividad de trasplante hepático en adultos y Unidad de Sangrantes es significativamente menor. Lo mismo sucede al analizar los centros en base a la presencia de guardias específicas de Aparato Digestivo para residentes o vinculación con facultades de Medicina. Los datos de los últimos cinco años sitúan a Madrid, Aragón y Euskadi como las comunidades autónomas más populares. Los centros con menor mediana de número de orden para el periodo 2011-2015 fueron los hospitales universitarios Ramón y Cajal, Santiago de Compostela y Gregorio Marañón. Conclusiones: Aparato Digestivo ha ido mejorando de manera progresiva en la elección de plazas de especialización hasta llegar a situarse entre las cinco más populares. Los electores se decantan por centros grandes, de mayor complejidad asistencial y elevada actividad investigadora.

Cost-effectiveness of a hepatitis B virus screening strategy to prevent reactivation in patients with hematologic neoplasms

Introduction: The effectiveness of a screening strategy for the detection of a hepatitis B virus (HBV) infection followed by prophylaxis in order to prevent HBV reactivation was assessed in patients with hematologic neoplasms. Material and methods: A decision tree was developed to compare the cost and effectiveness (prevented reactivations) over an 18 month period of a screening strategy prior to chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) with a non-screening approach. HBsAg+ (hepatitis B surface antigen) and/or anti-HBc+ (antibodies to hepatitis B core antigen) and HBV-DNA+ patients received oral antiviral prophylaxis with tenofovir disoproxil (245 mg once daily) from chemotherapy baseline until one year after chemotherapy completion. Non-screened patients received tenofovir in case of a reactivation. Model probabilities were obtained from the literature. The total cost (€, 2015) included: antiviral prophylaxis, R-CHOP, screening tests (HBsAg, anti-HBc, HBV-DNA) and liver function tests. Drug therapy costs were estimated using ex-factory prices with mandatory deductions. The incremental cost-effectiveness ratio (ICER) was calculated in order to assess the cost-effectiveness of this intervention in terms of cost per reactivation averted versus no screening. Results: In a hypothetical cohort of 1,000 patients, screening prevented 7.36 reactivations when compared to the non-screening approach (14.9 versus 22.3). Total cost/patient (including €8,282 for R-CHOP) was €8,584 for the screening strategy and €8,449 for the non-screening approach. The ICER for screening versus non-screening was €18,376/prevented reactivation. Conclusion: HBV screening followed by oral antiviral prophylaxis yielded more health benefits than non-screening, reducing HBV reactivation in patients with hematologic neoplasms on chemotherapy.

Introducción: se analizó la efectividad de una estrategia de cribado de la infección por el virus de la hepatitis B (VHB) con consiguiente profilaxis en pacientes con neoplasia hematológica para evitar la reactivación del VHB. Material y métodos: se utilizó un árbol de decisión para comparar costes y eficacia (reactivaciones evitadas), en 18 meses, de una estrategia con cribado previo a quimioterapia con R-CHOP (rituximab, ciclofosfamida, doxorrubicina, vincristina y prednisona) versus una estrategia sin cribado. Los pacientes HBsAg+ (antígeno de superficie de la hepatitis B) y/o antiHBc+ (anticuerpos del núcleo de la hepatitis B) y ADN-VHB+ recibieron profilaxis antiviral con tenofovir disoproxil desde el inicio de la quimioterapia hasta un año después de su finalización. Los pacientes sin cribado recibieron tenofovir en caso de reactivación. Las probabilidades del modelo se obtuvieron de la literatura. El coste total (€, 2015) incluyó: profilaxis antiviral, R-CHOP, pruebas de cribado (HBsAg, antiHBc y ADN-VHB) y función hepática. El coste farmacológico se calculó con el precio de venta al laboratorio aplicando la deducción obligatoria. Resultados: en una cohorte hipotética de 1.000 pacientes, el cribado evitó 7,36 reactivaciones frente a la estrategia sin cribado (14,9 versus 22,3). El coste total/paciente (incluyendo 8.282 € de coste de R-CHOP) fue de 8.584 € para la estrategia con cribado y 8.449 € para la estrategia sin cribado. La relación coste-efectividad incremental del cribado versus la estrategia sin cribado fue de 18.376 €/reactivación evitada. Conclusión: el cribado de la infección por el VHB permite implementar una profilaxis antiviral en pacientes con alto riesgo de reactivación, disminuyendo la frecuencia de dichas reactivaciones en pacientes con neoplasias hematológicas en tratamiento quimioterapia, con un coste incremental aceptable.

