Revista Española de Enfermedades Digestivas

Cápsula endoscópica y enteropatía por antiinflamatorios no esteroideos (AINE): un poco de luz en un largo y oscuro túnel

Valoración mediante cápsulas endoscópicas de las lesiones intestinales mucosas causadas por antiinflamatorios no esteroideos (AINE)

Objective: to evaluate the type, frequency, and severity of macroscopic small bowel mucosal injury after chronic NSAID intake as assessed by capsule endoscopy (CE), as well as to correlate the severity of gastroduodenal and intestinal damage in these patients. Material and methods:a prospective, endoscopist-blind, controlled trial. Sixteen patients (14F/2M; age: 57.06 ± 10.16 yrs) with osteoarthritis (OA) on chronic therapy with NSAIDs underwent CE and upper gastrointestinal endoscopy (UGE). Seventeen patients with OA (9F/2M; age: 57.47 ± 9.82 yrs) who did not take NSAIDs were included as a control group. A scale ranging from 0 to 2 (0 = no lesions, 1-minor = red spots or petechiae, denuded areas and/or 1-5 mucosal breaks; 2-major = > 5 mucosal breaks and/or strictures, or hemorrhage) was designed to assess the severity of small bowel mucosal injuries. Results: CE found intestinal lesions in 75% (12/16) of patients in the study group and in 11.76% (2/17) of controls (p < 0.01). Seven out of 16 NSAID consumers (43.75%) and none in the control group (0%) had a major small bowel mucosal injury (p < 0.01). The percentages of patients with grade 1 and 2 gastroduodenopathy in the study group, as assessed by UGE, were 37.14 and 23.81%, respectively. There was no significant difference in the rate of major enteropathy between patients with none or minor gastroduodenal injury, and those with major gastroduodenopathy (43.75 vs. 40%; p = N.S.). Conclusions: chronic NSAID intake is associated with a high rate of small bowel mucosal injuries. Our data have failed to demonstrate a relationship between the severity of gastroduodenal and intestinal injury.

La capnografía es superior a la pulsioximetría en la detección de depresión respiratoria durante las colonoscopias

Background: pulse oximetry is a widely accepted procedure for ventilatory monitoring during gastrointestinal endoscopy, but this method provides an indirect measurement of the respiratory function. In addition, detection of abnormal ventilatory activity can be delayed, especially if supplemental oxygen is provided. Capnography offers continuous real-time measurement of expiratory carbon dioxide. Objective: we aimed at prospectively examining the advantages of capnography over the standard pulse oximetry monitoring during sedated colonoscopies. Patients and methods:fifty patients undergoing colonoscopy were simultaneously monitored with pulse oximetry and capnography by using two different devices in each patient. Several sedation regimens were administered. Episodes of apnea or hypoventilation detected by capnography were compared with the occurrence of hypoxemia. Results: twenty-nine episodes of disordered respiration occurred in 16 patients (mean duration 54.4 seconds). Only 38% of apnea or hypoventilation episodes were detected by pulse oximetry. A mean delay of 38.6 seconds was observed in the events detected by pulse oximetry (two episodes of disturbed ventilation were simultaneously detected by capnography and pulse oximetry). Conclusions: apnea or hypoventilation commonly occurs during colonoscopy with sedation. Capnography is more reliable than pulse oximetry in early detection of respiratory depression in this setting.

**Absceso hepático piógeno versus amebiano: Estudio clínico comparativo de una serie de 58 casos**

Objective: to compare the clinical and epidemiological characteristics of patients with pyogenic liver abscess (PLA) and with amebic liver abscess (AHA) in order to determine the potential factors that may help improve diagnosis and treatment for this disease. Material and method: a retrospective study of clinical histories of 45 patients with PLA and 13 with ALA, diagnosed between 1985 and 2005 in Donostia Hospital in San Sebastián. Results: among the 45 patients with PLA (30 men and 15 women, with a mean age of 61 years and 11 months), more than a half were cholangitic (13 cases) or were of unknown origin (15 cases). In 10 patients, diabetes was considered to be a predisposing condition. Increased ESR (> 30), leukocytosis (> 12,000), fever and abdominal pain were observed in 95.5%, 86.7%, 82.8% and 68.9%, respectively. Twenty-five patients had single abscesses. Abscess and blood cultures were positive in 77.1% and 50% of cases, respectively (44.4% with polymicrobial infection). E. coli and S. milleri were the most commonly found germs. A percutaneous drainage was performed on 22 patients. Mean hospital stay was 27 days, and overall mortality, including that related to concomitant conditions, was 7 of 45 cases. Of the 13 cases of ALA (7 men and 6 women, with mean age of 42,9 years), 2 were locally acquired. Increased AF and GGTP (> 2N), fever, leukocytosis and ESR (> 30) were observed in 92.3, 77, 70 and 61.5% of cases, respectively. There were single abscesses in 10 patients and all except one were located in the right lobe. The serological test for E. histolytica (IFF ≥ 1/256) was positive in 100% of cases. A percutaneous drainage was carried out on 6 patients. Mean hospital stay was 18 days and two patients died. Conclusions: In our series, the clinical parameters suggesting pyogenic origin were: age 50 or older, male gender, diabetes, moderately elevated bilirubin and transaminases. In amoebic cases the associated features were being aged 45 or younger, diarrhoea, and presence of a single abscess in the right lobe. Parasitism by E. histolytica must be considered in the differential diagnosis of liver abscesses, even with no epidemiological clinical history of travel and/or immigration.

