Revista Española de Enfermedades Digestivas

Risk of bleeding in patients undergoing percutaneous endoscopic gastrotrostomy tube insertion under antiplatelet therapy

Risk of bleeding in patients undergoing percutaneous endoscopic gastrotrostomy (PEG) tube insertion under antiplatelet therapy: a systematic review with a meta-analysis

Background and aim: Patients undergoing percutaneous endoscopic gastrostomy (PEG) tube placement often are under antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. This systematic review aims to assess if maintaining aspirin and/or clopidogrel treatment increases the risk of bleeding following PEG placement. Methods: A systematic search of the MEDLINE, EMBASE, and SCOPUS databases was developed for studies investigating the risk of bleeding in patients on antiplatelet therapy undergoing PEG tube insertion. Summary estimates, including 95 % confidence intervals (CI), were calculated. A fixed or random effects model was used depending on heterogeneity (I²). Publication bias risks were assessed by means of funnel plot analysis. Results: Eleven studies with a total of 6,233 patients (among whom 3,665 were undergoing antiplatelet treatment), met the inclusion criteria and were included in the quantitative summary. Any PEG tube placement-related bleeding was found in 2.67 % (95 % CI 1.66 %, 3.91 %) of the entire population and in 2.7 % (95 % CI 1.5 %, 4.1 %) of patients not receiving antiplatelet therapy. Pooled relative risk (RR) for bleeding in patients under aspirin, when compared to controls, was 1.43 (95 % CI 0.89, 2.29; I² = 0 %); pooled RR for clopidogrel was 1.21 (95 % CI 0.48, 3.04; I² = 0 %) and for dual antiplatelet therapy, 2.13; (95 % CI 0.77, 5.91; I² = 47 %). No significant publication bias was evident for the different medications analyzed. Conclusion: Antiplatelet therapy was safe among patients undergoing PEG tube insertion. Future prospective and randomized studies with larger sample sizes are required to confirm the results of this study.

A pharmacokinetic approach to model-guided design of infliximab schedules in ulcerative colitis patients

Background: Infliximab, an anti-tumour necrosis factor approved for treatment of Crohn's disease and ulcerative colitis, is administered at predefined interdose-intervals. On insufficient response or loss of response, treatment can be intensified. The lack or loss of response is likely related to complex pharmacokinetics of infliximab. Aims: To explore optimal dosing strategies of infliximab in treatment-naïve patients with ulcerative colitis through predictive Monte Carlo simulations based on a validated population PK model. Methods: A population of 2,000 treatment-naïve patients was generated by Montecarlo simulation. Six dosing strategies for maintenance therapy were simulated on this population. Strategies 1 and 2 consisted on 5 mg/kg and 6 mg/kg doses, respectively, and 8 weeks inter-dose interval. Strategies 3 and 4 used Individualized doses, adjusted to albumin level, sex and body weight, and a fix inter-dose interval of 8 weeks to achieve a target trough concentration of 5 mg/L or 6 mg/L, respectively. Strategies 5 and 6 used a fix dose of 5 mg/kg and individualized inter-dose intervals, adjusted to the same covariates, to achieve a target concentration, of 5 mg/L or 6 mg/L, respectively. Results: Strategies 2-6 reached trough levels statistically higher than strategy 1 (p < 0.05). Strategy 5 proved to be the best dosing strategy. It was associated with a higher proportion of responder patients than strategy 1 (62 % vs. 40 %) without reaching higher peak concentrations. Conclusions: Optimization of maintenance treatment of colitis with infliximab by a pharmacokinetic approach could benefit infliximab-naive patients with ulcerative colitis.