Prevalence, risk factors and response to treatment of extra-intestinal manifestations in patients with inflammatory bowel disease

Introduction: Patients with inflammatory bowel disease can experience extra-intestinal manifestations that may cause significant morbidity. Aims: To describe the prevalence, characteristics, treatment and evolution of extra-intestinal manifestations in inflammatory bowel disease patients treated in our hospital and to identify associated risk factors. Methods: This was a retrospective, observational, case-control study. All inflammatory bowel disease patients with extra-intestinal manifestations were considered as cases and inflammatory bowel disease patients without extra-intestinal manifestations were considered as controls. Results: Six hundred and nineteen patients with inflammatory bowel disease (327 Crohn's disease, 265 ulcerative colitis, 27 indeterminate colitis) were included in the study; 16.5% experienced at least one extra-intestinal manifestation (CI 95% 13.5-19.5; n = 102). The most frequent extra-intestinal manifestations observed were musculoskeletal (n = 50; 40%) and cutaneous manifestations (n = 50; 40%). With regard to treatment, arthropathies were treated with non-steroidal anti-inflammatory drugs (31%) and corticosteroids (19%, oral or intra-articular), and the majority of the cutaneous manifestations were managed with corticosteroids. Overall, the efficacy of extra-intestinal manifestation treatment was 90% and only 13% of patients had a recurrence of extra-intestinal manifestations. The multivariate analysis showed that female gender (p = 0.012; OR = 1.61; 95% CI 1.11-2.34) and the severity of inflammatory bowel disease (p = 0.009; OR = 1.65; 95% CI 1.13-2.4 if immunosuppressant therapy alone, or p = 0.029; OR = 2.28; 95% CI 1.09-4.78 if in combination with adalimumab) were associated with an increased risk of developing extra-intestinal manifestations. Conclusions: The most frequent extra-intestinal manifestations in our environment were musculoskeletal and cutaneous manifestations. Female gender and a more severe disease were associated with a higher risk of developing extra-intestinal manifestations. Individualized treatment of extra-intestinal manifestations is effective and the risk is low in our series.

Introducción: los pacientes con enfermedad inflamatoria intestinal pueden presentar manifestaciones extraintestinales que en ocasiones asocian gran morbilidad. Objetivos: evaluar la prevalencia, las características, los tratamientos y la evolución de las manifestaciones extraintestinales en pacientes con enfermedad inflamatoria intestinal en nuestro centro e identificar los posibles factores de riesgo asociados. Métodos: estudio retrospectivo, observacional, tipo casos y controles. Los pacientes con enfermedad inflamatoria intestinal con manifestaciones extraintestinales fueron considerados casos y los que no las presentaban, controles. Resultados: fueron incluidos 619 pacientes con enfermedad inflamatoria intestinal (327 enfermedad de Crohn, 265 colitis ulcerosa, 27 colitis no clasificada). El 16,5% mostró al menos una manifestación extraintestinal (IC 95% 13,5-19,5; n = 102), siendo las más frecuentes las musculoesqueléticas (n = 50, 40%) y las cutáneas (n = 50, 40%). Respecto al tratamiento, en las artropatías predominó el uso de antiinflamatorios no esteroideos (31%) y corticoides (19%, orales o intraarticulares) y para las alteraciones cutáneas se recurrió mayoritariamente a los corticoides (83%). Globalmente, la eficacia del tratamiento fue del 90%. En el 13% se produjo recidiva de la manifestación extraintestinal. El análisis multivariante identificó el sexo femenino (p = 0,012; OR = 1,61; IC 95% 1,11-2,34) y la gravedad de la enfermedad inflamatoria intestinal (p = 0,009, OR = 1,65, 1,13-2,4, si precisaron terapia inmunosupresora; p = 0,029, OR = 2,28, 1,09-4,78, si requirieron terapia combinada con inmunosupresor y adalimumab) como factores de riesgo asociados al desarrollo de manifestaciones extraintestinales. Conclusiones: las manifestaciones extraintestinales más frecuentes en nuestro medio son las musculoesqueléticas y las cutáneas. El sexo femenino y la gravedad de la enfermedad inflamatoria intestinal asocian un mayor riesgo de desarrollar manifestaciones extraintestinales. El tratamiento individualizado de las mismas es eficaz y el porcentaje de recidiva es bajo.