Objetivo: comparar las características clínicas y epidemiológicas de los pacientes con absceso hepático piógeno (AHP) y con absceso hepático amebiano (AHA) para establecer posibles factores que ayuden a mejorar el diagnóstico y tratamiento de la enfermedad. Material y método: se realiza un estudio retrospectivo de las historias clínicas de 45 pacientes con AHP y de 13 con AHA, diagnosticados entre 1985 y 2005 en el Hospital Donostia de San Sebastián. Resultados: de los 45 casos de AHP (30 hombres y 15 mujeres con una edad media de 61 años y 11 meses), más de la mitad fueron de origen colangítico (13 casos) o criptogenético (15 casos). La diabetes como enfermedad predisponente se objetivó en 10. La elevación de la VSG (> 30), leucocitosis (> 12.000), fiebre y dolor abdominal se observaron en el 95,5, 86,7, 82,8 y 68,9% de los casos respectivamente. Los abscesos fueron solitarios en 25 casos. Los cultivos del absceso y los hemocultivos fueron positivos en el 77,1 y 50%, respectivamente (44,4% de los casos eran polimicrobianos). E. coli y S. milleri fueron los gérmenes más habituales. Se hizo drenaje percutáneo en 22 pacientes. La mortalidad global, incluida la relacionada con la patología subyacente, fue de 7 casos y la estancia media hospitalaria de 27 días. De los 13 casos de AHA (7 hombres y 6 mujeres con una edad media de 42 años y 9 meses), 2 fueron autóctonos. La elevación de la FA y GGTP (> 2N), fiebre, leucocitosis y VSG (> 30) se observaron en el 92,3, 77, 70 y 61,5% de los casos respectivamente. Los abscesos fueron únicos en 10 casos y excepto uno, 12 se localizaron en el lóbulo derecho. La serología a E. histolytica (IFI ≥ 1/256) fue positiva en el 100% de los casos. Se hizo drenaje percutáneo en 6 pacientes. La mortalidad fue de 2 casos y la estancia media hospitalaria de 18 días. Conclusiones: en nuestra serie, las características clínicas que sugieren un origen piógeno son: la edad superior a 50 años, el sexo masculino, la diabetes y la bilirrubina y transaminasas moderadamente elevadas. En el amebiano, la edad menor de 45 años, la diarrea y la localización solitaria del absceso en el lóbulo derecho. La parasitación por E. histolytica se debe considerar en el diagnóstico diferencial de los abscesos hepáticos, incluso sin el antecedente epidemiológico de viajes o de inmigración.

Estudio retrospectivo sobre la endoscopia pediátrica desarrollada en un servicio de endoscopias de adultos

Gastrointestinal endoscopy is a safe, efficient technique with minimal complications, and a useful diagnostic tool for the pediatric population. Under ideal conditions endoscopies for children should be performed by experienced pediatric endoscopists. In this study we report our experience with pediatric endoscopy at the general adult endoscopy unit in our hospital. Our goal is to quantify the number of endoscopies performed in children, as well as their indications and findings, the type of sedation or anesthesia used, and the time waiting for the test to occur. Our experience demonstrates that endoscopists in a general adult gastroenterology department, working together with pediatricians, may perform a relevant number of endoscopies in children in a fast, safe, effective manner.