Quality standards in 480 pancreatic resections: a prospective observational study

Pancreatic resection is a standard procedure for the treatment of periampullary tumors. Morbidity and mortality are high, and quality standards are scarce in our setting. International classifications of complications (Clavien-Dindo) and those specific for pancreatectomies (ISGPS) allow adequate case comparisons. The goals of our work are to describe the morbidity and mortality of 480 pancreatectomies using the international classifications ISGPS and Clavien-Dindo to help establish a quality standard in our setting and to compare the results of CPD with reconstruction by pancreaticogastrostomy (1,55) versus 177 pancreaticojejunostomy). We report 480 resections including 337 duodenopancreatectomies, 116 distal pancreatectomies, 11 total pancreatectomies, 10 central pancreatectomies, and 6 enucleations. Results for duodenopancreatectomy include: 62 % morbidity (Clavien ≥ III 25.9 %), 12.3 % reinterventions, and 3.3 % overall mortality. For reconstruction by pancreaticojejunostomy: 71.2 % morbidity (Clavien ≥ III 34.4 %), 17.5 % reinterventions, and 3.3 % mortality. For reconstruction by pancreaticogastrostomy: 51 % morbidity (Clavien ≥ III 15.4%), 6.4 % reinterventions, and 3.2 % mortality. Differences are significant except for mortality. We conclude that our series meets quality criteria as compared to other groups. Reconstruction with pancreaticogastrostomy significantly reduces complication number and severity, as well as pancreatic fistula and reintervention rates.

Introducción: la resección pancreática es un procedimiento estándar para el tratamiento de los tumores periampulares. La morbimortalidad es elevada y los estándares de calidad en nuestro medio son escasos. Las clasificaciones internacionales de las complicaciones Clavien-Dindo y las específicas de las pancreatectomías (ISGPS) permiten una adecuada comparación de casuísticas. Objetivos: los objetivos de nuestro trabajo son describir la morbimortalidad de 480 pancreatectomías utilizando las clasificaciones internacionales ISGPS y Clavien-Dindo para contribuir al establecimiento de un estándar de calidad en nuestro medio, y comparar los resultados de la DPC con reconstrucción mediante pancreaticogastrostomía (1.55) frente a la pancreaticoyeyunostomía (177). Métodos: presentamos 480 resecciones que incluyen 337 duodenopancreatectomías, 116 pancreatectomías distales, 11 pancreatectomías totales, 10 pancreatectomías centrales y 6 enucleaciones. Resultados: los resultados en la duodenopancreatectomía son: 62 % de morbilidad (Clavien ≥ III 25,9 %), 12,3 % de reintervenciones y 3,3 % de mortalidad global. En las reconstrucción con pancreaticoyeyunostomía: 71,2 % de morbilidad (Clavien ≥ III 34,4 %), 17,5 % de reintervenciones y 3,3 % de mortalidad. En la reconstrucción con pancreaticogastrostomía: 51 % de morbilidad (Clavien ≥ III 15,4 %), 6,4 % de reintervenciones y 3,2 % de mortalidad, las diferencias son significativas, excepto en la mortalidad. Conclusiones: concluimos que nuestra serie cumple criterios de calidad en comparación con la experiencia de otros grupos. La reconstrucción con pancreaticogastrostomía disminuye significativamente el número de complicaciones, su gravedad, la tasa de fístula pancreática y las reintervenciones.

Validity and reliability of the minimum basic data set in estimating nosocomial acute gastroenteritis caused by rotavirus

Introduction: Rotavirus is the principal cause of nosocomial acute gastroenteritis (NAGE) under 5 years of age. The objective is to evaluate the validity and reliability of the minimum basic data set (MBDS) in estimating the NAGE caused by rotavirus (NAGER) and to analyze any changes during the three years that the Rotarix® and Rotateq® vaccines were used in Spain. Material and methods: A descriptive, retrospective study was carried out in the University Hospital of Guadalajara (UHG) (Spain) between 2003-2009 using the MBDS, positive microbiological results for rotavirus (PMRs), and medical histories. Three methods of estimation were used: 1) An ICD-9-CM code 008.61 in the secondary diagnosis fields (DIAG2) of MBDS; 2) method 1 and/or PMRs with a current or recent hospitalization; and 3) the reference method or method 2 contrasted with patient medical histories. The validity of methods 1 and 2 was determined -sensitivity, specificity, predictive values and likelihood ratios (LRs)-, along with their agreement with method 3 (Kappa coefficient). In addition, the incidence rate ratio between the NAGER rate in 2007-2009 (commercialization period of both vaccines) was calculated with respect to 2003-2005 (pre-commercialization period). Results: Method 1 identified 65 records with a DIAG2 of 008.61. Method 2 found 62 probable cases, and the reference method, 49 true cases. The sensitivity of the MBDS was 67 %, the positive predictive value was 51 %, and both negative LR (LR-) and reliability were moderate (LR- 0.33, Kappa coefficient 0.58). During 2007-2009, the NARGE decreased by 5 cases per 10³ hospitalizations by 9 per 10(4) days of hospitalization. Method 2 overestimated both the decline in incidence by 2 per 10³ hospitalizations and the decreased risk per day of stay by 10 %. The MBDS found no differences between the two three-year periods, but, like method 2, showed an excellent level of diagnostic evidence (LR+ 67). Conclusion: The MBDS taken together with microbiological results, is more exact, safer and more reliable than the MBDS alone in estimating NAGER; and more useful in ruling out it. Nevertheless, the MBDS alone may be used to estimate and compare such disease in contexts with different prevalences.

