Revista Española de Enfermedades Digestivas

Coeliac disease in the oral mucosa?

An economic analysis of inadequate prescription of antiulcer medications for in-hospital patients at a third level institution in Colombia

Introduction: The prescription and costs of antiulcer medications for in-hospital use have increased during recent years with reported inadequate use and underused. Aim: To determine the patterns of prescription-indication and also perform an economic analysis of the overcost caused by the non-justified use of antiulcer medications in a third level hospital in Colombia. Materials and methods: Cross-sectional study of prescription-indication of antiulcer medications for patients hospitalized in "Hospital Universitario San Jorge" of Pereira during July of 2012. Adequate or inadequate prescription of the first antiulcer medication prescribed was determined as well as for others prescribed during the hospital stay, supported by clinical practice guidelines from the Zaragoza I sector workgroup, clinical guidelines from the Australian Health Department, and finally the American College of Gastroenterology Criteria for stress ulcer prophylaxis. Daily defined dose per bed/day was used, as well as the cost for 100 beds/day and the cost of each bed/drug. A multivariate analysis was carried out using SPSS 21.0. Results: 778 patients were analyzed, 435 men (55.9%) and 343 women, mean age 56.6 ± 20.1 years. The number of patients without justification for the prescription of the first antiulcer medication was 377 (48.5%), and during the whole in-hospital time it was 336 (43.2%). Ranitidine was the most used medication, in 438 patients (56.3%). The cost/month for poorly justified antiulcer medications was 3,335.6. The annual estimated cost for inadequate prescriptions of antiulcer medications was 16,770.0 per 100 beds. Conclusion: A lower inadequate prescription rate of antiulcer medications was identified compared with other studies; however it was still high and is troubling because of the major costs that these inadequate prescriptions generates for the institution.

Introducción: la prescripción y coste de antiulcerosos a nivel hospitalario se incrementaron en años recientes, reportándose usos inadecuados. Objetivo: determinar los patrones de prescripción-indicación y el análisis económico del sobrecoste por uso injustificado de antiulcerosos en un hospital de tercer nivel de atención en Colombia. Materiales y métodos: estudio de corte transversal, de prescripción-indicación de antiulcerosos en pacientes internados en el Hospital Universitario San Jorge de Pereira en julio 2012. Se determinaron: indicación adecuada o inadecuada del primer antiulceroso prescrito y del prescrito durante la hospitalización, apoyados en guías de práctica clínica del Grupo de Trabajo Sector Zaragoza I, del Departamento Gubernamental Australiano de la Salud y los criterios del Colegio Americano de Gastroenterología para profilaxis de úlceras de estrés. Se definió la dosis diaria definida por cama/día, se obtuvo el coste por 100 camas/día y costes de cada medicamento. Se hizo análisis multivariado mediante SPSS 21.0. Resultados: se analizaron 778 pacientes, 435 hombres (55,9%) y 343 mujeres, edad promedio 56,6 ± 20,1 años. No tenían justificación para la prescripción del primer antiulceroso 377 pacientes (48,5%), ni durante toda la hospitalización 336 pacientes (43,2%). Ranitidina fue el más usado en 438 pacientes (56,3%). El coste/mes por antiulcerosos no indicados fue 3.335,62 . El coste anual estimado por inadecuada prescripción de antiulcerosos fue 16.770,0 por 100 camas. Conclusión: se presentó una menor prescripción inadecuada de antiulcerosos en comparación con otros estudios, sin embargo sigue siendo alta y preocupante por los importantes costes en que incurre la institución para financiar medicamentos que no requieren los pacientes.

Histopathological findings in the oral mucosa of celiac patients

Background: Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible subjects. Although the small intestinal mucosa is the main site of the gut's involvement in CD, other mucosal surfaces belonging to the gastrointestinal tract and the gut-associated lymphoid tissue are known to be affected. Aim: Assuming that the oral mucosa could reflect the histopathological inflammatory alterations of the intestine in CD patients, this study wishes to assess the pattern of T-cell subsets in the oral mucosa of young adults with CD. Methods: A group of 37 patients (age range 20-38 years; female: male ratio 28:9) with CD were enrolled. Out of 37 patients, 19 patients (group A) followed a gluten free diet (GFD) -2 patients from less than one year; 6 patients between 1 and 5 years; 11 patients more than 5 years- while 18 patients (group B) were still untreated. Fifteen healthy volunteers (age range 18-35 years, female: Male ratio 11:4) served as controls for the CD patients. Ethical approval for the research was granted by the Ethics Committee. Biopsy specimens were taken from normal looking oral mucosa. The immunohistochemical investigation was performed with monoclonal antibodies to CD3, CD4, CD8, and γδ-chains T cell receptor (TCR). Results: The T-lymphocytic inflammatory infiltrate was significantly (p < 0.0001) increased in group B (both compared with group A and with the control group). Conclusion: This study confirms the oral cavity to be a site of involvement of CD and its possible diagnostic potentiality in this disease.

