Revista Española de Enfermedades Digestivas

Escala de Bristol: ¿un sistema útil para valorar la forma de las heces?

Adaptación y validación de las escalas de Bristol a la lengua española por profesionales sanitarios y pacientes

Background: stool type represents an important semiologic part of medical interviews. The Bristol Scale Stool Form is a clinical tool to evaluate stool consistency and form. The aim of this study was to translate and adapt the Bristol Scale Stool Form into Spanish. Differences in validation results between health professionals and patients surveyed were also evaluated. Methods: the study population included 79 physicians, 79 nurses, and 78 patients. Subjects were invited to match a randomly selected text defining one of the seven stool types in the scale with one of seven drawings described originally. A random selection of samples was offered for re-test reliability. Results: the overall Kappa index was 0.708. Thirty-two subjects repeated the test for a test-retest assessment in a mean interval of 7.76 days, and the percentage concordance between definition and image was 84.4% with a Kappa index of 0.816. There were no differences in the validation study between physicians, nurses, and patients. Conclusions: this study has shown that the Spanish version of the Bristol Scale Stool Form is reliable for use as a tool to evaluate stool consistency and form.

Seguimiento endoscópico de la úlcera gástrica en una población de riesgo intermedio de cáncer gástrico

Objetivos: Primario: valorar la necesidad de una segunda endoscopia con estudio anatomopatológico para confirmar la curación de todas las úlceras gástricas diagnosticadas previamente mediante endoscopia, en una población de riesgo intermedio de cáncer gástrico. Secundario: correlacionar el juicio diagnóstico del endoscopista y el diagnóstico anatomopatológico. Pacientes y métodos: análisis prospectivo de todos los pacientes diagnosticados de úlcera gástrica mediante endoscopia en el Hospital General de Ciudad Real durante tres años. Se recogieron datos demográficos, clínicos, endoscópicos y anatomopatológicos de la primera y sucesivas endoscopias. Se tomaron al menos seis muestras de biopsia del nicho y se valoró la presencia de H. pylori. Resultados: se incluyeron 302 pacientes. Se diagnosticó infección por H. pylori en 173 (57%) y se documentó la toma de AINE en 113 (37%). El valor predictivo positivo y negativo para malignidad del diagnóstico endoscópico atendiendo a los pliegues, fondo y bordes del nicho fue de 34 y 97%, respectivamente. La segunda endoscopia sólo diagnosticó un paciente. Al final del seguimiento, el diagnóstico etiológico fue de 276 casos de úlcera péptica, 1 de úlcera por enfermedad de Crohn y 25 de úlcera neo-plásica (21 adenocarcinomas, 4 linfomas). Conclusiones: en una población de riesgo intermedio de cáncer gástrico, no está indicada la realización sistemática de una segunda endoscopia en pacientes con úlcera gástrica en los que la visión endoscópica y la biopsia del nicho no indican malignidad.

Objectives: Primary: to assess the necessity of a second endoscopy with a pathology study to confirm the healing of all gastric ulcers previously diagnosed through endoscopy in a population at intermediate risk for gastric cancer. Secondary: to assess correlation between endoscopic findings and pathology diagnosis. Patients and methods: a prospective analysis of patients diagnosed with gastric ulcer through endoscopy at Hospital General de Ciudad Real (Spain) over three years. We collected demographic, clinical, endoscopic, and pathological data for the first and subsequent endoscopies. We collected at least six biopsies obtained from ulcer margins, and assessed H. pylori infection. Results: Three hundred and two patients were included in this study. H. pylori infection was diagnosed in 173 (57%), and 113 (37%) patients had used NSAIDs. The positive and negative predictive value for malignancy of endoscopic diagnosis regarding ulcer fold, base, and margins were 34 and 97%, respectively. Only one patient was diagnosed with a tumor during the second endoscopy. At the end of follow-up, the etiology of the ulcer was considered as peptic in 276 patients; Crohn's disease-related in one, and neoplastic in 25 patients (21 adenocarcinomas, 4 lymphomas). Conclusions: in an intermediate-risk population for gastric cancer a second endoscopy is not justified for gastric ulcer patients when endoscopy and biopsy results do not suggest malignancy.

