Revista Española de Enfermedades Digestivas

Cepillado de la pared del quiste. Explorando los límites de la citología

Endoscopic ultrasound cytologic brushing vs endoscopic ultrasound -fine needle aspiration for cytological diagnosis of cystic pancreatic lesions. A multicenter, randomized open-label trial

ABSTRACT Introduction: the incidence of cystic pancreatic lesions (CPL) in the asymptomatic population is increasing. Achieving a preoperative diagnosis of CPL still remains a challenge. Objectives: to evaluate the diagnostic accuracy of the cytological diagnosis of CPL from samples obtained by cytology brush versus standard endoscopic ultrasound fine needle aspiration (EUS-FNA). Methods: a multicenter, randomized, open-label trial was performed of EUS-cytology brush (EUS-EB) versus EUS-FNA for the cytological diagnosis of CPL. Patients that underwent EUS-FNA with a CPL > 15 mm were included and randomized into two groups: group I, EUS-EB; group II, EUS-FNA. The final diagnosis was based on the histological evaluation of surgical specimens and clinical parameters, imaging and a five year follow-up in non-operated patients. The main outcome was the diagnostic accuracy of both methods. Secondary outcomes were the diagnostic adequacy of specimens and the rate of adverse events. Data were compared using the Chi-squared test. An intention to treat (ITT) and per-protocol (PP) analysis were performed. Results: sixty-five patients were included in the study, 31 in group I and 34 in group II. Three patients initially randomized to group I were changed to group II as it was impossible to obtain a sample using the brush. The mean size of the CPL was 28.2 mm (range 16-60 mm). The diagnostic accuracy of EUS-EB was not superior to EUS-FNA, neither in the ITT nor the PP analysis (44.8% vs 41.1%, p = 0.77 and 38.4% vs 45.9%, p = 0.55). Conclusions: EUS-EB does not improve the diagnostic accuracy of CPL in comparison with EUS-FNA.

Análisis retrospectivo en pacientes con cáncer de vesícula biliar: tratamiento quirúrgico y supervivencia en función del estadio tumoral

RESUMEN Introducción: el cáncer de vesícula biliar es la neoplasia más frecuente de vías biliares y el sexto de los tumores del aparato digestivo, presentando un pronóstico ominoso, con una supervivencia a cinco años alrededor del 5%. Suele diagnosticarse de forma tardía y la única posibilidad de curación es la resección quirúrgica. Métodos: se realizó un estudio retrospectivo en el cual fueron analizados 92 pacientes (64 mujeres y 28 hombres) diagnosticados por anatomía patológica con cáncer de vesícula entre enero de 2000 y enero de 2016. Resultados: la edad media de la serie fue 72 ± 11 años. Los síntomas de los pacientes al ingreso fueron: dolor abdominal (78%), anorexia (77%), náuseas (76%) e ictericia (45%). La cirugía se indicó en los 92 (100%) pacientes y se realizó una resección con intención curativa en 59 (64%) de ellos. Entre los procedimientos quirúrgicos realizados en la cirugía inicial, la colecistectomía simple se efectuó en 69 (75%) y la colecistectomía extendida, en once (11%) pacientes. La cirugía de rescate se realizó en 15 pacientes después del hallazgo tumoral en la pieza de colecistectomía, realizando una resección curativa R0 en diez pacientes. Además, la terapia adyuvante se utilizó en 30 (33%) pacientes. La mediana de la supervivencia de nuestra serie fue de 12,5 meses, con supervivencias del 57%, 30% y 20% a uno, tres y cinco años, respectivamente. Conclusión: en conclusión, en todos los pacientes se debe plantear el tratamiento quirúrgico con resección tumoral completa, siempre y cuando la situación clínica del paciente lo permita.