Towards the centralization of digestive oncologic surgery: changes in activity, techniques and outcome

Aim: The objective of the present study was to examine changes in the activity, surgical techniques and results from the process of centralization of complex digestive oncologic surgery in 2005-2012 as compared to 1996-2000. Material and methods: A retrospective cohort study employing the minimum basic data set of hospital discharge (MBDSHD 1996-2012) from public centers in Catalonia (Spain) was performed. The population consisted of individuals aged > 18 who underwent digestive oncologic surgery (esophagus, pancreas, liver, stomach or rectum). Medical centers were divided into low, medium, and high-volume centers (≤ 5, 6-10, and > 10 interventions/year, respectively). The tendency Chi-squared test was used to assess the centralization of patients in high-volume centers and hospital mortality evolution during the study period. Logistic regression was performed to assess the relationship between volume and outcome. Results: A centralization of complex oncologic digestive surgery between 10% (liver) and 46% (esophagus) was obtained by means of a reduction in the number of hospitals that perform these interventions and a significant rise in the number of patients operated in high-volume centers (all types p ≤ 0.0001, except for esophagus). A significant decrease in mortality was observed, especially in esophagus (from 15% in 1996/2000 to 7% in 2009/12, p = 0.003) and pancreas (from 12% in 1996/2000 to 6% in 2009/12, p trend < 0.0001). Conclusions: A centralization of oncologic digestive surgery in high-volume centers and a reduction of hospital mortality in Catalonia were reported among esophageal and pancreatic cancers. However, no significant changes were found for others cancer types.

Objetivo: se examinaron los cambios en actividad, técnicas quirúrgicas y resultados del proceso de concentración de la cirugía oncológica digestiva compleja entre 2005-2012 en relación a 1996-2000. Material y métodos: se realizó un estudio de cohortes retrospectivo a partir del Conjunto Mínimo Básico de Datos (CMBD) al alta hospitalaria (1996-2012) de centros públicos de Catalunya. Población > 18 años intervenida de cáncer de: esófago, páncreas, hígado, estómago y recto. Los centros se clasificaron en: bajo, medio y alto volumen (≤ 5, 6-10 y > 10 procedimientos/año, respectivamente). Utilización del test tendencia Chi-cuadrado para valorar la concentración de pacientes en centros de alto volumen y la evolución de la mortalidad hospitalaria y regresión logística para estudiar la relación entre volumen y resultado en el periodo de concentración (2005-2012). Resultados: se ha producido una progresiva concentración de la cirugía oncológica digestiva compleja, mediante la reducción de entre un 10% (hígado) y 46% (esófago) del número de hospitales que realizan estas intervenciones y el aumento significativo del porcentaje de pacientes intervenidos en centros de alto volumen (todas las p tendencia < 0,0001, excepto esófago). También se observa una reducción significativa de la mortalidad, especialmente en esófago (de 15% en 1996/2000 a 7% en 2009/12, p tendencia = 0,003) y páncreas (de 12% en 1996/2000 a 6% en 2009/2012, p tendencia < 0,0001). Conclusiones: se ha producido una concentración efectiva de la cirugía oncológica digestiva en Cataluña en centros de alto volumen que se ha acompañado de una reducción de la mortalidad hospitalaria clara en esófago y páncreas, aunque sin cambios significativos en los otros cánceres estudiados.