Evaluación de la fibrosis hepática en la hepatitis crónica por virus C mediante la aplicación prospectiva del Sabadell's NIHCED score: Sabadell's Non Invasive, Hepatitis C Related-Cirrhosis Early Detection Score

Introducción: la hepatitis crónica por VHC cursa de forma asintomática desarrollando cirrosis hepática y sus complicaciones en un 20-40% de los casos. En estudios previos se ha demostrado que la fibrosis avanzada es un factor pronóstico fundamental. El método gold standard para la valoración del grado de fibrosis es la biopsia hepática. Nuestro grupo ha validado un índice predictivo, el NIHCED (Sabadell's Non Invasive, Hepatitis C related-Cirrosis Early Detection Score), basado en datos demográficos, analíticos y ecográficos para determinar la presencia de cirrosis. Objetivo: nuestro objetivo es el de evaluar si el NIHCED predice la presencia de fibrosis avanzada en los pacientes con hepatitis crónica por virus C. Material y métodos: estudio prospectivo donde se incluyeron pacientes con hepatitis crónica por VHC. Se les realizó una biopsia hepática y el NIHCED. El grado de fibrosis se correlacionó con el valor del NIHCED mediante curva de ROC y el coeficiente de correlación de Spearman. Resultados: se incluyeron un total de 321 pacientes (ratio hombre/mujer 1,27) con una edad media de 48 ± 14 años. La biopsia hepática mostró que 131 (30,5%) no tenían fibrosis o era expansión portal, mientras que 190 (69,5%) tenían fibrosis avanzada o cirrosis. Para un punto de corte de 6 puntos, la sensibilidad fue del 72%, especificidad del 76,3%, VPP del 81%, VPN del 63,7% y una precisión diagnóstica del 72,5%, con un área bajo la curva fue de 0,787 y un coeficiente de correlación de Spearman de r = 0,65. Conclusiones: el NIHCED predice la presencia de fibrosis avanzada en un elevado porcentaje de pacientes sin necesidad de realizar biopsia hepática.

Introduction: liver disease resulting from chronic hepatitis C virus (HCV) infection follows an asymptomatic course towards cirrhosis and its complications in 20-40% of cases. Earlier studies demonstrated that advanced fibrosis is a prognostic factor. The "gold standard" for the evaluation of fibrosis grade is liver biopsy. Our group validated a predictive index - NIHCED - based on demographic, laboratory parameters, and echoghraphic data to determine the presence of cirrhosis. Objective: our objective is to evaluate whether the NIHCED score predicts the presence of advanced fibrosis in patients with chronic HCV infection. Material and methods: this prospective study included patients with chronic HCV infection who underwent liver biopsy and were administered the NIHCED score. Fibrosis grade correlated with the NIHCED score using the ROC curve analysis and Spearman's correlation coefficient. Results: in total 321 patients were included (male/female ratio 1.27) with a mean age of 48 ± 14 years. Liver biopsy showed that 131 (30.5%) had no fibrosis or had portal expansion while 190 (69.5%) had advanced fibrosis or cirrhosis. At a cut-off point of 6, sensitivity was 72%, specificity was 76.3%, positive predictive value (PPV) was 81%, negative predictive value (NPV) was 63.7%, and diagnostic accuracy was 72.5%, with an area under the curve (AUC) of 0.787, and a Spearman's correlation coefficient of r = 0.65. Conclusions: the NIHCED score predicts the presence of advanced fibrosis in an elevated percentage of patients with a need of liver biopsy.

Pseudodestrucción intestinal crónica: un diagnóstico a tener en cuenta

Chronic intestinal pseudoobstruction (CIPO) is a rare entity characterized by recurrent clinical episodes of intestinal obstruction in which no mechanical cause is identified. There are multiple causes for this syndrome but two main groups can be distinguished: a) secondary to a systemic non-gastrointestinal disease; and b) primary or idiopathic originated from alterations in the components of the intestinal wall. The latter forms are the most uncommon and their diagnosis is generally difficult. In the present article, we describe nine patients with CIPO that were diagnosed in our center over the last six years. Four of them were diagnosed with primary or idiopathic form of CIPO and another four were clearly secondary to a systemic disease. The ninth case, which was initially diagnosed as secondary, is probably also a primary form of the disease. The number of patients diagnosed in our center, even thought small, makes us to hypothesize that the prevalence of CIPO is probably greater than is generally believed and that the reasons of its rarity are the incomplete understanding of its physiopathology and the difficulties to achieve a correct diagnosis.

