Revista Española de Enfermedades Digestivas

Probióticos en el tratamiento erradicador de Helicobacter pylori: sin evidencia para su uso generalizado

Suplemento probiótico conteniendo Lactobacillus aumenta la tasa de erradicación de Helicobacter pylori: evidencia de un meta-análisis

Background: Helicobacter pylori infection is recognized as a major contributory factor to many diseases, but recommended eradication therapies demonstrated unsatisfactory eradication rates. Currently, some studies suggested that lactobacillus species have an inhibitory action on Helicobacter pylori both in vitro and in vivo. Objective: this meta-analysis broadly examined the efficacy of eradication regimens supplemented with lactobacillus -containing probiotic on eradication rates and side effects. Methods: eligible articles were identified by comprehensive searches. Statistical analysis was performed with Review Manager 5.2. Outcomes were finally evaluated according to GRADE system. Results: nine randomized controlled trials of high-quality met eligible criteria. Risk ratio of eradication was available for 1,163 patients. Lactobacillus -containing probiotics significantly increased the eradication rate compared with the control group based upon intention-to-treat analysis [RR = 1.14; 95 %CI (1.06-1.22); number needed to treat (NNT) = 10] by the fixed effect model without significant publication bias, but no significant reduction associated with overall side effects was observed [RR = 0.88; 95 %CI (0.73-1.06)]. In the subgroup analysis, eradication rates raised significantly by 17 % in lactobacillus administrated alone group [RR = 1.25; 95 %CI (1.13-1.37); NNT = 6]. In multistrain probiotics group, eradication rates enhanced only 2.8 % [RR = 1.04; 95 %CI (0.94-1.14)]. It also showed that lactobacillus -containing probiotics improved the eradication rates, respectively, both in adults [RR = 1.12; 95 %CI (1.04-1.20); NNT = 12] and in children [RR = 1.25; 95 %CI (1.01-1.53); NNT = 7]. Conclusions: Lactobacillus -containing probiotic as an adjunct is effective to eradication therapy, while side effects caused by eradication treatment may not decrease. Furthermore, lactobacillus administrated alone will distinctly benefit eradication therapy.

Resultados oncológicos tras la extirpación endoscópica de pólipos colorrectales malignos

Objective: malignant colorectal polyp, defined by submucosally invasive adenocarcinoma, is the earliest form of clinically relevant colorectal cancer (CRC). After endoscopic resection additional surgery may be necessary, although decision criteria remain debatable. The objective of this study was to assess oncologic outcomes in terms of locoregional disease and to identify areas of improvement that may facilitate patients' management. Methods: retrospective study of 40 patients with T1 CRC endoscopically resected between 2007 and 2012. Clinicopathological features were assessed and correlated with residual disease (RD), defined as presence of adenocarcinoma in intestinal wall and/or lymph nodes. Results: thirty-one patients underwent surgery while 9 were followed-up. After surgery, RD was confirmed in 15 (48.4 %) patients: 8 (53.3 %) wall disease, 5 (33 %) nodal metastasis, and 2 (13.3 %) with both. No recurrence was detected in the follow-up group. The characteristics of the lesions that were associated with DR were sessile configuration (p = 0.03), the degree of differentiation G3 (p = 0.01) and intercepted/indeterminate margins (p = 0.01). Twenty-two patients were operated because of inadequate evaluation, mainly due to piecemeal resection, and half of them were disease free. Postoperative complications were found in 9 (30 %) patients, mainly anastomotic leakage that was associated with rectum anterior resection (p = 0.03). Conclusions: surgery should be considered in the presence of any risk factor for residual disease, while follow-up can be offered in low risk settings. Was also demonstrated a clear need for technical improvement in endoscopic resection and pathology evaluation in order to prevent unnecessary surgeries.

Efectividad de los marcadores serológicos de activación del eosinófilo en la monitorización de la actividad de la esofagitis eosinofílica

Background: it is necessary to find serological markers accessible in clinical practice to prevent the need to perform repeated endoscopies. Objective: to assess the efficacy of eosinophil activity markers in monitoring eosinophilic esophagitis (EoE). Material and methods: thirty patients were included prospectively, all under dietary treatment -diets excluding 6 foods, and allergy test based diet (skin prick test and specific IgE). The variables assessed were demographic parameters, eosinophil cationic protein (ECP) levels (μg/mL), total IgE (KU/L), peripheral blood eosinophils (PBE) (U/mm³), and the maximum peak of eosinophils/hpf in esophageal biopsies. The variation found between these figures was assessed in line with response to dietary treatment. Results: thirty patients (66.7 % males; mean age 33.43 years) were included in the study, 22 responders and 8 non-responders. Ninety percent presented a personal history of atopy. No significant decrease was detected in serum total IgE and ECP after diet in responder and nonresponders. However, the PBE decreased significantly in responders but not in nonresponders, PBE in responders (pre-diet. 397.27 vs. post-diet 276.81, p = 0.024) and non-responders PBE (pre-diet. 460 vs. post-diet 317.5, p = 0.23). Conclusion: serum total IgE and ECP do not act as markers for EoE activity. However PBE may play a role in this regard, bearing in mind that this parameter may be influenced by concomitant atopic conditions.

