Revista Española de Enfermedades Digestivas

Colonic diverticular bleeding: have we identified the risk factors for massive bleeding yet?

Risk factors for severity and recurrence of colonic diverticular bleeding

Background: Colonic diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Risk factors related to severity and repeated bleeding episodes are not completely clearly defined. Objective: To characterize a Portuguese population hospitalized due to colonic diverticular bleeding and to identify the clinical predictors related to bleeding severity and rebleeding. Methods: Retrospective analysis of all hospitalized patients diagnosed with colonic diverticular bleeding from January 2008 to December 2013 at our institution. The main outcomes evaluated were bleeding severity, defined as any transfusion support requirements and/or signs of hemodynamic shock, and 1-year recurrence rate. Results: Seventy-four patients were included, with a mean age of 75.7 ± 9.5 years; the majority were male (62.2%). Thirty-six patients (48.6%) met the criteria for severe bleeding; four independent risk factors for severe diverticular bleeding were identified: low hemoglobin level at admission (≤ 11 g/dL; OR 18.8), older age (≥ 75 years; OR 4.7), bilateral diverticular location (OR 14.2) and chronic kidney disease (OR 5.6). The 1-year recurrence rate was 12.9%. We did not identify any independent risk factor for bleeding recurrence in this population. Conclusion: In this series, nearly half of the patients hospitalized with diverticular bleeding presented with severe bleeding. Patients with low hemoglobin levels, older age, bilateral diverticular location and chronic kidney disease had a significantly increased risk for severe diverticular bleeding. In addition, a small number of patients rebled within the first year after the index episode, although we could not identify independent risk factors associated with the recurrence of diverticular bleeding.

Mercaptopurine and inflammatory bowel disease: the other thiopurine

Background: Data about use and effectiveness of mercaptopurine in inflammatory bowel disease are relatively limited. Aims: To assess the possible therapeutic indications, efficacy and safety of mercaptopurine as an alternative to azathioprine in inflammatory bowel disease. Methods: Retrospective observational study in patients treated with mercaptopurine in a total cohort of 1,574 patients with inflammatory bowel disease. Results: One hundred and fifty-two patients received mercaptopurine, 15.7% of these patients as an initial thiopurine, 5.3% after azathioprine failure, and 79% after azathioprine intolerance. In 52.6% of patients (n = 80), adverse effects of mercaptopurine occurred, resulting in withdrawal in 49 of them. Mercaptopurine was effective in 39% of cases (95% CI 31-48%). In the remaining patients, failure was due mainly to withdrawal due to side effects (55.1%) and therapeutic step-up (33.7%). The average total time of mercaptopurine exposure was 36 months (IQR: 2-60). Myelotoxicity with mercaptopurine was more common in patients with intermediate TPMT activity than in those with normal activity (p = 0.046). Conclusions: In our setting, mercaptopurine is primarily used as a rescue therapy in patients with azathioprine adverse effects. This could explain its modest efficacy and the high rate of adverse effects. However, this drug is still an alternative in this group of patients, before a therapeutic step-up to biologics is considered.

Influence of sustained viral response on the regression of fibrosis and portal hypertension in cirrhotic HCV patients treated with antiviral triple therapy