Dental erosion, an extraesophageal manifestation of gastroesophageal reflux disease: the experience of a center for digestive physiology in Southeastern Mexico

Background: Dental erosion (DE) is the loss of the hard tissues of the tooth produced by the action of gastric juice, pepsin and acid on the dental enamel, its frequency ranges from 5to 53.41%. In Mexico there are no reports on the frequency and possible association. Objective: To establish the prevalence of dental erosion and its relationship to GERD. Patients and methods: Prospective, observational, descriptive and comparative study was conducted in 60patients diagnosed with GERD and 60healthy patients at the Institute of Medical and Biological Research of the Universidad Veracruzana in Veracruz city. Anthropometric characteristics, dietary habits, oral hygiene, alcohol consumption, smoking, ED index and Index of decayed/missing dental pieces/sealed and correlation between severity of ED and GERD were analyzed. Results: 78.67% of patients with GERD had ED, 23.33% corresponded to grade 0, 41.67% to N1, N2and 23.33% to 11.67% to N3. Predominance of females (2.3:1). The mean age was 50.92± 13.52years. The severity of dental erosion was significantly related to the severity of reflux, halitosis, CPO index and poor eating habits. There was no statistically significant difference in the other variables analyzed. Conclusions: Dental erosion has a high frequency in patients with GERD and reflux characteristics are directly related to their severity and therefore should be considered as a manifestation of GERD extraesophageal.

Antecedentes: la erosión dental (ED) es la pérdida de los tejidos duros del diente producida entre otras cosas por la acción del jugo gástrico, la pepsina y el ácido sobre el esmalte dentario, su prevalencia varía entre 5y 53,41%. En México no existen publicaciones sobre su frecuencia y posible asociación. Objetivo: establecer la prevalencia de las erosiones dentales y su relación con la enfermedad por reflujo gastroesofágico (ERGE). Pacientes y métodos: estudio prospectivo, observacional, descriptivo y comparativo realizado en 60 pacientes con diagnóstico de ERGE y 60sujetos sanos en el Instituto de Investigaciones Médico-Biológicas de la Universidad Veracruzana en la ciudad de Veracruz. Se analizaron las características antropométricas, hábitos alimentarios, higiene oral, consumo de alcohol, tabaquismo, índice de ED e índice de piezas dentales cariadas/perdidas/obturadas (CPO) y la correlación entre severidad de ED y la ERGE. Resultados: El 78,67% de los pacientes con ERGE presentaron ED; el 23,33% correspondieron al grado N0, 41,67% al N1, 23,33% al N2 y 11,67% al N3. Predominó el género femenino (2,3:1). La edad promedio fue 50,92± 13,52 años. La gravedad de la erosión dental se relacionó significativamente con la severidad del reflujo, halitosis, índice CPO y con malos hábitos alimentarios. No hubo diferencia estadísticamente significativa en las demás variables analizadas. Conclusiones: la erosión dental tiene una alta frecuencia en pacientes con ERGE y las características del reflujo se relacionan directamente con su severidad por lo cual debe ser considerada como una manifestación extraesofágica más de la ERGE.

**Experimental study of hybrid-knife endoscopic submucosal dissection (ESD) versus standard ESD in a Western country**

Background: Endoscopic submucosal dissection (ESD) is an effective but time-consuming treatment for early neoplasia that requires a high level of expertise. Objective: The objective of this study was to assess the efficacy and learning curve of gastric ESD with a hybrid knife with high-pressure water jet and to compare with standard ESD. Material and methods: We performed a prospective non-survival animal study comparing hybrid-knife and standard gastric ESD. Variables recorded were: Number of en-bloc ESD, number of ESD with all marks included (R0), size of specimens, time and speed of dissection and adverse events. Ten endoscopists performed a total of 50 gastric ESD (30 hybrid-knife and 20 standard). Results: Forty-six (92%) ESD were en-bloc and 25 (50%) R0 (hybrid-knife: n = 13, 44%; standard: n = 16, 80%; p = 0.04). Hybrid-knife ESD was faster than standard (time: 44.6 ± 21.4 minutes vs. 68.7 ± 33.5 minutes; p = 0.009 and velocity: 20.8 ± 9.2 mm²/min vs. 14.3 ± 9.3 mm²/min (p = 0.079). Adverse events were not different. There was no change in speed with any of two techniques (hybrid-knife: From 20.33 ± 15.68 to 28.18 ± 20.07 mm²/min; p = 0.615 and standard: From 6.4 ± 0.3 to 19.48 ± 19.21 mm²/min; p = 0.607). The learning curve showed a significant improvement in R0 rate in the hybrid-knife group (from 30% to 100%). Conclusion: despite the initial performance of hybrid-knife ESD is worse than standard ESD, the learning curve with hybrid-knife ESD is short and is associated with a rapid improvement. The introduction of new tools to facilitate ESD should be implemented with caution in order to avoid a negative impact on the results.