Introducción: resulta necesario encontrar marcadores serológicos de actividad en esofagitis eosinofílica (EoE) accesibles en la práctica clínica que eviten la realización de endoscopias repetidas a los pacientes. Objetivo: evaluar la eficacia de los marcadores de actividad del eosinófilo en la monitorización de la EoE. Material y métodos: se reclutaron de forma prospectiva, pacientes con EoE tratados con dietas (dieta de exclusión de 6 alimentos y dieta dirigida en base a los test de alergia). Se analizaron parámetros demográficos, valor sérico de proteína catiónica eosinofílica (PCE) (μg/ml), IgE sérica total (KU/l), eosinófilos en sangre periférica (ESP) (U/mm³), así como pico máximo de eosinófilos/campo de gran aumento en las biopsias esofágicas. Se analizó la variación encontrada en estos valores de acuerdo con la respuesta a las dietas. Resultados: 30 pacientes (66,7 % varones; edad media 33,43 años) fueron incluidos, 22 respondedores y 8 no respondedores. El 90 % de los pacientes presentaba antecedentes personales de atopia. No se detectó descenso significativo de IgE sérica total ni PCE tras la dieta en respondedores y no respondedores. Sin embargo los ESP descendieron significativamente en los pacientes respondedores (ESP pre-dieta 397,27 vs. post-dieta 276,81; p = 0,024) pero no así en los no respondedores (ESP pre-dieta 460 vs. post-dieta 317,5; p = 0,23). Conclusión: la IgE sérica total y PCE no se comportan como marcadores de actividad de la EoE. Sin embargo los ESP podrían desempeñar una función en este sentido, aunque considerando que este parámetro puede verse influenciado por las enfermedades atópicas concomitantes.

Enfermedad celiaca y genotipo HLA-DQ: diagnóstico de diferentes perfiles de riesgo genético relacionados con la edad en Badajoz, suroeste de España

Background and objectives:celiac disease is associated with the HLA class II alleles: DQA1*05-DQB1*02 and DQB1*0302. The genetic risk for celiac disease may depend on the presence or absence of such alleles, their combination or number of copies. This study aimed to establish the differences in HLA genotypes between celiac patients diagnosed during childhood and adulthood, and between patients and healthy controls, and to determine the risk of disease in each genotypic category. Methods: we classified 350 celiac patients at time of diagnosis and 218 controls into 14 categories according to their HLA genotype, based on the presence or absence of risk alleles. Results: we found statistically significant differences between the genotype frequencies of celiac patients diagnosed as being children and adults. DQA1*05 (x 1 copy), DQB1*02 (x 1 copy), DQB1*0302 (x 0 copies) was the most frequent genotype in individuals diagnosed in childhood, whereas DQA1*05 (x 1 copy), DQB1*02 (x 2 copies), DQB1*0302 (x 0 copies) was the most frequent in adults. The risk for disease in each genotypic category in celiac children and adults turned out to be different. The presence of DQB1*0302 did not increase risk in children, but did in adults. Conclusion: in our celiac population, we found a different genetic pattern according to age of diagnosis. That could suggest that the pathogenic mechanism of the disease is not exactly the same in both age groups, which could somehow determine clinical presentation of the disease, its epidemiology, coexisting diseases, and complications.

Helicobacter enterohepáticos distintos de Helicobacter pylori

The Helicobacter genus includes Gram negative bacteria which were originally considered to belong to the Campylobacter genus. They have been classified in a separate genus since 1989 because they have different biochemical characteristics, with more than 24 species having been identified and more still being studied. H. pylori is the best known. It has an important etiopathogenic role in peptic ulcer disease and gastric cancer. Enterohepatic Helicobacter s (EHH) other than H. pylori colonize the bowel, biliary tree and liver of animals and human beings with pathogenic potential. The difficulties existing to correctly isolate these microorganisms limit the description of their true prevalence and of the diseases they cause. Many studies have tried to discover the different clinical implications of EHH. Diseases like chronic liver disease, autoimmune hepatitis, hepatocarcinoma, autoimmune hepatobiliary disease, biliary lithiasis, cholangiocarcinoma and gallbladder cancer, Meckel's diverticulum, acute appendicitis and inflammatory bowel disease have been related with different EHH species with different results, although their prevalence is greater than in healthy subjects. However, these data are currently not sufficient to draw definitive conclusions. Finally, the best known role of EHH in bowel disease is production of acute and chronic diarrhea pictures initially referred to as Campylobacter. H. pullorum has been identified in patients with acute gastroenteritis. The correct identification of EHH as producers of infectious gastroenteritis is found in its antibiotic susceptibility. It is generally macrolide-susceptible and quinolone-resistant.

