Revista Española de Enfermedades Digestivas

Specialist care in the management of inflammatory bowel disease

Epidemiology of Barrett's esophagus and esophageal adenocarcinoma in Spain: a unicentric study

Background: Barrett's esophagus (BE) is an acquired disease defined by the presence of intestinal metaplasia with goblet cells in the distal esophagus. The prevalence of BE has increased dramatically over the last years. Aims: The primary aims of the study were to analyze the characteristics of BE and esophageal adenocarcinoma (EAC) in a Spanish health district during a follow-up period. Methodology: Sociodemographic factors, alcohol consumption and cigarette smoking were analyzed. We also studied the histological behavior and cause of death in each group. Results: In the present study 430 patients were included, 338 with BE and 92 with EAC. Incidence rates have risen from 2.25 and 1.25 per 100,000 inhabitants in 1996 to 6.5 and 4.75 per 100,000 in 2011, respectively. In the EAC group, male gender, age and alcohol consumption were higher in comparison to the BE group, and the overall survival was 23 months. In the BE group, the main causes of death were non-esophageal cancer and cardiovascular disease. Conclusions: The incidence and prevalence rates of AEC and BE have risen over the past years. Risk factors for these conditions were male gender, age and alcohol consumption. Long BE (> 3 cm) is involved in dysplasia progression. AEC diagnosis mainly occurs after neoplasia is detected and, in a few cases, due to a previous BE. Cardiovascular diseases and non-esophageal cancers have been found to be the main cause of death in BE patients.

Introducción: el esófago de Barrett (EB) es una enfermedad adquirida definida por la presencia de metaplasia intestinal en el esófago distal. Su prevalencia se ha incrementado de forma alarmante en los últimos años. Objetivos: los objetivos primarios del presente trabajo fueron analizar el comportamiento del EB y del adenocarcinoma esofágico (ACE) en un área sanitaria española durante el seguimiento del periodo del estudio. Métodos: se analizaron características sociodemográficas y el consumo de alcohol y tabaco. También se valoró el comportamiento histológico así como las causas de defunción en cada uno de los grupos. Resultados: se incluyeron 430 pacientes, 338 con EB y 92 con ACE. La tasa de incidencia pasó de 2,25 y 1,25 por 100.000 habitantes en 1996 a 6,5 y 4,75 en 2011, en EB y ACE, respectivamente. Hubo más varones, mayor edad e ingesta etílica en el grupo adenocarcinoma respecto al grupo de Barrett. La supervivencia del ACE fue de 23 meses. Las principales causas de muerte en los pacientes con Barrett fueron el cáncer no esofágico y la enfermedad cardiovascular. Conclusiones: existe una mayor incidencia y prevalencia tanto del EB como del ACE en los últimos años. Como factores de riesgo encontramos el sexo masculino, mayor edad y consumo de alcohol. El EB largo (> 3 cm) está implicado en la progresión de la displasia. El diagnóstico de ACE se hace, la mayor parte de las veces, con el debut de la enfermedad neoplásica y, en el menor de los casos, sobre un EB previo. La enfermedad cardiovascular y neoplásica no esofágica han sido las principales causas de mortalidad en los pacientes con EB.

How is inflammatory bowel disease managed in Spanish gastroenterology departments?: the results of the GESTIONA-EII survey

Introduction: Not all national health centers include specialized units or clinicians devoted to inflammatory bowel disease. The goal of the survey was to gain an insight into the management of this disease within Spanish gastroenterology departments via a survey among their members. Material and methods: An online survey was conducted in February and March 2015, among SEPD members (2017 clinician members), who were split into three categories: heads of department, general gastroenterologists, and experts in this disease. The results of the last two surveys are reported, including demography-related questions and specific questions on the strategies and resources available for the care of these patients. Results: A total of 166 responses were received (response rate 8.19%), excluding those from heads of department (previously published). Sixty gastroenterologists considered themselves experts in inflammatory bowel disease, and 106 non-experts in it, the latter being either general gastroenterologists or specialists in other areas, mainly endoscopy. Twenty-eight percent of non-expert gastroenterologists said their hospitals had specific units, with a monographic clinic in 46%. However, 26% reported that they were treating affected patients themselves. Experts in inflammatory bowel disease reported that their institute had resources to support their work, but there was a lack of surgeons with expertise in this condition, particularly in county hospitals. Conclusions: At least, within SEPD members, 2 out of 3 experts in inflammatory bowel disease seem to have the resources available for their work (nurses, day unit, telephone line, database, referrals, joint sessions). Although there is room for improvement (email to contact patients, devoted surgeon, absence of referral protocols), and 2 out of 3 are concerned about pharmacy costs. Since a substantial number of patients remain treated by general practitioners, rapid referral programs might be helpful in this setting.

