Revista Española de Enfermedades Digestivas

Trasplante de microbiota fecal: algo más que una curiosidad terapéutica

**Initial experience with fecal microbiota transplantation in Clostridium difficile infection: transplant protocol and preliminary results**

Background and aims: Clostridium difficile infection (CDI) constitutes an important cause of antibiotic-associated diarrhea. Recurrence after first-line treatment with antibiotics is high and fecal microbiota transplantation (FMT) may be effective for refractory and recurrent CDI. This series aims to describe the efficacy of FMT in the treatment of refractory and recurrent CDI. Methods: A prospectively recorded single-centre case series of patients with persistent or recurrent CDI treated with FMT between June 2014 and March 2015 was analyzed. Primary and secondary outcomes were defined as resolution of diarrhea without recurrence of CDI within 2 months after one or more FMT, respectively. A descriptive analysis was performed. Results: 8 FMT were performed in 6 patients, 3 with refractory CDI and 3 with recurrent CDI. The median age of recipients was 71 years and 66.7% were women. One FMT was delivered through colonoscopy and the remaining 87.5% through esophagogastroduodenoscopy. One upper FMT was excluded due to recurrence of CDI after antibiotic exposure for a respiratory infection. The overall cure rate of FMT was total with lower route and 83.3% with upper route. Primary cure rate was achieved in 83.3% of patients and secondary cure rate was achieved in all patients. Median time to resolution of diarrhea after FMT was 1 day and no complications were reported during follow-up. Conclusion: FMT appears to constitute a safe and effective approach in the management of refractory and recurrent CDI. Difference between primary and secondary cure rates may result of insufficient restoration of intestinal microbiota with a single FMT.

Patología esofagogástrica en el obeso mórbido: diagnóstico preoperatorio e influencia en la selección de la técnica quirúrgica

Introduction: Given the difficulty in accessing to the excluded stomach after gastric bypass and the increase in gastroesophageal reflux after sleeve gastrectomy, it is justified to perform a preoperative fibrogastroscopy. The influence of the fibrogastroscopy (FGS) findings in the therapeutic approach is analyzed. Patients and methods: A retrospective study of preoperative FGS findings is performed, from 04/06 to 12/12. The influence of the FGS results on the surgical technique selection, in the endoscopic or medical treatment and its relation to gastric fistula is analyzed by means of multivariate regression (confounding factors: Age, body mass index, arterial hypertension, diabetes mellitus, antiplatelet therapy, surgical technique (bariatric surgery, sleeve gastrectomy). Results: Three hundred thirty one patients are included: 32.6% biopsy of gastric lesion; 27% gastritis; 18.1% hiatal hernia; 3% metaplasia; 0.6% Barrett esophagus; 2.1% esophagitis; 0.3% dysplasia; 0.3 Schatzky's ring; 1.5% incompetent cardia; 2.4% duodenitis; 0.3% gastric erosions; 0.6% gastric xanthoma; 1.8%, gastric polyp; 1.6% duodenal ulcer; 0.6% papulo-erosive gastritis; 0.6% esophageal papilloma; 0.3% submucosal tumor. Helicobacter pylori+ 30.2% (triple therapy eradication in all patients). The FGS findings led to a variation in the surgical technique or to the completion of endoscopic treatment in 22.2% of cases. The gastric lesions did not influence the development of gastric fistula. Independent prognostic factors of fistula: Sleeve gastrectomy (7.9% vs. 2.7%; p = 0.02; OR: 1.38 IC95: 1.01-1.87) and the body mass index > 50 kg/m²) (6.7% vs. 2.2%; p = 0.04; OR: 3.7 IC95: 1.12-12.4). Conclusions: The diagnosis of gastroesophageal disease through preoperative FGS motivated variations in the therapeutic approach in 52% of patients, so we consider essential to include the preoperative FGS in bariatric surgery.