El género Helicobacter engloba bacterias Gram negativas que en un principio se consideraban pertenecientes al género Campylobacter, y desde 1989 se clasificaron en un género separado debido a características bioquímicas diferentes, con más de 24 especies identificadas y otras aún en estudio. H. pylori es el más conocido y tiene un importante papel etiopatogénico en la patología péptica y cáncer gástrico. Otros Helicobacter enterohepáticos (HEH) distintos de H. pylori colonizan el intestino, el árbol biliar y el hígado de animales y seres humanos con potencial patógeno. Las dificultades para el correcto aislamiento de estos microorganismos limitan la descripción de su prevalencia real y de las patologías que provocan. Múltiples estudios intentan desvelar las diferentes implicaciones clínicas de los HEH. Patologías como la hepatopatía crónica, hepatitis autoinmune, hepatocarcinoma, enfermedad hepatobiliar autoinmune, litiasis biliar, colangiocarcinoma y cáncer de vesícula biliar, cáncer de páncreas, diverticulitis de Meckel, apendicitis aguda y enfermedad inflamatoria intestinal se han relacionado con diferentes especies de HEH con diferentes resultados, aunque con una mayor prevalencia que en sujetos sanos. No obstante, estos datos son insuficientes para sacar conclusiones definitivas por el momento. Por último, el papel más conocido de los HEH en la patología intestinal es la producción de cuadros diarreicos agudos y crónicos referidos inicialmente como Campylobacter. H. pullorum se ha identificado en pacientes con gastroenteritis aguda. La correcta identificación de HEH como productores de gastroenteritis infecciosa radica en su sensibilidad antibiótica, generalmente sensible a macrólidos y resistente a quinolonas.

Neumatosis quística en colonografía TC y correlación endoscópica

Melanoma primario maligno de esófago: diagnóstico erróneo y revisión de la literatura

Remisión a largo plazo con rituximab en paciente con crioglobulinemia grave asociada al virus de la hepatitis C

Mixed cryoglobulinemia (MC) is a small-vessel systemic vasculitis characterized by the presence of cryoglobulins, immunoglobulin complexes that precipitate at low temperatures (< 37 ºC) inducing the inflammatory process. The most frequent etiology is hepatitis C infection (HCV) (1). Rituximab (RTX), an anti-CD20 monoclonal antibody, has recently emerged as the treatment of choice for severe MC (2). We present a case of severe hepatitis C virus-induced MC that was controlled and maintained in remission with RTX for 26 months, a remarkable prolonged period of time.

La crioglobulinemia (CG) es una vasculitis sistémica de pequeño vaso caracterizada por la presencia de crioglobulinas, las cuales son inmunocomplejos circulantes que, a bajas temperaturas (< 37 ºC), precipitan desencadenando el proceso inflamatorio. La etiología más frecuente es la infección por el virus de la hepatitis C (VHC) (1). En los últimos años el anticuerpo monoclonal anti-CD20 rituximab (RTX) se ha ido posicionando como el tratamiento de primera línea en las CG de presentación agresiva (2). Presentamos el caso de una paciente con brote grave de una CG asociada al VHC que respondió al tratamiento con RTX, manteniéndose posteriormente en remisión de manera inusualmente prolongada durante 26 meses.

Hemorragia diverticular de colon: colonoscopia urgente sin preparación y tratamiento endoscópico con hemoclips y adrenalina

Diverticular disease is the most frequent cause of lower gastrointestinal bleeding. Most of the times, bleeding stops without any intervention but in 10-20 % of the cases it is necessary to treat the hemorrhage. Several modalities of endoscopic treatment have been described after purging the colon. We present five cases of severe diverticular bleeding treated with injection of epinephrine and hemoclips. All the colonoscopies were performed without purging of the colon in an emergency setting, with correct visualization of the point of bleeding. Patients recovered well avoiding other aggressive procedures such as angiography or surgery.

La enfermedad diverticular en la causa más frecuente de hemorragia digestiva baja. En la mayoría de las ocasiones el sangrado cesa sin ninguna intervención, pero en un 10-20 % de los casos es necesario tratar la hemorragia. Se han descrito varias modalidades de tratamiento endoscópico tras preparar el colon. Presentamos cinco casos de hemorragia diverticular severa tratados con inyección de adrenalina y hemoclips. Todas las colonoscopias se realizaron de urgencia y sin preparación del colon, con correcta visualización del punto de sangrado. Los pacientes evolucionaron favorablemente evitando otros procedimientos agresivos como una arteriografía o cirugía.

Pseudo-obstrucción crónica intestinal

Diagnóstico de meningioma espinal por punción aspiración con aguja fina guiada por ultrasonografía endoscópica (PAAF-USE)

Expulsión espontánea de gran lipoma de colon izquierdo

Schwannoma en colon descendente: presentación de una neoplasia en rara localización

Fístula entero-vesical y obstrucción intestinal por endometriosis ileal

Tumores del estroma gastrointestinal (GIST): nuevas expectativas de tratamiento