La endoscopia gastrointestinal es una técnica segura y eficiente con mínimas complicaciones, así como una útil herramienta diagnóstica en la población pediátrica. En condiciones ideales, las endoscopias en niños deberían ser realizadas por endoscopistas pediátricos experimentados. En este estudio reportamos nuestra experiencia en la realización de endoscopias pediátricas en la Unidad de Endoscopias general de adultos de nuestro hospital. El objetivo es cuantificar la cantidad de endoscopias realizadas en niños, así como las indicaciones y hallazgos de las mismas, el tipo de sedación o anestesia empleado y el tiempo de espera para la realización de la prueba. Nuestra experiencia demuestra que los endoscopistas de un servicio de gastroenterología general de adultos, en colaboración con pediatras, pueden realizar un número importante de endoscopias a niños, de forma rápida, segura y eficaz.

Enfermedad de Whipple en España: Revisión clínica de 91 pacientes diagnosticados durante 1947-2001

Background: to determine the epidemiological, clinical, diagnostic and therapeutic characteristics of Whipple's disease in Spain. Patients and method: cases of Whipple's disease reported in the Spanish literature between 1947 and 2001 which meet histological or PCR criteria are reviewed. Results: 91 cases were included, 87.5% of which were male. The maximum incidence was between 40 and 60 years of age (68%). There was no family clustering or susceptibility by profession or surroundings. The most common symptoms and signs were: weight loss (80%), diarrhoea (63%), adenopathies (35%), skin problems (32%), abdominal pain (27%), fever (23%), joint problems (20%) and neurological problems (16%). Arthralgias, diarrhoea and fever were noted prior to diagnosis in 58, 18 and 13% of patients, respectively. Diagnosis was histological in all cases except two, which were diagnosed by PCR. Intestinal biopsy was positive in 94%. Adenopathic biopsies (mesenteric or peripheral) were suggestive in 13% of cases, and treatment was effective in 89%. There were nine relapses, four of which were neurological, although all occurred before the introduction of cotrimoxazole. Conclusions: Whipple's disease is not uncommon, although it requires a high degree of suspicion to be diagnosed in the absence of digestive symptoms. The most common and most sensitive diagnostic method is duodenal biopsy. PCR is beginning to be introduced to confirm the diagnosis and as a therapeutic control. Initial antibiotic treatment with drugs that cross the blood-brain barrier, such as cotrimoxazole and ceftriaxone, is key to achieving a cure and avoiding relapses.

Fundamento: conocer las características epidemiológicas, clínicas, diagnósticas y terapéuticas de la enfermedad de Whipple en España. Pacientes y método: se revisan los casos de enfermedad de Whipple de la literatura española que cumplen criterios histológicos o de PCR desde 1947 hasta 2001. Resultados: se incluyeron 91 casos. El 87,5% eran hombres. La incidencia máxima fue entre los 40 y 60 años de edad (68%). No hubo agregación familiar ni preferencia por profesión o entorno ambiental. Los síntomas y signos más habituales fueron: adelgazamiento (80%), diarrea (63%), adenopatías (35%), cutáneos (32%), dolor abdominal (27%), fiebre (23%), articulares (20%) y neurológicos (16%). Artralgias, diarrea y fiebre se referían previamente al diagnóstico en el 58, 18 y 13% de los enfermos, respectivamente. El diagnóstico fue histológico en todos salvo en dos que se diagnosticaron por PCR. La biopsia intestinal fue positiva en el 94%. Las biopsias de adenopatías (mesentéricas o periféricas) fueron orientadoras en un 13%. El tratamiento fue eficaz en el 89%. Hubo 9 recidivas, 4 neurológicas, estas antes de la introducción del cotrimoxazol. Conclusiones: la enfermedad de Whipple no es tan infrecuente. Se precisa un alto índice de sospecha para diagnosticarla en ausencia de síntomas digestivos. El método diagnóstico más empleado y más sensible es la biopsia duodenal. Se empieza a introducir la técnica de PCR para confirmar el diagnóstico y como control terapéutico. El tratamiento antibiótico inicial con antibióticos que pasan la barrera hematoencefálica como cotrimoxazol y ceftriaxona es determinante para la curación de los pacientes y evitar las recidivas.

Guía de práctica clínica para el manejo de la coagulación en pacientes sometidos a técnicas endoscópicas

Manifestación subcutánea inusual de la pancreatitis aguda

Ectopia esofágica de glándulas sebáceas

Quistes hepáticos en el adulto

Diverticulitis yeyunal por cuerpo extraño

Tratamiento con infliximab en paciente con enfermedad de Crohn íleo-colónica y arteritis de Takayasu

Histiocitoma fibroso maligno, un tumor hepático raro

Hipercalcemia agravada por el uso de furosemida en un paciente con hepatitis granulomatosa secundaria a alopurinol