ABSTRACT Introduction: gallbladder cancer is the most common biliary neoplasm and the sixth most common tumor of the digestive system. The disease has an ominous prognosis, with a 5-year survival rate of approximately 5%. It is usually diagnosed late and surgical resection is the only potential cure. Methods: a retrospective study was carried out in 92 patients with a pathological diagnosis of gallbladder cancer from January 2000 to January 2016. Results: the mean age of cases was 72 ± 11 years; 64 subjects were females and 28 were males. Symptoms at admission included abdominal pain (78%), anorexia (77%), nausea (76%) and jaundice (45%). Surgery was indicated in 92 (100%) patients and 59 (64%) underwent a curative/intent resection. The initial surgical procedures included simple cholecystectomy in 69 (75%) cases and extended cholecystectomy in eleven (11%) subjects. Rescue surgery was performed in 15 patients with tumor tissue in the cholecystectomy specimen; ten individuals underwent an R0 curative resection. Adjuvant therapy was administered in 30 (33%) patients. The median survival in our series was 12.5 months, with survival rates of 57%, 30% and 20% at one, three and five years, respectively. Conclusion: to conclude, surgical treatment with a complete tumor resection should be considered for all patients, provided that their clinical status allows it.

Diez años de seguimiento de la cohorte española del estudio Europeo PreventCD: lecciones aprendidas

RESUMEN Objetivo: evaluar la influencia del consumo de gluten en el desarrollo de enfermedad celiaca y describir la historia natural de la misma, en una cohorte española de riesgo genético participante en el estudio Europeo PreventCD. Métodos: estudio prospectivo multicéntrico doble ciego, incluyendo 225 niños, controlados desde el nacimiento, en tres centros de Madrid, Reus y Valencia, todos HLA-DQ2/HLA-DQ8 positivos y con un familiar de primer grado con enfermedad celiaca. Entre cuatro y diez meses, la ingesta de gluten estaba pautada por protocolo. Entre los 11-36 meses, la ingesta fue libre, siendo cuantificada prospectivamente mediante registros dietéticos. Se realizaron visitas clínicas y análisis de anticuerpos específicos de enfermedad celiaca periódicamente. Resultados: se diagnosticaron 26 casos, todos con biopsia y serología positiva, 21 con síntomas gastrointestinales y cinco asintomáticos. Se analizaron 2.565 registros que mostraron diferencias estadísticamente significativas (p < 0,001) en el consumo de gluten entre los tres centros, pero no entre niños celiacos y no celiacos (p = 0,025). El genotipo HLA-DQ2.5/DQ2.5 y DQ2.5/DQ2.2 presentó un riesgo relativo de 4,7 (IC 95%: 0,80-27,55; p = 0,08), superior al resto de genotipos, y el género femenino presentó un riesgo relativo cinco veces superior al masculino. Conclusiones: ni la cantidad de gluten consumida entre los 11 y los 36 meses ni la duración de la lactancia son factores de riesgo de desarrollo de EC en la población española, siendo el genotipo HLA y el sexo los factores más relevantes asociados a la misma. En este grupo de riesgo, la mayoría de casos debutaron antes de los dos años, encontrándose a esta temprana edad pacientes con escasa expresividad clínica.

ABSTRACT Aim: to evaluate the influence of gluten consumption on celiac disease development and to describe its natural history in the Spanish cohort of the European PreventCD study. Methods: prospective multi-center double blind study of 225 children that were followed up from birth. All cases were HLA-DQ2/HLA-DQ8 positive with a 1st degree relative with celiac disease and were followed up in three centers from Madrid, Reus and Valencia. Gluten intake was determined between four and ten months according to the protocol. Gluten intake was ad libitum between eleven and 36 months and was prospectively quantified by means of dietary records. Clinical visits and specific antibody analysis for celiac disease were performed periodically. Results: twenty-six cases were diagnosed, all had a positive biopsy and serology; 21 had gastrointestinal symptoms and five were asymptomatic. In addition, 2,565 food records were analyzed and statistically significant differences (p < 0.001) were found with regard to gluten consumption among the three centers, although not between celiac and non-celiac children (p = 0.025). The HLA-DQ2.5/DQ2.5 and DQ2.5/DQ2.2 genotypes had a relative risk of 4.7 (95% CI: 0.80-27.55; p = 0.08), which was higher than for the rest of genotypes. Female gender also had a relative risk that was five times higher than that for males. Conclusions: the amount of gluten intake between 11 and 36 months or the duration of breast feeding were not risk factors for the development of CD in the Spanish population. The HLA genotype and gender were the most relevant associated factors. In this at-risk group, the disease presented before two years of age in the majority of the cases with a weak clinical expression.