EUS-guided recanalization of complete gastrointestinal strictures

Background and aim: Complete gastrointestinal strictures are a technically demanding problem. In this setting, an anterograde technique is associated with a high risk of complications and a combined anterograde-retrograde technique requires a prior ostomy. Our aim was to assess the outcome of a first case series for the management of complete gastrointestinal strictures using endoscopic ultrasound (EUS)-guided puncture as a novel endoscopic approach. Patients and methods: This retrospective case-series describes four cases that were referred for treatment of complete benign gastrointestinal strictures, three upper and one lower. Recanalization was attempted with EUS-guided puncture using a 22G or 19G needle and contrast filling was visualized by fluoroscopy. Afterwards, a cystotome and/or a dilator balloon were used under endoscopic and fluoroscopic guidance. A fully covered metal stent was placed in two cases, keeping the strictures open in order to prevent another stricture. Feasibility, adverse events, efficacy and the number of dilations required after recanalization were evaluated. Results: Technical and clinical success was achieved in three of the four cases (75%). A first dilation was performed using a dilator balloon in all successful cases and fully covered metal stents were used in two cases. These patients underwent a consecutive number of balloon dilatations (range 1-4) and all three were able to eat a soft diet. No adverse events were related to the EUS-guided approach. In the failed case with a long stricture (> 3 cm), an endoscopic rendezvous technique was attempted which caused a pneumothorax requiring a chest tube placement. Conclusion: EUS-guided recanalization, as a first approach in the treatment of complete digestive stricture, is a feasible and promising procedure that can help to avoid major surgery.

New psychological therapies for irritable bowel syndrome: mindfulness, acceptance and commitment therapy (ACT)

The current goal of treatment in irritable bowel syndrome (IBS) focuses primarily on symptom management and attempts to improve quality of life. Several treatments are at the disposal of physicians; lifestyle and dietary management, pharmacological treatments and psychological interventions are the most used and recommended. Psychological treatments have been proposed as viable alternatives or compliments to existing care models. Most forms of psychological therapies studied have been shown to be helpful in reducing symptoms and in improving the psychological component of anxiety/depression and health-related quality of life. According to current NICE/NHS guidelines, physicians should consider referral for psychological treatment in patients who do not respond to pharmacotherapy for a period of 12 months and develop a continuing symptom profile (described as refractory irritable bowel syndrome). Cognitive behavioral therapy (CBT) is the best studied treatment and seems to be the most promising therapeutic approach. However, some studies have challenged the effectiveness of this therapy for irritable bowel syndrome. One study concluded that cognitive behavioral therapy is no more effective than attention placebo control condition and another study showed that the beneficial effects wane after six months of follow-up. A review of mind/body approaches to irritable bowel syndrome has therefore suggested that alternate strategies targeting mechanisms other than thought content change might be helpful, specifically mindfulness and acceptance-based approaches. In this article we review these new psychological treatment approaches in an attempt to raise awareness of alternative treatments to gastroenterologists that treat this clinical syndrome.

Hepatic abscesses secondary to a foreign body in the common bile duct

Efficacy and safety of vedolizumab as a treatment option for moderate to severe refractory ulcerative colitis in two patients after liver transplant due to primary sclerosing cholangitis

Vedolizumab is a humanized IgG1 monoclonal antibody that selectively blocks the lymphocyte integrin α4β7 and prevents its interaction with endothelial adhesion molecules and subsequent transmigration to the gastrointestinal tract. The drug was approved in 2014 for the induction and maintenance treatment of ulcerative colitis and moderate to severe Crohn's disease that is refractory or intolerant to conventional treatment with corticoids and immunosuppressants and/or anti-TNFα drugs. However, inflammatory bowel disease has a variable behavior following liver transplant. One third of patients with ulcerative colitis associated with primary sclerosing cholangitis are expected to deteriorate despite receiving immunosuppression to prevent rejection. There is limited experience with anti-TNFα agents in patients with inflammatory bowel disease in the setting of liver transplantation and the studies to date involve a limited number of cases. The efficacy and safety data of vedolizumab in this situation are unreliable and very preliminary. We present two cases with the aim to present the efficacy and safety of vedolizumab after one year of treatment in two patients who underwent a transplant due to primary sclerosing cholangitis. One case had de novo post-transplant ulcerative colitis refractory to two anti-TNFα drugs (golimumab and infliximab). The other patient had a colostomy due to fulminant colitis and developed severe ulcerative proctitis refractory to infliximab after reconstruction with an ileorectal anastomosis.