Introducción: no en todos los centros nacionales existen unidades ni especialistas dedicados a la EII. El objetivo de la SEPD fue conocer, a través de una encuesta a sus socios, datos sobre el manejo de la EII en los servicios de digestivo de España. Material y métodos: encuesta en línea (telemática) realizada entre el 2 de febrero y el 9 de marzo de 2015, a socios de la SEPD (remitida a 2.017 socios numerarios con actividad clínica) divididos en tres categorías: jefes de servicio, digestivos generales y digestivos especializados en EII. Se muestran los resultados de las últimas dos incluyendo preguntas demográficas y otras más específicas sobre el modo y recursos con los que se cuenta para atender a estos pacientes. Resultados: se recibieron 166 encuestas completas (tasa de respuesta del 8,19%, con distribución entre todas las CC. AA. menos La Rioja), excluyendo las de los jefes de servicio. Sesenta digestivos se consideraban expertos en EII y 106 se consideraban no expertos en EII, bien generales o especializados en otros ámbitos, siendo el principal el área de endoscopias. Un 28% de los digestivos no expertos afirmaron que sus hospitales tienen unidades de EII y en un 46% existe una consulta monográfica. Pero un 26% refería que ellos mismos son los que ven y tratan los pacientes de EII. Los digestivos expertos en EII refieren disponer de una estructura con recursos para desarrollar su tarea aunque existe carencia de cirujanos expertos en EII sobre todo en centros comarcales. Conclusiones: al menos 2 de cada 3 expertos en EII, socios de la SEPD parecen disponer de recursos para desarrollar su tarea (enfermería, unidad de día, línea telefónica, base de datos, derivación, sesiones conjuntas). Existe ámbito de mejora (correo-e para contacto con pacientes, cirujano con dedicación específica, ausencia de protocolos de derivación) y 2 de cada 3 están preocupados por el control del gasto farmacéutico. Dado que un número de pacientes considerable sigue siendo tratado por médicos generalistas, programas para favorecer una rápida derivación podrían ayudar.

Management of refractory esophageal stenosis in the pediatric age

Introduction: Refractory esophageal stenosis (RES) is a major health problem in the pediatric population. Several techniques such as stent placement or C-mitomycin (CM) have been described as alternative treatments. We present our experience with both techniques, in our case with biodegradable stents (BS) and sometimes the association with stents and CM. Material and methods: Six patients have been included: 2 post-operative fistulas in patients with type I esophageal atresia; 1 operated atresia without fistula; and 3 caustic strictures. 5 BS were placed in 4 children: 3 of them in cases of atresia (2 prosthesis in one case) and the other one in a case of stricture. CM was used in 5 cases: in 2 of them from the beginning, and in the other 3 cases after failure of the stent. Results: When placed in fistulas, BS were fully covered. One of them successfully treated the fistula, but the other one was not effective. One stenosis was successfully treated with SB (in the case of persistent fistula), but recurrence was observed in the other 2 cases. One of these was solved with CM, and the other one needed a second stent. In the remaining 2 cases (one atresia and one caustic stricture) CM was effective after 1 and 2 sessions respectively. Overall, 5 out of 6 stenosis have been successfully treated (83.3%), and 1 out of 2 fistulas (50%). Conclusions: Association of BS and CM has been effective in the management of RES in children.

Introducción: las estenosis esofágicas refractarias (EER) a las dilataciones suponen un importante problema de salud en la pediatría. Se han descrito técnicas alternativas como la colocación de prótesis y el uso de mitomicina C (MC). Presentamos nuestra experiencia en una serie consecutiva con ambas técnicas, en nuestro caso con prótesis biodegradables (PB) y a veces ambas técnicas asociadas. Material y métodos: se incluyeron 6 pacientes, dos con fístula postquirúrgica en atresias esofágicas tipo 1 operadas, otro con atresia operada sin fístula y otros tres con estenosis caústicas. Se colocaron 5 PB en 4 niños, 3 en atresias operadas (en un paciente 2 prótesis) y 1 en estenosis. Dos de los niños con atresia tenían fístula asociada.<>Se utilizó MC en 5 casos, en dos de forma primaria y en tres tras recidiva al fracasar la prótesis. Resultados: las PB colocadas en las fístulas fueron recubiertas y en un caso solucionaron la fístula y en otro no. En las estenosis fueron efectivas en solo una (con la fístula no resuelta), recidivando en 2. La MC solucionó uno de estos casos, debiendo ponerse una segunda prótesis en el otro paciente. En los otros dos (una atresia y otra por caústicos), la MC fue efectiva, solucionando las estenosis tras 1 y 2 sesiones respectivamente. En el cómputo total hemos solucionado las estenosis en 5 de 6 estenosis refractarias (83,3%) y en 1 de 2 fístulas (50%). Conclusiones: la asociación de prótesis biodegradables y mitomicina ha sido efectiva en el rescate de algunos casos de estenosis esofágicas refractarias en niños, teniendo un papel secundario en la resolución de fístulas.