Background and aims: The regression of liver fibrosis and portal hypertension (PH) and their influence on the natural history of compensated hepatitis C virus (HCV)-related cirrhosis has not been studied previously. Our objective was to evaluate the influence of sustained virologic response (SVR) on the portal pressure gradient (HVPG) and non-invasive parameters of PH and prognostic factors of response. Methods: Sixteen patients with compensated HCV genotype 1-related cirrhosis with PH (HVPG > 6 mmHg) without beta-blocker therapy were considered as candidates for PEGα2a + RBV + BOC (48 weeks; lead-in and accepted stopping rules). A hemodynamic study and Fibroscan® were performed at baseline, at eight weeks and, in the case of SVR, 24 weeks after treatment. In each hemodynamic study, serum samples were analyzed for inflammatory biomarkers associated with PH. Results: In eight cases, SVR was obtained; five patients relapsed, and treatment was stopped early for non-response to lead in (one case) and a decrease of < 3 log at week 8 (two patients). Compared to baseline, there was a significant decrease in HVPG and Fibroscan® at weeks 8 and 72 (10.31 ± 4.3 vs 9.4 ± 5.04 vs 6.1 ± 3.61 mmHg, p < 0.0001 and 21.3 ± 14.5 vs 16.2 ± 9.5 vs 6.4 ± 4.5 kPa, p < 0.0001, respectively). The average HVPG decrease in SVR was 40.8 ± 17.53%, achieving an HVPG < 6 mmHg in five patients (62.5%) and a Fibroscan® < 7.1 kPa in three patients (37.5%). Conclusions: Complete hemodynamic response (HVPG < 6 mmHg) and fibrosis regression (Fibroscan® < 7.1 kPa) occur in more than half and one-third of patients achieving SVR, respectively, and must be another target in cirrhotic patients with SVR.

Malnutrition risk questionnaire combined with body composition measurement in malnutrition screening in inflammatory bowel disease

The purpose of malnutrition screening is to predict the probability of a worse outcome due to nutritional factors. The Malnutrition Universal Screening Tool (MUST) can be used for screening in inflammatory bowel disease (IBD); however, it does not provide details about body composition. Our aim was to assess the body composition and combine this with the MUST method to screen risk of malnutrition and sarcopenia. A total of 173 IBD outpatients were enrolled in this cross-sectional study. The MUST scale indicated 21.4% of IBD patients to be at risk of malnutrition. A risk of sarcopenia was detected in 27.7%. However, one third of these patients were not considered to be at risk by their MUST score. Furthermore, Crohn's disease (CD) patients had a strongly unfavorable fat-free mass index (FFMI) value compared to ulcerative colitis (UC) patients, and these differences were significant among men (FFMI: 18.62 ± 2.16 vs 19.85 ± 2.22, p = 0.02, in CD and UC males, respectively). As sarcopenia is a relevant prognostic factor, the MUST method should be expanded to include body composition analysis to detect more IBD patients at risk of malnutrition and sarcopenia in order to start their nutritional therapy immediately.

A survey-based analysis on endoscopic quality indicators compliance among Spanish endoscopists

Introduction: Endoscopy plays a key role for the diagnosis and management of gastrointestinal disorders. Therefore, quality indicators have been widely proposed in order to optimize endoscopic practice. The aims of this study, promoted by the Spanish Society of Digestive Diseases (SEPD), were to assess the knowledge and compliance to endoscopy quality indicators among Spanish gastroenterologists. Methods: A 31-questionnaire survey was created based on the endoscopy quality indicators proposed by international guidelines. The survey was distributed among Spanish gastroenterologists who are members of the society. Using only fully completed surveys, a descriptive analysis was performed. Those factors related with a suboptimal quality performance were also investigated. Results: A total of 1,543 surveys were sent and 281 (18.2%) were received completed. Based on the answers obtained, the management of 14 (70%) out of 20 assessed quality indicators was poor: 5 (83.3%) out of 6 pre-procedure items, 7 (58.3%) out of 12 intra-procedure items and 2 (100%) out of 2 post-procedure items. Young age, public setting, no colorectal cancer (CRC) screening program at the institution and a low volume of procedures/week are factors related to poorer management of the assessed quality indicators. Conclusions: A significant proportion of Spanish endoscopists do not comply with main endoscopic quality indicators. Factors such as "young" age, public setting, no colorectal cancer screening program and low volume of procedures/week are related to a poorer management of the assessed quality indicators and should be the target for future formative activities.