Citoquinas: papel patogénico y terapéutico de las hepatitis crónicas víricas

Cytokines make up a network of molecules involved in the regulation of immune response and organ functional homeostasis. Cytokines coordinate both physiological and pathological processes occurring in the liver during viral infection, including infection control, inflammation, regeneration, and fibrosis. Hepatitis B and hepatitis C viruses interfere with the complex cytokine network brought about by the immune system and liver cells in order to prevent an effective immune response, capable of viral control. This situation leads to intrahepatic sequestration of nonspecific inflammatory infiltrates that release proinflammatory cytokines, which in turn favor chronic inflammation and fibrosis. The therapeutical administration of cytokines such as interferon alpha may result in viral clearance during persistent infection, and revert this process.

Megarrecto y megacolon idiopático

Hernia de hiato y lesiones por enfermedad por reflujo gastroesofágico diagnosticadas por cápsula endoscópica

Hernia diafragmática paraesternal de Morgagni-Larrey en adulto

Con una prevalencia de 0,3-0,5/1.000 nacimientos, la hernia diafragmática congénita (HDC) sigue siendo una anomalía grave, no bien entendida, alta mortalidad y tratamiento no siempre efectivo. En España se ha informado de una frecuencia del 0,69%oo con una tendencia decreciente en el periodo 1980-2006 del 0,10%oo por año. No obstante, hasta un 5% se diagnostican en adultos durante la realización de un reconocimiento por otra causa. Presentamos un cuadro de vómitos de tres meses de evolución en una mujer de 74 años por hernia diafragmática paraesternal de Morgagni-Larrey (retrocondroesternal, retrocostoxifoidea, retroesternal, subcostal, subesternal o subcostoesternal), que nos ha permitido realizar una actualización de esta patología en adultos y de la morfogénesis del diafragma toracoabdominal. Es en la embriología del diafragma donde encontramos explicación de algunas de sus alteraciones morfológicas y características clínicas, si bien persisten aspectos confusos de la misma. También analizamos el grado de controversia que persiste en algunos aspectos de su tratamiento quirúrgico (vías de acceso, uso o no de mallas y reducción o no del saco herniario). Por lo general priman las técnicas mínimamente invasivas. Consideramos el abordaje laparoscópico como de elección en pacientes adultos con hernia paraesternal candidatos a la cirugía.

With a prevalence of 0.3-0.5/1000 births, congenital diaphragmatic hernia (CDH) remains a serious, poorly understood abnormality with a high mortality rate that cannot always be effectively managed. Its reported frequency in Spain is 0.69%oo with a yearly decreasing trend of 0.10%oo during the period 1980-2006. Up to 5% of cases are incidentally identified in adults undergoing studies for other reasons. We report the case of a 74-year-old woman with vomiting for three months due to parasternal diaphragmatic hernia of Morgagni-Larrey (retrochondrosternal, retrocostoxyphoid, retrosternal, subcostal, substernal or subcostosternal hernia), which allowed us to report an update on this condition in the adult, and on thoracoabdominal diaphragm morphogenesis. It is in the embryology of the diaphragm where an explanation may be found for some morphological changes and clinical manifestations, even though a number of uncertainties remain. We also analyze the extent of controversy persisting on some aspects of surgical treatment (access routes, mesh use, hernial sac reduction). Overall, minimally invasive techniques predominate. We consider laparoscopy the approach of choice for adult patients with parasternal hernia eligible for surgery.

Colangitis esclerosante primaria

Esofagitis herpética por herpes simple en adulto inmunocompetente

Cistoadenocarcinoma hepático: Diagnóstico diferencial de tumores quísticos hepáticos

Eficacia de la talidomida en la hemorragia digestiva por angiodisplasias

Pancreatitis crónica con gran dilatación del Wirsung

Actinomicosis esofágica

In Memoriam. Dr. Carlos Losa Martínez (1936-2009)