**Peroral endoscopic myotomy versus pneumatic dilation for achalasia in patients aged ≥ 65 years**

Background and aim: Both peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) has proved to be effective for treating achalasia in patients aged ≥ 65 years. However little is known about the comparison between POEM and PD. The aim of the study was to compare the safety and efficacy of POEM and PD for the treatment of achalasia in these patients. Methods: We retrospectively reviewed the medical records of patients aged 65 years-old or more who received POEM or PD for the treatment of achalasia at our hospital from January 2010 to December 2015, they were divided into the POEM group and the PD group. Demographics and data about safety and efficacy were collected retrospectively and compared between the two groups. Results: A total of 31 patients were enrolled, and 21 of them received POEM, while the other 10 received PD. The treatment success (Eckardt score ≤ 3) rate of POEM and PD at 3, 6, 12, 24 and 36 months after the treatment were comparable (p > 0.05). Treatment failure was noticed in 3 cases, 1 of them was in the POEM group and the other 2 in the PD group, there was no significant difference (p > 0.05). Multivariate analysis showed that sigmoid-type achalasia was a predictive factor of treatment failure. No severe complications were observed during operation and periodical follow-up. Conclusion: Short-term and intermediate efficacy of POEM and PD for treating achalasia in patients aged ≥ 65 years was comparable. A large scale, randomized study with long-term follow-up is necessary in order to make a definitive conclusion.

**Adalimumab versus infliximab in treating post-operative recurrence of Crohn's disease: a national cohort study**

Aim: Perform a comparison between adalimumab (ADA) and infliximab (IFX) in treating post-operative recurrence of Crohn's disease (a comparative analysis of efficacy and safety). Methods: From the 267 patients treated with adalimumab or infliximab between January 2005 and June 2014 in Romania, 44 received anti-TNF (tumor necrosis factor) therapy for prevention of post-operative recurrence. A comparison between patients treated with IFX and ADA was made with the Chi-square and t-student test, with the aid of the statistical program Mini Tab 17. Results: Twenty-one patients received IFX and 23 ADA. This included 49% males (22/44), with a mean age of 41 years, mean disease duration of 6 years, and 84.1% had previously received azathioprine. The IFX group is comparable with the ADA group regarding most of the parameters, except for therapy duration. Mean duration of therapy was 33 months. The rate of complete response was comparable between the two groups: 67% in the IFX group vs. 78.3% in the ADA group, the same as the rate of re-resection, 19.1% vs. 4.4% and the rate of endoscopic recurrence, 29 vs. 33% at 12 months. Risk factors for postoperative recurrence (POR) (male sex, younger age, ileocolonic location, stricturing or penetrating behaviour) were studied, only ileocolonic location was found to be associated with Crohn's disease recurrence in patients treated with ADA. Conclusions: Overall infliximab and aalimumab are equally efficient in patients with resected Crohn's disease (CD) with a complete response of 72.7%, a rate of re-resection of 11.4% and a rate of endoscopic recurrence of 35%. Ileocolonic location might be a predictive factor for loss of response to adalimumab in resected Crohn's disease patients.

New insights on an old medical emergency: non-portal hypertension related upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition and the most common medical emergency managed by gastroenterologists. Despite being one of the most antique medical problems, recent studies have been slowly changing the management of these patients, which should nowadays include not only initial resuscitation, but also risk stratification, pre-endoscopic therapy, endoscopy treatment, and post-procedure care. The aim of this paper is to review the extended approach to the patient with non-portal hypertension related UGIB.

Ultrasound-assisted technique for challenging jejunostomy balloon-tube replacements

Pseudomelanosis duodeni: is there a common denominator?