Introducción: la dificultad de acceso al estómago excluido tras el bypass gástrico (BG) y el empeoramiento del reflujo gastroesofágico tras la gastrectomía vertical (GV) justifican la fibrogastroscopia (FGS) preoperatoria. Se analiza la influencia de los hallazgos de FGS en la actitud terapéutica. Pacientes y métodos: estudio retrospectivo de hallazgos de FGS previa a cirugía bariátrica desde 04/06 a 12/12. Influencia del resultado FGS en la selección de la técnica quirúrgica y en el tratamiento médico o endoscópico; y su relación con la fístula gástrica mediante regresión multivariada (factores de confusión: edad, índice de masa corporal, hipertensión arterial, diabetes mellitus, tratamiento antiagregante, técnica quirúrgica (bypass gástrico o gastrectomía vertical). Resultados: se incluyen 331 pacientes: 32,6% biopsia de lesión gástrica; 27% gastritis. 18,1% de hernia de hiato; 3% metaplasia, 0,6% Barret, 2,1% esofagitis, 0,3% displasia, 0,3 anillo de Schalzsky, 1,5% de cardias incompetente, 2,4% de duodenitis, 0,3% erosiones gástricas, 0,6% xantoma gástrico, 1,8%, pólipos gástricos, 1,6%, úlcera duodenal, 0,6% gastritis papuloerosiva, 0,6% papiloma esofágico, 0,3% tumor submucoso. Helicobacter pylori+ 30,2% (triple terapia añadida en todos). Variación de técnica quirúrgica o tratamiento endoscópico debido a FGS 22,2%. Las lesiones gástricas no influyeron en el desarrollo de fístula gástrica. Factores pronósticos independientes de fístula: GV (7,9% vs. 2,7%; p = 0,02; OR: 1,38 IC95: 1,01-1,87) y el índice de masa corporal (IMC) > 50 kg/m² (6,7% vs. 2,2%; p = 0,04; OR: 3,7 IC95: 1,12-12,4). Conclusiones: el diagnóstico de patología esofagogástrica mediante FGS preoperatoria motivó variaciones en la actitud terapéutica del 52% de los procedimientos, por lo que consideramos imprescindible incluir la FGS en el preoperatorio de la cirugía bariátrica.

Diferentes mecanismos de acción de la genisteína y quercetina en las contracciones espontáneas del duodeno de conejo

Flavonoids are known to relax precontracted intestinal smooth muscle and delay intestinal transit or intestinal peristalsis. The aim of this study was to determine the effects of genistein and quercetin on spontaneous contractions of rabbit duodenum in vitro in an organ bath. Genistein and quercetin (0.1-10 µM) reduced the amplitude of spontaneous contractions in the longitudinal and circular smooth muscle of rabbit duodenum, but they did not modify the frequency. Bay K8644 (L-type Ca2+ channel activator), apamin, charybdotoxin, and tetraetylammonium (K+ channel blockers) reverted the inhibition of amplitude of spontaneous contractions induced by genistein in longitudinal and circular smooth muscle. H-89 (protein kinase A inhibitor) antagonized the reduction of the amplitude of spontaneous contractions induced by quercetin in longitudinal and circular smooth muscle of duodenum, while 2,5-dideoxiadenosine (adenylyl cyclase inhibitor) reverted only the reduction of the amplitude in circular smooth muscle. In conclusion, genistein and quercetin reduce the spontaneous contractions in the duodenum by different mechanisms of actions. The effect of genistein would be mediated by Ca2+ and K+ channels, while the effect of quercetin would be mediated by cAMP and protein kinase A.

Los flavonoides son conocidos por relajar el músculo intestinal precontraído y retrasar el tránsito o la peristalsis intestinal. El objetivo de este estudio era determinar los efectos de la genisteína y quercetina sobre las contracciones espontáneas del duodeno de conejo in vitro en un baño de órganos. La genisteína o quercetina (0,1-10 µM) redujeron la amplitud de las contracciones espontáneas en el músculo liso longitudinal y circular de duodeno de conejo sin modificar la frecuencia. El Bay K8644 (activador del canal de Ca2+ tipo L), apamina, caribdotoxina y tetraetilamonio (inhibidores de los canales de K+) revertieron la inhibición de la amplitud de las contracciones espontáneas inducidas por la genisteína en el músculo longitudinal y circular. El H-89 (inhibidor de la proteína kinasa A) antagonizó la reducción inducida por la quercetina sobre la amplitud de las contracciones espontáneas del músculo longitudinal y circular de duodeno, mientras la 2,5-dideoxiadenosina (inhibidor de la adenil ciclasa) revertió solamente la reducción de la amplitud en el músculo circular. En conclusión, la genisteína y la quercetina reducen las contracciones espontáneas del duodeno por diferentes mecanismos de acción. El efecto de la genisteína actuaría sobre canales de Ca2+ y de K+, y el efecto de la quercetina actuaría sobre el AMPc y la proteína kinasa A.