Endoscopic resection of colorectal polyps in patients on antiplatelet therapy: an evidence-based guidance for clinicians

Due to the rising prevalence of coronary heart disease, endoscopists are more frequently performing a polypectomy in patients on antiplatelet therapy (APT) and dual antiplatelet therapy (DATP). Despite the availability of several guidelines with regard to the management of antiplatelet drugs during the periprocedure period, there is still variability in the current clinical practice. This may be influenced by the low quality of the evidence supporting recommendations, because most of the studies dealing with APT and polypectomy are observational and retrospective, and include mainly small (< 10 mm) polyps. However, some recommendations can still be made. An estimation of the bleeding and thrombotic risk of the patient should be made in advance. In the case of DAPT the procedure should be postponed, at least until clopidogrel can be safely withheld. If possible, non-aspirin antiplatelet drugs should be withheld 5-7 days before the procedure. Polyp size is the main factor related with post-polypectomy bleeding and it is the factor that should drive clinical decisions regarding the resection method and the use of endoscopic prophylactic measures. Non-aspirin antiplatelet agents can be reintroduced 24-48 hours after the procedure. In conclusion, there is little data with regard to the management of DAPT in patients with a scheduled polypectomy. Large randomized controlled trials are needed to support clinical recommendations.

Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction

Pneumatosis cystoides intestinalis

Wilkie's syndrome

Endoscopic retrieval of toothbrushes in a schizophrenic patient

All that glitters is not gold: a different cause for an "ulcerative colitis"

Boerhaave's syndrome: diagnostic gastroscopy

Celiac crisis in adults: a case report and review of the literature focusing in the prevention of refeeding syndrome

Introduction: Celiac crisis is a life-threatening complication of celiac disease that is rarely described in adults. Case report: We report the case of a 31-year-old man with celiac crisis as a first manifestation of celiac disease. The patient presented with severe diarrhea, metabolic acidosis, and electrolyte disturbances accompanied by electrocardiographic alterations. A satisfactory clinical response was obtained after the correction of electrolyte abnormalities, hydration, and nutritional support with a gluten-free diet according to recommendations for patients at high risk of refeeding syndrome. Discussion: Celiac crisis generally occurs in patients with no previous diagnosis of celiac disease. The physician should therefore be aware of this diagnosis and consider celiac crisis in cases of unexplained intense secretory diarrhea, metabolic acidosis and severe electrolyte alterations in adults. The risk of refeeding syndrome should be assessed when a gluten-free diet is introduced and treatment of celiac crisis should include prevention and management of this possible complication.

Pelvic hemangiopericytoma: an unusual location of a vascular tumor

Background: The hemangiopericytoma is an uncommon vascular tumour. We report a case of interest because of its rarity, size and location. Case report: We present the case of a 63-year-old woman who consulted for abdominal pain. TAC, MRI and arteriography showed a pelvic mass occupying Douglas' space, displacing the uterus, bladder and sigma, with vascularisation relative to the inferior mesenteric artery and both hypogastric arteries. The vascularity of the tumour itself was selectively embolised before the mass was resected. There were no intra- or postoperative complications. Pathology confirmed the diagnosis of hemangiopericitoma. The patient is being monitored as an outpatient, with no signs of recurrence to date. Discussion: The hemangiopericytoma is a tumour of the pericyte cells so it can occur in any location. The pelvic location is exceptional. The tumour may appear as nonspecific abdominal pain, show signs of compression of adjacent organs or occasionally be associated with paraneoplastic syndromes. The diagnosis is suspected via CT and angiography findings, but confirmation is only made by analysing the surgical specimen. The treatment of choice is surgery, in some cases after preoperative embolisation of the vascularisation of the mass. There is no agreement on chemo/radiotherapy as the primary treatment for hemangiopericytoma, although adjuvant radiation therapy has been found to improve local control and reduce recurrences. The prognosis is good if complete resection is achieved, with five- and 10-year survival rates between 70 and 80%, depending on the series.