Introducción: la gastroenteritis aguda nosocomial por rotavirus (GEANOR) representa la principal causa de GEA nosocomial en menores de 5 años. El objetivo es evaluar la validez, fiabilidad y verosimilitud del conjunto mínimos básico de datos (CMBD) para estimarla y analizar posibles cambios en el primer trienio de comercialización de las vacunas Rotarix® y Rotateq® en España. Material y métodos: estudio descriptivo-retrospectivo en el Hospital Universitario de Guadalajara en 2003-2009 mediante el CMBD (altas neonatales y pediátricas), los resultados positivos para rotavirus de microbiología (RPM) y las historias clínicas. Los métodos de estimación fueron: 1 (CIE9-MC 008.61 en los campos de diagnóstico secundario del CMBD); 2 (método 1 y/o RPM con ingreso actual-reciente); y método 3 o referencia (método 2 contrastado con las historias clínicas). Se determinó la validez de los métodos 1 y 2 y su concordancia con el método 3 (índice kappa). También, las razones de verosimilitud (LHR) de estos métodos. Además, se calculó la razón de tasas de incidencia de 2007-2009 respecto a 2003-2005. Resultados: se encontraron 65 registros con DIAG2 008.61 y 62 casos probablemente nosocomiales por el método 2, cuyas historias clínicas fueron revisadas junto con 11 registros posiblemente nosocomiales. La sensibilidad del CMBD resultó del 67 %, la seguridad del 51 % y su fiabilidad y LHR negativo moderados (índice kappa 0,58 y LHR- 0,33). En 2007-2009, respecto a 2003-2005, la enfermedad se redujo en 5 casos por 10³ ingresos y en 9 por 10(4) días de estancia. El método 2 sobreestimó el descenso en 1 por 10³ ingresos y el descenso de riesgo por día de estancia en un 10 %. El CMBD no encontró diferencias intertrienios pero presentó al igual que el método 2, un excelente nivel de evidencia diagnóstica (LHR+ 67). Conclusión: el CMBD junto a la microbiología es más exacto, seguro y consistente que el CMBD per se en la estimación de la GEANOR, y también más útil para descartarla. Sin embargo, el CMBD por sí mismo podría ser utilizado en la estimación de la infección nosocomial en contextos con diferentes prevalencias.

New trends in the management of diverticulitis and colonic diverticular disease

Colonic diverticular disease is a chronic disorder presenting with a variety of abdominal symptoms and recurrent episodes of acute diverticulitis. It is close linked to age so its prevalence has risen notably during the last decades in western countries, increasing costs related to medical attention. Recently, several works have provided evidence to a series of measures that could improve the outcomes as well as reduce expenses associated to this process. The aim of the present review is to expose a view of the new trends in the management of diverticulitis and colonic diverticular disease, based on the highest clinical evidence available.