Implicaciones de las variantes arteriales hepáticas durante la duodenopancreatectomía cefálica oncológica

Introduction: The anatomical variants of the hepatic artery may have important implications for pancreatic cancer surgery. The aim of our study is to compare the outcome following a pancreatoduodenectomy (PD) in patients with or without a variant hepatic artery arising from superior mesenteric artery. Material and methods: We reviewed 151 patients with periampullary tumoral pathology. All patients underwent oncological PD between January 2005 and February 2012. Our series was divided into two groups: Group A: Patients with a hepatic artery arising from superior mesenteric artery; and Group B: Patients without a hepatic artery arising from superior mesenteric artery. We expressed the results as mean ± standard deviation for continuous variables and percentages for qualitative variables. Statistical tests were considered significant if p < 0.05. Results: We identified 11 patients with a hepatic artery arising from superior mesenteric artery (7.3%). The most frequent variant was an aberrant right hepatic artery (n = 7), following by the accessory right hepatic artery (n = 2) and the common hepatic artery trunk arising from the superior mesenteric artery (n = 2). In 73% of cases the diagnosis of the variant was intraoperative. R0 resection was performed in all patients with a hepatic artery arising from superior mesenteric artery. There were no significant differences in the tumor resection margins and the incidence of postoperative complications. Conclusion: Oncological PD is feasible by the presence of a hepatic artery arising from superior mesenteric artery. The complexity of having it does not seem to influence in tumor resection margins, complications and survival.

Introducción: las variantes anatómicas de la arteria hepática pueden tener importantes implicaciones en la cirugía oncológica del páncreas. Nuestro objetivo es comparar los resultados tras un procedimiento de Whipple en pacientes con y sin presencia de una arteria hepática variante procedente de la arteria mesentérica superior. Material y métodos: estudio analítico observacional retrospectivo en el que hemos analizado 151 pacientes con patología tumoral periampular sometidos a una duodenopancreatectomía desde enero de 2005 hasta febrero de 2012. Diferenciamos entre 2 grupos: grupo A (variante de la arteria hepática) y grupo B (no evidencia de variante de la arteria hepática). Hemos expresado los resultados como la media ± desviación estándar para las variables continuas y porcentajes para las cualitativas. Los test estadísticos fueron considerados significativos si la p < 0,05. Resultados: hemos detectado 11 pacientes con anomalías de la arteria hepática (7,3%). La variante más frecuentemente fue la arteria hepática derecha aberrante (n = 7), seguida de la arteria hepática derecha accesoria (n = 2) y tronco de la arteria hepática común procedente de la arteria mesentérica superior (n = 2). En el 73% de los casos la detección de la variante arterial fue intraoperatoria. En todos los pacientes se realizó una resección R0. No se han apreciado diferencias significativas en los márgenes de resección tumoral, complicaciones, ni en la supervivencia. Conclusión: la cirugía oncológica de la región céfalo-pancreática en presencia de una variante de la artería hepática es factible. La complejidad que supone tener una variante anatómica de la arteria hepática no parece influir en los márgenes de resección tumoral, complicaciones o supervivencia.

The potential usefulness of human leukocyte antigen typing for celiac disease screening: a systematic review and meta-analysis

Background and aim: The presence of specific human leukocyte antigen-DQ2 and DQ8 seems to be necessary for celiac disease development, but the real contribution of its typing for screening is still uncertain. We aim to conduct a systematic review and meta-analysis of the diagnostic performance of human leukocyte antigen typing tests for celiac disease screening. Methods: Systematic review of published studies assessing accuracy of human leukocyte antigen DQ2 and DQ8 typing for the detection of celiac disease were selected. MEDLINE and EMBASE were searched from 1st January 2004 until 31st December 2013. Two independent researchers carried out selection and classification of studies, data extraction and analysis. Meta-analysis combining sensitivities, specificities and likelihood ratios of HLA-DQ2 and DQ8 for the diagnosis of celiac disease were carried out. Results: 6 studies including 1303 individuals were finally evaluated. Pooled sensitivity was 98% (95% confidence interval: 97-99). Overall specificity was 45% (95% confidence interval: 41-48). Regarding specificity, studies were heterogeneous and a subgroup analysis was done according to the type of population included. Overall negative likelihood ratio was 0.05 (0.03-0.09). Conclusions: Due to its great sensitivity and low negative likelihood ratio, human leukocyte antigen-DQ2/DQ8 typing would be an appropriate test for ruling out celiac disease in the general population suffering related symptoms, and even more in at risk population.