Nodular colitis: endoscopic image, an unusual finding

A typical but seldom recognized foreign body in the esophagus of a laryngectomized patient

Acute abdomen from duodenal diverticulitis: a case report

**Fatal Campylobacter jejuni ileocolitis**

Conservative management of splenic abscess septic emboli after tooth extractions

Splenic abscesses are rare but may be associated with high mortality. Usually they occur in patients with systemic infection related to some immunocompromised state. The symptoms are nonspecific and the diagnosis is often late, but the development of better imaging techniques has enabled better diagnosis of splenic abscess and percutaneous drainage is a valid and safe complementary treatment option. We report a case of a patient with splenic abscess secondary to septic emboli after tooth extractions, managed conservatively with antibiotics and percutaneous drainage.

Los abscesos esplénicos son poco frecuentes pero pueden asociar una mortalidad elevada. Generalmente suceden en pacientes con una infección sistémica relacionada con algún estado de compromiso inmunitario. La clínica es inespecífica y el diagnóstico suele ser tardío, aunque el desarrollo de técnicas de imagen más avanzadas ha permitido un mejor diagnóstico de los abscesos esplénicos y disponer del drenaje percutáneo como una opción terapéutica complementaria válida y segura. Presentamos un caso de un paciente con un absceso esplénico por émbolos sépticos tras extracciones dentarias, manejado conservadoramente con antibioticoterapia y drenaje percutáneo.

Primary esophageal melanoma: report of a case

Introduction: Primary malignant melanoma of the esophagus is a rare tumor representing only 0.1-0.2% of esophageal malignancies. The goal of the study was to report on the management of a new case diagnosed and treated in our site. Case report: A 67-year-old patient presented with dysphagia to solids with no other remarkable history or associated skin lesions. He underwent gastroscopy, which revealed a polypoid mass suggestive of neoplasm in the distal third of the esophagus. Biopsy indicated melanoma with positive immunohistochemical markers S100 and HMB45, and negative cytokeratins and CEA. Computerized tomography (CT) and positron-emission tomography (PET) scans showed no local infiltration or distant metastases. An Ivor-Lewis esophagectomy procedure was performed with regional lymphadenectomy. Postoperative stay lasted for three weeks, and no remarkable postsurgical complications arose. The pathological study of the specimen confirmed the diagnosis of primary esophageal melanoma. Discussion: Primary malignant melanoma of the esophagus has an unfortunate prognosis as it is an aggressive tumor usually diagnosed at an advanced stage, with local invasion and metastatic disease. Currently, surgery is the treatment of choice, with the remaining adjuvant therapies obtaining limited results.

Introducción: el melanoma esofágico primario es un tumor muy poco frecuente que constituye únicamente el 0,1-0,2% de las enfermedades malignas del esófago. El objetivo del estudio fue presentar el manejo de un nuevo caso clínico diagnosticado y tratado en nuestro centro. Caso clínico: paciente de 67 años que presentaba clínica de disfagia a sólidos sin otros antecedentes ni lesiones cutáneas asociadas. Se le realizó una gastroscopia, apreciándose una formación polipoide en tercio distal esofágico sugestiva de neoplasia. La biopsia fue positiva para melanoma con marcadores inmunohistoquímicos S100 y HMB45 positivos; citoqueratinas y CEA negativos. La tomografía computarizada (TC) y la tomografía por emisión de positrones (PET) no mostraron infiltración local ni metástasis a distancia. Se practicó una esofaguectomía de Ivor-Lewis con linfadenectomía regional. La estancia postoperatoria fue de tres semanas sin producirse complicaciones postoperatorias reseñables. El estudio anatomopatológico de la pieza confirmó el diagnóstico de melanoma esofágico primario. Discusión: el pronóstico del melanoma primario de esófago es infausto, debido a que se trata de un tumor agresivo que suele diagnosticarse en fases avanzadas de la enfermedad, con presencia de invasión local y metástasis. El tratamiento de elección actualmente es la cirugía, obteniéndose resultados limitados con el resto de terapias adyuvantes.

Gastric varicella: two cases in cancer patients

Gastric involvement with the varicella-zoster virus is an uncommon clinical condition where early suspicion and diagnosis are important to prevent the consequences deriving from its high morbidity and mortality, which in immunocompromised patients oscillate between 9% and 41% according to the various series. Two cases of gastric involvement with the varicella-zoster virus (VZV) in two patients with blood cancer are reported below. Gastric lesions are usually preceded by typical papulovesicular skin lesions. When gastric involvement is the first symptom of the disease its diagnosis and management may be delayed, which may entail severe consequences for immunocompromised patients. It is therefore that we suggest its inclusion in the algorithm for immunocompromised patients with abdominal pain and ulcer-like endoscopic lesions.