La enfermedad diverticular del colon es una entidad crónica con una variada sintomatología abdominal que puede cursar con episodios recurrentes de diverticulitis aguda. Debido a su estrecha relación con la edad, su prevalencia ha aumentado de forma muy significativa en los países de occidente en las últimas décadas, incrementando sobremanera los gastos derivados de su tratamiento. Recientemente, varios trabajos han aportado evidencia a una serie de medidas que podrían mejorar los resultados al tiempo que disminuir los gastos asociados a este proceso. El objetivo de la presente revisión es exponer una visión, basada en la mayor evidencia disponible, de las nuevas tendencias en el manejo de la diverticulitis aguda y enfermedad diverticular del colon.

Acral injury as first manifestation of a metastatic adenocarcinoma of the colon

Acute gastric volvulus: a case report

Ultrasound-guided percutaneous drainage and sclerotherapy in a patient with isolated autosomal dominant polycystic liver disease

Isolated polycystic liver disease (IPLD) is a rare genetic condition characterized by the presence of multiple liver cysts with no association with polycystic kidney disease. Most patients are asymptomatic and acute complications (cyst torsion, bleeding, infection) are uncommon. Imaging techniques, including abdominal ultrasounds, computerized axial tomography, and magnetic resonance imaging, represent a vital diagnostic modality. They are also useful for therapy support in this disease. Below we report a peculiar case of a female patient recently diagnosed with IPLD who, having received treatment with ultrasound-guided percutaneous drainage and sclerotherapy for a giant liver cyst, showed symptom and laboratory improvement.

La enfermedad hepática poliquística aislada (EHPA), es una rara entidad genética que se caracteriza por la presencia de múltiples quistes hepáticos, sin estar asociada a la poliquistosis renal. La mayoría de los pacientes son asintomáticos, y son infrecuentes las complicaciones agudas (torsión quística, hemorragia e infecciones). Las técnicas de imagen, como la ecografía abdominal, tomografía axial computarizada y resonancia magnética, son un método diagnóstico fundamental. Además, son útiles como apoyo terapéutico en esta enfermedad. A continuación les presentamos un caso clínico peculiar de una paciente recientemente diagnosticada de enfermedad hepática poliquística aislada, quien tras recibir un tratamiento con drenaje percutáneo de un quiste hepático gigante y escleroterapia guiada por ecografía, presentó mejoría sintomática y analítica.

Individualized exercise prescription in non-alcoholic steatohepatitis: a case report

The effect of an individualized exercise programme on a non-alcoholic steatohepatitis case is presented. Before entering the programme the patient was treated with conventional recommendations on diet plus aerobic exercise during fourteen years, without major improvements of his analytical parameters. Two years after including him in a tailored exercise programme, aimed to fulfil the recommendations of the American College of Sports Medicine, his blood markers of liver dysfunction and cardio-metabolic risk tended to improve. Consequently, our data support the idea that in non-alcoholic steatohepatitis the exercise-based therapeutic interventions should be individualized taking into account the cardio-respiratory and muscular fitness of the patient, rather than using generic behavioural recommendations.

Se presenta un caso de esteatohepatitis no alcohólica de dieciséis años de evolución, tratado durante catorce años con recomendaciones dietéticas y de práctica de actividad física regular y que, en los dos últimos años, fue incluido en un programa de ejercicio controlado, monitorizado y supervisado, acorde a las recomendaciones del American College of Sports Medicine. Tras la inclusión del paciente en este programa se observó un cambio en la tendencia de diferentes parámetros analíticos de función hepática y riesgo cardiometabólico, que pasaron de mostrar una tendencia al alza, a estabilizarse o tender a disminuir. A raíz de estas observaciones se sugiere que la mera recomendación de realización autónoma de ejercicio regularmente, sin evaluación de la condición física del sujeto, así como sin unas adecuadas planificación y periodización del mismo, puede resultar una medida ineficaz en el tratamiento de esta enfermedad.

Arton: its use in gastroenterology

Cholecystitis and duodenal fistula as EndoBarrier^®-associated complications: minimally invasive treatment

Eosinophilic gastroenteritis and bowel obstruction: can surgery be avoided?

Treatment with ribavirin of hepatitis E virus chronic infection in transplanted patients

Clinical presentation of anal duct adenocarcinoma as benign anal stenosis

Penicillamine induced pseudo-pseudoxanthoma elasticum in a patient with Wilson's disease: which role plays the hepatologist?