Self-expandable metal stents are a valid option in long-term survivors of advanced esophageal cancer

ABSTRACT Background: self-expandable metal stents are often used for the palliative treatment of dysphagia in patients with advanced esophageal cancer and an anticipated limited survival. Due to previous reports of a high rate of adverse event when used long-term, concerns have been raised with regard to the use of self-expandable metal stents in patients with a longer survival. Aim: assess the role of esophageal self-expandable metal stents in patients with advanced esophageal cancer that have survived longer than six months. Methods: retrospective study of patients with advanced esophageal cancer with a self-expandable metal stent and a stent placement time greater than six months. Results: forty-two patients were followed up for 298 days. There was a clinical improvement in all patients. However, 59% of patients experienced an adverse event. The median stent patency was 236 days. Endoscopic management was attempted in all self-expandable metal related adverse events, with a clinical success rate of 100%. However, the previously treated adverse event recurred in seven patients. Multivariate analysis showed that strictures that were traversable with an ultrathin gastroscope were associated with a higher risk of adverse events (p = 0.035). Conclusions: long-term esophageal stenting in patients with advanced esophageal cancer is associated with a high prevalence of adverse events without an impact on mortality; most cases can be managed endoscopically.

El diclofenaco rectal no previene la pancreatitis post-CPRE en pacientes consecutivos de alto y bajo riesgo

RESUMEN Objetivo: el diclofenaco rectal, un antiinflamatorio no esteroideo (AINE), se utiliza para prevenir la pancreatitis en pacientes de alto riesgo en la colangiopancreatografía retrógrada endoscópica (CPRE). La Sociedad Europea de Endoscopia Digestiva (ESGE) recomienda profilaxis con indometacina o diclofenaco a todos los pacientes a los que se les realice una CPRE, incluso en aquellos de riesgo medio-bajo de pancreatitis. Hemos realizado un estudio para investigar la eficacia de esta recomendación. Métodos: estudio de cohortes mixto. Se incluyeron 1.512 CPRE efectuadas en nuestro centro entre enero de 2009 y julio de 2016. Hasta junio de 2012, 718 pacientes no recibieron diclofenaco. Posteriormente, 794 pacientes sin contraindicaciones recibieron 100 mg rectales de diclofenaco al inicio del procedimiento. Se registraron los factores de riesgo para pancreatitis aguda post-CPRE (PAPC) y los casos de PAPC que se definieron por criterios de consenso. Resultados: hubo 47 PAPC (3,1%), un 3,4% de las cuales correspondió al grupo con diclofenaco y un 2,8%, al grupo no tratado (p = 0,554). El 26,1% de todos los pacientes presentaba factores de riesgo para PAPC. En el grupo con diclofenaco hubo un 4,4%, 0,5% y 2,6% de PAPC en papilas intactas, con esfinterotomía previa y con ampliación de la misma, respectivamente, similar al grupo no tratado (4% papila intacta, 0,9% esfinterotomía previa y 2,5% ampliación). La gravedad de la PAPC fue similar en los dos grupos. Conclusiones: en nuestro estudio, el diclofenaco rectal antes de la CPRE en pacientes consecutivos no seleccionados no previene la aparición de pancreatitis aguda post-CPRE.

ABSTRACT Objective: rectal diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that is used to prevent pancreatitis in high-risk patients during endoscopic retrograde cholangiopancreatography (ERCP). The European Society of Gastrointestinal Endoscopy (ESGE) recommends the use of prophylaxis with indomethacin or diclofenac in all patients undergoing ERCP, including those at low or intermediate risk of pancreatitis. A study to investigate the efficacy of this recommendation was performed. Methods: this was a mixed cohort study. A total of 1,512 ERCP procedures performed in our institution from January 2009 to July 2016 were included in the study. Until June 2012, 718 patients did not receive diclofenac. Subsequently, 794 patients without contraindications received 100 mg of rectal diclofenac at the onset of the procedure. Risk factors for post-ERCP pancreatitis (PEAP) and PEAP cases defined using consensus criteria were recorded. Results: a total of 47 PEAP events (3.1%) were reported, 3.4% in the diclofenac group and 2.8% in the non-diclofenac group (p = 0.554); 26.1% of patients had risk factors for PEAP. In the diclofenac group, PEAP developed in 4.4%, 0.5% and 2.6% of subjects with intact papillae, prior sphincterotomy and extended sphincterotomy, respectively. The results were similar for the non-diclofenac group: 4% with intact papillae, 0.9% with prior sphincterotomy, and 2.5% with extended sphincterotomy, respectively. PEAP severity was similar in both groups. Conclusions: rectal diclofenac before ERCP did not prevent the development of post-ERCP acute pancreatitis in non-selected consecutive patients.

Endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) with the Procore(tm) needle provides inadequate material for the histological diagnosis of early chronic pancreatitis

ABSTRACT Background: diagnosis of early chronic pancreatitis (CP) is hampered due to the low accuracy of current imaging techniques and the absence of methods for histological confirmation. We aimed to evaluate the efficacy of endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for the histological diagnosis of early CP. Methods: a prospective, cross-sectional, single-center study was designed. Consecutive patients referred for EUS with a clinical suspicion of CP were evaluated for inclusion into the study. Inclusion criteria were age > 18 years and indeterminate EUS findings for the diagnosis of CP according to the Rosemont classification. EUS-FNB of the body of the pancreas was performed with Procore(tm) needles. Tissue samples were immersed into a methanol-based buffered preservative solution for cytohistological evaluation. The quality of the samples obtained and the histological findings were evaluated. Procedure-related complications were recorded. Results: the study was stopped after eleven patients were included due to safety concerns and poor diagnostic yield. The mean age of the patients was 50.3 years (range 33-70 years) and six were male. Samples were of poor quality in five cases, but were sufficient for cell-block evaluation. An inflammatory infiltration with mild fibrosis was identified in two cases and neither inflammatory infiltration nor fibrosis was identified in three cases. With regard to the other six cases, isolated inflammatory cells were observed in one case, although the cellularity was poor and unsuitable for cytological evaluation in five cases. There was one major complication (9.1%) of acute pancreatitis that required hospitalization for 48 hours. Conclusion: EUS-FNB is technically feasible in patients with EUS findings categorized as indeterminate for a CP diagnosis. However, the diagnostic yield is poor and there is a non-negligible risk of complications.

Revisión de las perforaciones duodenales tras colangiopancreatografía retrógrada endoscópica en el Hospital Puerta de Hierro de 1999 a 2014

RESUMEN Introducción: la colangiopancreatografía retrógrada endoscópica (CPRE) sigue siendo la prueba de elección para el diagnóstico y el tratamiento de la patología biliar y pancreática, pero cuenta con una tasa de morbimortalidad no desdeñable, por lo que se proponen algoritmos para el manejo y tratamiento de sus complicaciones. Objetivo: revisar las perforaciones post-CPRE tratadas en el Servicio de Cirugía General del Hospital Puerta de Hierro de 1999 a 2014, evaluando los resultados en función del tipo de perforación y el tratamiento. Métodos y resultados: se ha realizado un estudio descriptivo y observacional de todas las perforaciones post-CPRE comunicadas y tratadas por el Servicio de Cirugía General del Hospital Puerta de Hierro de 1999 a 2014, en relación a la indicación de la prueba y hallazgos, el tipo de perforación (clasificación de Stapfer), el tiempo hasta el diagnóstico y el método de diagnóstico, el tiempo hasta la intervención y la técnica empleada, las complicaciones posteriores, así como la evolución y el tiempo de ingreso. Los resultados se han evaluado en función del tipo de perforación (Stapfer) y del tipo de tratamiento realizado. Se comunicaron 36 perforaciones (21 de tipo I, ocho de tipo II, dos de tipo III y cinco de tipo IV), lo que supone una incidencia menor del 1%. El diagnóstico fue inmediato (en las primeras 24 horas) en el 67% de los casos, siendo las de tipo I las más frecuentes. Se intervino a 28 de los 36 pacientes (77,7%), realizándose en la mayoría una colecistectomía seguida, siempre que fue posible, de sutura, colangiografía intraoperatoria y exploración de la vía biliar y drenaje. Fallecieron cuatro pacientes (dos intervenidos y dos manejados de manera conservadora), todos con perforaciones de tipo I. La complicación más frecuente fue la colección/fístula, que apareció en el 21,42% de los pacientes intervenidos. Conclusiones: el tratamiento de las perforaciones periduodenales secundarias a CPRE debe orientarse en función de los hallazgos clínicos y radiológicos. Según nuestra experiencia, las perforaciones de tipo I requieren una intervención quirúrgica inmediata, mientras que las perforaciones tipo II y III permiten, en algunos casos, un manejo conservador, siempre ante la ausencia de complicaciones como colecciones abdominales asociadas y/o signos de sepsis o de irritación peritoneal. Las perforaciones tipo IV responden bien al manejo conservador