La afectación gástrica por el virus varicela-zóster es una entidad clínica poco frecuente, cuya sospecha y diagnóstico precoz es importante para evitar las consecuencias derivadas de su elevada morbimortalidad que en pacientes inmunocomprometidos varía entre un 9% y 41% según las series. A continuación se describen dos casos de afectación gástrica por el virus de la varicela-zóster (VVZ) en dos pacientes con enfermedad hematooncológica. Habitualmente las lesiones gástricas van precedidas de la aparición de lesiones cutáneas pápulo-vesiculares características. Cuando la afectación gástrica es el primer síntoma de la enfermedad se puede producir un retraso en el diagnóstico y tratamiento de esta infección que puede conllevar consecuencias graves para el paciente inmunocomprometido. Es por ello que proponemos que sea una entidad tenida en cuenta en el algoritmo de estudio del paciente inmunocomprometido que presenta dolor abdominal y lesiones endoscópicas de tipo ulceroso.

Glycogenic hepatopathy in young adults: a case series

Glycogenic hepatopathy is a rare and underecognized complication in long-standing poorly controlled type 1 diabetes mellitus patients. This is a distinct entity from other causes of hepatomegaly and elevated liver enzymes in diabetics, such as nonalcoholic fatty liver disease. Glycogenic hepatopathy is characterized by the combination of poorly controlled diabetes, acute liver injury with marked elevation in serum aminotransferases, and the characteristic histological features on liver biopsy. It is important to distinguish this entity as it has the potential for resolution following improved glycemic control. In this report, we describe four cases of adult patients presenting elevated serum transaminases and hepatomegaly with a history of poorly controlled type I diabetes mellitus. One of the patients had also elevated amylase and lipase in the serum, without clinical or imagiologic evidence of acute pancreatitis. Liver biopsy was performed in all patients and revealed glycogenic hepatopathy. Clinician's awareness of glycogenic hepatopathy should prevent diagnostic delay or misdiagnosis and will provide better insight and management for this condition.

Endoscopic resection of rectal granular-cell tumor using elastic band ligation

Granular cell tumor (GCT) is a rare neoplasm that develops in the gut's submucosal layer. We report the case of a male with a history of surgically excised colon neoplasm where a rectal polyp was identified during a follow-up endoscopy. The lesion, eventually identified as a GCT, was endoscopically removed by band ligation-assisted mucosectomy. This may be the second report of a colorectal GCT successfully managed using band ligation, and the first one on a rectal GCT excised with this technique.

El tumor de células granulares (TCG) es un tumor raro que se localiza en la capa submucosa del tubo digestivo. Presentamos a continuación a un varón con antecedentes de neoplasia de colon extirpada mediante cirugía en el que durante una colonoscopia de control se identificó un pólipo en el recto que extirpamos endoscópicamente realizando una mucosectomia asistida con banda elástica, resultando ser un TCG. Estamos ante lo que puede ser la segunda publicación de un TCG colorrectal tratado con éxito mediante banda elástica y el primer caso de TCG extirpado en el recto con esta técnica.

Pancreatic pseudocyst drainage performed with a new prototype forward-viewing linear echoendoscope

Interventional endoscopy is a field that continues to grow rapidly. A novel prototype forward-viewing echoendoscope (FV-EUS) has been recently developed in an attempt to overcome some of the limitations of conventional curved linear-array echoendoscopes (OV-EUS). We present a case of a successful endoscopic ultrasound-guided drainage of a pancreatic pseudocyst using a forward-viewing echoendoscope. Although the use of this newly developed echoendoscope has not yet become widespread, its unique characteristics can help to easily perform routine therapeutic procedures and contribute to the expansion of interventional endoscopic ultrasound.

El intervencionismo guiado por ecoendoscopia es un campo que se encuentra en rápido desarrollo. Recientemente se ha diseñado un nuevo prototipo de ecoendoscopio de visión frontal que pretende superar ciertas limitaciones de los ecoendoscopios convencionales (de visión oblicua). Se presenta a continuación el caso de un drenaje de pseudoquiste pancreático con un encoendoscopio de visión frontal llevado a cabo de forma exitosa. Si bien la difusión de este nuevo modelo de ecoendoscopio es aún escasa, las particularidades del mismo podrían contribuir a la ejecución con mayor sencillez de procedimientos terapéuticos habituales en la práctica clínica, así como a la consolidación de las potenciales aplicaciones del intervencionismo endoscópico.

**About human taeniasis and Taenia saginata diagnosis by endoscopy**

Author's reply: **about human taeniasis and Taenia saginata diagnosis by endoscopy**

Clinical, laboratory, serological, and histological profile of sprue-like enteropathy associated with olmesartan use