Endoscopic diagnosis and therapies for Barrett esophagus: a review

Barrett's esophagus is an area of great interest in Gastroenterology, with an increasing number of research studies being published in recent years and decades. Due to the fast growing evidence regarding this disease, it has become extremely difficult to keep updated on this subject. The present review article aims to summarize and update what is known regarding diagnosis and therapy in Barrett's esophagus. A critical and detailed review is made and the role of surveillance for this condition, techniques available for diagnosis (standard white light endoscopy, virtual chromoendoscopy, magnification...) and treatment (mucosectomy, ablation...) are presented. New and emerging technologies are described in detail and existing evidence is presented.

Endoscopic submucosal dissection: Sociedad Española de Endoscopia Digestiva (SEED) clinical guideline

Diffuse colon opacifications due to lanthanum carbonate

Mechanical colonic obstruction due to diaphragmatic hernia: report of a case

Transoral endoluminal approach to Zenker's diverticulum using Ligasure^TM: early clinical experience

The development of minimally invasive procedures has rekindled interest in endoluminal techniques for the management of Zenker's diverticulum. Tissue sealers as employed in laparoscopic surgery have not been previously used for Zenker's diverticulum septotomy. Supported by the established safety of linear cutters, bipolar forceps, and ultrasonic scalpels, we have started a procedure using the Ligasure 5TM tissue sealer. Safety and efficacy results in our early clinical experience are shown for a prospective series of 5consecutive Zenker's diverticulum cases that were perorally managed with tissue sealing. The procedure was quickly and safely performed in the endoscopy room under sedation. Mean number of seals per patient was2, and mean procedure duration was 33minutes. No complications developed during or after the procedure, and patients were discharged with immediate dysphagia relief and adequate oral tolerance. No diverticular relapses occurred after a mean follow-up of 21months (range18-30). This procedure may be repeated as often as desired with no need for hospital admission. Safety should be prospectively assessed by further studies using a higher number of procedures.

El desarrollo de los procedimientos mínimamente invasivos ha reavivado el interés por las técnicas endoluminales para el tratamiento del divertículo de Zenker. Los selladores titulares empleados en cirugía laparoscópica no han sido empleados previamente en la septotomía del divertículo de Zenker. Avalados por la seguridad previa del empleo de las cortadoras lineales, de las pinzas bipolares y de los bisturís por ultrasonidos, hemos iniciado dicho procedimiento mediante el empleo del sellador tisular Ligasure 5TM. Se muestran los resultados de seguridad y eficacia en la experiencia clínica inicial de una serie prospectiva de 5 casos consecutivos de divertículo de Zenker tratados por vía peroral con el sellador tisular. El procedimiento se realizó en la sala de endoscopia, con sedación, de manera rápida y segura. La media de sellados por paciente fue de 2 y la duración media del procedimiento de 33minutos. No se presentaron complicaciones durante el procedimiento ni derivadas del mismo, siendo dados de alta los pacientes con desaparición inmediata de la disfagia y correcta tolerancia oral. Con un seguimiento medio de 21meses (rango 18-30), no existió recidiva del divertículo en ningún caso. Este procedimiento puede ser repetido tantas veces como se desee y ser realizado sin ingreso hospitalario. La seguridad mostrada deberá ser evaluada prospectivamente en estudios posteriores con mayor número de procedimientos.

Severe spruelike enteropathy due to olmesartan

Villous atrophy and negative serologic testing is a diagnostic challenge, and the rarer possibility of drug-induced enteritis should be considered. We report a rare case of severe spruelike enteritis due to olmesartan that completely resolved after withdrawal of the drug. The possibility that patient labeled as "refractory" celiac disease may actually be due to drug treatment should always be taken into consideration, to avoid unnecessary investigations.

Non cirrhotic portal hypertension

Acute pancreatitis as fatal complication after chemoembolization of hepatocellular carcinoma

Acute necrotizing pancreatitis after transarterial chemoembolization of hepatocellular carcinoma: an usual complication

Ectopic hepatocellular carcinoma in the gallbladder

Ulcerative colitis and isotretinoin: is there a causal relationship?

Conservative management of isolated dissection of the superior mesenteric artery