Introducción: el hemangiopericitoma es una neoplasia infrecuente de estirpe vascular. Presentamos un caso clínico de interés dada su escasa frecuencia, tamaño y localización. Caso clínico: se trata de una mujer de 63 años que consultó por dolor abdominal. Se realizaron TAC, RMN abdominal y arteriografía que mostraban una gran masa pélvica que ocupaba el espacio de Douglas y desplazaba útero, vejiga y sigma y presentaba vascularización dependiente de la arteria mesentérica interior y ambas arterias hipogástricas. Se embolizó selectivamente la vascularización propia de la neoplasia y seguidamente se resecó la masa, sin presentarse complicaciones ni intra ni postoperatorias. La anatomía patológica confirmó el diagnóstico de hemangiopericitoma. La paciente sigue controles en consultas externas sin signos de recidiva hasta la fecha. Discusión: el hemangiopericitoma procede de las células del pericito por lo que puede presentarse en cualquier localización. La localización pélvica es excepcional. Puede presentarse como dolor abdominal inespecífico, dar síntomas de compresión de órganos vecinos y, ocasionalmente, asociarse a síndromes paraneoplásicos. El diagnóstico de sospecha es mediante TAC y angiografía aunque la confirmación es histológica tras analizar la pieza de resección. El tratamiento de elección es quirúrgico, precediéndose en algunos casos de embolización preoperatoria de la vascularización de la masa. No hay acuerdo sobre la quimio/radioterapia como tratamiento primario del hemangiopericitoma, aunque se ha descrito la radioterapia adyuvante para mejorar del control local y disminuir las recurrencias. El pronóstico es bueno si se consigue una resección completa, con supervivencias a 5 y 10 años entre el 70 y el 80% según las series.

Hemobilia due to intracholecystic papillary neoplasm

We report the case of a 39-year-old patient who presented an episode of upper gastrointestinal bleeding due to hemobilia. The imaging tests showed the gallbladder occupied by solid tissue, with a diagnosis of intracholecystic papillary neoplasm after the cholecystectomy. The intracholecystic papillary neoplasm of the gallbladder is a newly established entity and it is considered a subtype of intraductal papillary neoplasm of the bile duct. Its presentation in the form of hemobilia has barely been described in the literature.

Exponemos el caso de un paciente de 39 años que presentó un episodio de hemorragia digestiva alta secundario a hemobilia. Mediante las pruebas de imagen realizadas se objetivó ocupación de la vesícula biliar por tejido sólido, que tras colecistectomía se diagnosticó de neoplasia papilar intracolecística. Se trata una entidad recientemente establecida y se considera un subtipo de la neoplasia papilar intraductal de la vía biliar. La presentación en forma de hemobilia apenas ha sido descrita en la literatura.

Endoscopic removal of retained large surgical gauze: a case report

In this paper, a 63-year-old woman was reported with recurrent abdominal pain after cholecystectomy. A retained surgical towel was seen by CT-scan in the peritoneal cavity, where it migrated across duodenum wall toward pre-pyloric region of the stomach. Endoscopic removal of the large retained gauze in size of 40 cm x 40 cm was successfully performed without laparotomy and with no complication. In the last years, the main method for removal of retained foreign objects has been open laparotomy or laparoscopy. We claimed that removal of large retained surgical long gauze is actually possible using upper GI endoscopy by expert endoscopists, and, therefore, there is no need for anesthesia or surgery as well as no occurrence of complication and laceration.

Mesenteric schwannoma: an unusual cause of abdominal mass

Schwannomas (or neurilemmomas) are slow-growing mesenchymal neoplasms of the peripheral nerve sheath that may arise at almost any anatomical site. Mesentery schwannoma is extremely rare, with less than ten previously described cases. We present the case of a 38-year-old woman with arterial hypertension and chronic kidney disease with an abdominal painless mass of two years duration and an inconclusive pre-operative clinical diagnosis; she was successfully treated by complete surgical resection of the mass. The aim of this report is to recognize the possibility of schwannomas in the differential diagnosis of abdominal slowly growing tumors.

Rectal neuroendocrine neoplasia: a rare tumour

Unusual presentation of infection by Helicobacter pylori: gastritis associated with Russell bodies, infrequent and poorly understood pathology

Peroral endoscopic myotomy for an achalasia patient with multiple esophageal diverticula

Anisakiasis and intestinal endometriosis: under-recognized conditions in the differential diagnosis of acute abdomen

Multiple perforation of small-intestine diverticula in a patient with Ehlers-Danlos syndrome

Alopecia areata as a paraneoplastic syndrome of gastric cancer