ABSTRACT Introduction: endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard in biliary and pancreatic pathology. Although the procedure has a significant morbidity and mortality rate. Algorithms are needed for the management and treatment of the associated complications. Objective: to review the post-ERCP perforations treated in the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The results were evaluated according to the types of perforation and treatment. Methods and results: this is a descriptive and observational study of all post-ERCP perforations reported and treated by the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The following data were collected: indication for the test and findings, type of perforation, time and method of diagnosis, time to surgery and the technique used; the subsequent complications as well as the evolution and time of admission were registered. Results were evaluated according to the type of perforation (Stapfer classification) and the treatment performed. Thirty-six perforations were reported (21 type I, eight type II, two type III and five type IV), with an associated incidence of less than 1%. The diagnosis was immediate (in the first 24 hours) in 67% of cases; type I was the most frequent: 28 of 36 patients (77.7%) required surgery. The majority underwent a cholecystectomy followed by suture, intraoperative cholangiography, bile duct exploration and drainage whenever possible. Four patients died with type I perforations; two were intervened and two were managed conservatively. The most frequent complication was a collection/fistula which occurred in 21.42% of patients who underwent surgery. Conclusions: periduodenal perforations secondary to ERCP treatment should be oriented according to the clinical and radiological findings. In our experience, type I perforations require immediate surgical intervention, whereas type II and III perforations can be managed conservatively in some cases when there are no complications such as associated abdominal collections, peritoneal irritation and/or sepsis. Type IV perforations respond to conservative management.

Ictericia indolora como debut de adenocarcinoma pulmonar

Trasplante hepático en hemofilia A y enfermedad de von Willebrand tipo 3. Manejo perioperatorio y evolución postrasplante

RESUMEN Introducción: la infección por virus hepatitis C (VHC) ha sido causa de importante morbi-mortalidad en hemofilia, planteándose el trasplante hepático (TH) por cirrosis y/o carcinoma hepatocelular (CHC). Caso clínico: presentamos los casos con coagulopatías congénitas e infección por VHC sometidos a TH en nuestro centro: tres pacientes con hemofilia A y uno con enfermedad de von Willebrand (EvW) tipo 3. Evaluamos el curso de la coagulopatía, el manejo perioperatorio, el consumo de factor y componentes sanguíneos y la supervivencia postrasplante. El factor deficitario se comenzó a administrar en bolo iv directo una hora antes del inicio de la cirugía para alcanzar un nivel deseado de dicho factor de 100 UI/dl, mantenido hasta conseguir el control estable de la hemostasia. Los tres pacientes con hemofilia A curaron su coagulopatía postrasplante. El factor VIII (FVIII) fue 93 UI/dl a los once años, 59 UI/dl a los 13 meses y 109 UI/dl a los nueve meses postrasplante en cada uno de los casos. El consumo medio perioperatorio de concentrados de FVIII fue 175 UI/kg, infundido hasta 36 h postrasplante de media. El paciente con EvW tipo 3 consiguió atenuar el curso natural de su sintomatología hemorrágica sin que se detectaran niveles hemostáticos del antígeno del factor von Willebrand (FVW:Ag) postrasplante. Discusión: tras el trasplante hepático, se produce la curación de la hemofilia A y la mejoría del fenotipo hemorrágico en la EvW tipo 3.