Vedolizumab (VDZ), un anticuerpo monoclonal humanizado IgG1 que bloquea selectivamente la integrina α4β7 de los linfocitos impidiendo su interacción con moléculas de adhesión endotelial y su migración a la submucosa del tracto gastrointestinal, fue aprobado en 2014 para el tratamiento de inducción y mantenimiento de la colitis ulcerosa (CU) y la enfermedad de Crohn (EC) moderada-grave refractarias o intolerantes a tratamiento convencional con esteroides e inmunosupresores y/o agentes anti-TNFα. El comportamiento de la enfermedad inflamatoria intestinal tras el trasplante hepático es variable. En el caso concreto de la CU asociada a colangitis esclerosante primaria (CEP), se estima que un tercio de los pacientes experimentarán un empeoramiento a pesar de recibir inmunosupresión para evitar el rechazo. Si la experiencia con agentes anti-TNFα en pacientes con enfermedad inflamatoria intestinal en el entorno del trasplante hepático es exigua, con series de casos que incluyen a un número limitado de pacientes, la experiencia descrita sobre la eficacia y seguridad de VDZ en esta situación es anecdótica y muy preliminar. Presentamos dos casos que pretenden ilustrar la eficacia y seguridad de VDZ tras un año de tratamiento en dos pacientes trasplantadas por CEP: una de ellas con CU de novo postrasplante y refractaria a dos agentes anti-TNFα (golimumab e infliximab) y otra paciente colectomizada previamente por colitis fulminante que desarrollo una proctitis ulcerosa grave y refractaria a infliximab tras la reconstrucción del tránsito mediante anastomosis ileorrectal.

Synchronous intraductal papillary mucinous neoplasm and a pancreatic neuroendocrine tumor: more than a coincidence?

Background: Although the association between intraductal papillary mucinous neoplasm of the pancreas (IPMN) and pancreatic neuroendocrine tumor (PNET) has been increasingly reported, whether this association is real or coincidence remains unclear. We report a case of synchronous IPMN and a PNET which were diagnosed preoperatively and discuss the tumorigenesis, clinicopathological features and management of these rare tumors based on the published literature. Case report: A 56-year-old male was incidentally diagnosed with a 14 mm branch duct IPMN and a 3.6 mm non-functional PNET during an evaluation due to persistent upper abdominal pain via endoscopic ultrasound. Close follow-up of the patient was decided as the IPMN had no worrisome features. A review of twenty-two previously reported cases of synchronous IPMN and PNET indicated that: a) only seven cases were diagnosed preoperatively; b) abdominal pain was the main presenting symptom; c) IPMN was the dominant tumor and presented with low grade dysplasia; d) the PNET was small and non-functional and had an indolent behavior; and e) only one case underwent radiologic follow-up. Discussion: IPMN are associated with other pancreatic and extrapancreatic malignancies. Thus, the entire pancreatic parenchyma should be examined closely during the evaluation of an IPMN in order to exclude other pancreatic lesions, for example, a PNET.

Segmental intestinal necrosis in a young patient

Duodenal hematoma caused by endoscopic hemostatic procedures (sclerotherapy)

Long survival in a patient with metastatic colorrectal carcinoma: reality or utopia?

Rectal inflammatory stenosis secondary to Chlamydia trachomatis: a case report

Endoscopic retreatment of Zenker's diverticulum using novel endoscopic scissors: the Clutch Cutter device

Bowel obstruction secondary to intraluminal migration of the abdominal wall mesh

**Fecal transplantation as a treatment for Clostridium difficile infection in patients with ulcerative colitis**

Cytomegalovirus: associated ischemic colitis in an immunocompetent patient

Neuroendocrine tumors of the pancreas: keys issues in dealing with heterogeneity

A case of a mixed adenoneuroendocrine tumor of the colon

Sternal cutaneous metastasis of hilar cholangiocarcinoma

Post-transfusion hyperhemolysis syndrome following gastrointestinal bleeding secondary to prehepatic portal hypertension