ABSTRACT Introduction: infection with the hepatitis C virus (HCV) causes significant morbidity and mortality in patients with hemophilia. Finally, patients are considered for a liver transplantation (LT) due to cirrhosis and/or hepatocellular carcinoma (HCC). Case report: we report the cases of congenital coagulopathy and HCV infection that underwent LT in our institution. There were three patients with hemophilia A and one patient with von Willebrand disease (vWD) type 3. The coagulopathy outcome, perioperative management, factor and blood product usage and post-transplant survival were assessed. The deficient factor was initially administered in a direct bolus one hour before surgery with a target level of 100 IU/dl, which was sustained until stable hemostasis was reached. All three patients with hemophilia A were cured of their coagulopathy following transplantation. Factor VIII (FVIII) was 93 IU/dl at eleven years, 59 IU/dl at 13 months and 109 IU/dl at nine months post-transplant, in each case. The mean perioperative usage of FVIII concentrates was 175 IU/kg; concentrates were infused for an average of 36 hours post-transplant. The natural course of the bleeding symptoms of the patient with type-3 vWD was attenuated, with no detectable hemostatic levels of von Willebrand factor antigen (vWF:Ag) after transplantation. Discussion: after transplantation, hemophilia A cure and improved bleeding phenotype of type-3 vWD reduced morbidity and mortality. However, potential graft reinfection with HCV and relapsing HCC cast a shadow over these optimum results.

La papilomatosis biliar difusa puede recidivar después del trasplante hepático en ausencia de focos de carcinoma infiltrante

RESUMEN La neoplasia papilar intraductal (NPI) o papilomatosis biliar (PB) es una enfermedad recurrente con un alto riesgo de transformación maligna. Cuando la enfermedad afecta de forma difusa a la vía biliar (VB), el trasplante hepático (TH) es la única alternativa terapéutica disponible. Presentamos el caso de un varón de 43 años que debutó con un cuadro de colangitis aguda, siendo diagnosticado de papilomatosis biliopancreática difusa. El paciente fue sometido a una pancreatectomía total en dos tiempos y finalmente, a un TH, descartándose la presencia de focos de carcinoma infiltrante o de afectación ganglionar tanto en el páncreas inicialmente como en el hígado a posteriori. A los dos años de seguimiento, el paciente desarrolló una recidiva hepática multicéntrica cuya biopsia fue compatible con adenocarcinoma de origen biliar. En 2010, Vibert y cols. describieron que en los casos de PB sin presencia de carcinoma infiltrante o afectación ganglionar, el TH era una opción de tratamiento eficaz. Este caso es el primero que describe recidiva de la enfermedad después del TH en ausencia de focos de carcinoma infiltrante y de afectación ganglionar. Cuando la papilomatosis afecta de forma extensa a la VB, es posible que durante el análisis histopatológico pequeños focos de microinfiltración puedan no ser detectados. No obstante, aunque se trata de una enfermedad recidivante, la patogenia es desconocida, y no sabemos si la papilomatosis podría recidivar sobre el injerto después del TH incluso en ausencia de carcinoma infiltrante.

ABSTRACT Intraductal papillary neoplasm of the bile duct (IPNB) or biliary papillomatosis (BP) is a premalignant entity with high risk of malignant transformation. When the disease extends widely from the intrahepatic to the extrahepatic biliary tree, liver transplantation (LT) is the only option available. We present the case of a 43-year-old male who was admitted in our hospital with an acute cholangitis. He was diagnosed of diffuse biliary and pancreatic papillomatosis. Firstly, we performed a cephalic pancreaticoduodenectomy, then we completed a total pancreatectomy, and finally, after confirming the absence of foci of carcinoma infiltration or lymph nodes involvement, a LT was performed. Foci of carcinoma infiltration or lymph nodes involvement in the liver were not found. After a two-year follow-up the patient developed liver recurrence and the biopsy showed a biliary adenocarcinoma. In 2010, Vibert et al. published a series of three cases concluding that in the absence of invasive carcinoma and positive lymph nodes, LT can be performed with success. The present case is the first to describe recurrence of the disease after LT in the absence of invasive carcinoma and positive lymph nodes in the literature. When the disease affects widely the entire biliary duct, small micro-invasive foci may not be detected. Nevertheless, although we know that it is a recurrent entity, the pathogenesis is unknown, and we do not know if it is possible that papillomatosis recurs over the new liver.

Keriorrea (diarrea cérea), un nuevo signo a tener en cuenta

Síndrome de Sweet tras inicio de vedolizumab en paciente con enfermedad de Crohn

Dispepsia, dispepsia funcional y criterios de Roma IV

Neumoperitoneo secundario a neumatosis quística intestinal asociado a inhibidores de la tirosina quinasa

Adenoma tubular de íleon como causa de sangrado intestinal bajo en lactante menor

Neoplasia intraepitelial anal en pacientes de riesgo: ¿cómo y a quién realizar un programa de cribado?