Cromoendoscopia submucosa: una técnica que remarca los epitelios, diferencia los componentes histológicos, y facilita y ofrece seguridad a la polipectomía de colon

Submucosal chromoendoscopy involves the injection of a solution containing a vital stain, usually indigo carmine, into the intestinal wall submucosal layer. This allows to: Better delimit and characterize the various epithelia present (colonic mucosa, adenoma, hyperplastic polyp, serrated polyp, small bowel mucosa); expose and delimit lesion implantation areas; cooperate in the lifting of resectable lesions; ensure section across the submucosal plane; identify intestinal wall structures; render complex polypectomy feasible; and facilitate the identification of perforations. The present paper offers information on the endoscopic technique for submucosal injection, solution preparation and concentration, and on the potential benefits it may provide for polypectomy or endocopic mucosal resection whether en block or piecemeal. This endoscopic technique simultaneously combines a diagnostic and a therapeutic aspect, since lesion lifting in association with better delimited contours may improve not only accuracy but also endoscopic resection safety and feasibility.

La cromoendoscopia submucosa consiste en la inyección de una solución que contiene un colorante vital, por lo general índigo carmín, en la capa submucosa de la pared del intestino. Con ello se consigue: delimitar y caracterizar mejor los diferentes epitelios (mucosa de colon, adenoma, pólipo hiperplásico, pólipo serrado o la mucosa del intestino delgado), exponer y delimitar la base de implantación de las lesiones, colaborar en la sobreelevación de una lesión extirpable, asegurar la sección por el plano submucoso, identificar las estructuras constituyentes de la pared intestinal, hacer factible una polipectomía compleja o facilitar la detección de una perforación. Este artículo ofrece información sobre la técnica endoscópica de la inyección submucosa, la composición de la solución, su concentración y las ventajas que puede ofrecer para realizar una polipectomía o una resección endoscópica mucosa en bloque o en fragmentos. Esta técnica endoscópica combina de forma simultánea una vertiente diagnóstica y otra terapéutica, pues la sobreelevación de la lesión, junto con la mejorar caracterización de los contornos de la misma, puede mejorar su definición y delimitación además de incrementar la seguridad y la viabilidad de la resección endoscópica.

Metástasis gástrica de un adenocarcinoma de endometrio

Coexistence of Kaposi sarcoma and gastric diffuse large B-cell lymphoma in a HIV-infected patient

Taenia saginata: descripción de un caso importado

Usefulness of magnifying endoscopy with narrow-band imaging for identification of early gastric cancer around an ulcer scar

Long segments of columnar-lined lower esophagus are not always metaplastic

The presence of columnar epithelium in the esophagus is associated with two conditions: Barrett's esophagus and heterotopic gastric mucosa. The former results from the metaplastic replacement of the normal distal squamous esophageal lining, is associated with gastroesophageal reflux and is a pre-neoplastic condition. The second is thought as a congenital condition, resulting from the incomplete squamous epithelialization of the esophagus during embryologic development. It is found mainly in the cervical esophagus. Histologically, Barrett's esophagus is composed of an admixture of cardiac mucosa, oxintocardiac mucosa and intestinal metaplasia. Most of heterotopic gastric mucosa consists of oxyntic mucosa where the mucosal glands are straight and composed of parietal and chief cells. There are few reports of heterotopic gastric mucosa in the lower esophagus, generally presenting as small islands. In the present report, a series of four cases of large lower esophageal heterotopic gastric mucosa is described. All patients were initially misdiagnosed with Barrett's esophagus and referred for surveillance. The correct diagnosis was based in endoscopic and histological features. In all, a circular tiny strip of squamous mucosa was observed at endoscopy between the lower end of the columnar-lined esophagus and the esophagogastric junction, defined as the proximal end of the gastric folds. Biopsy samples taken from the columnar-lined segments of the four patients showed pure oxyntic mucosa. When columnar-lined esophagus is observed in the distal esophagus not in continuity with gastric mucosa, the diagnosis of heterotopic gastric mucosa must be thought and confirmed histologically by the presence of pure oxyntic mucosa.

Braquiterapia endoluminal esofágica en el tratamiento del cáncer de esófago: descripción de la técnica, a propósito de un caso y revisión de la literatura

Endoesophageal brachytherapy is a useful technique for the palliative treatment of dysphagia in advanced oesophageal cancer. This technique offers good results on dysphagia control and quality of life. We report the case of a patient treated with this technique presenting complete response to the dysphagia. We describe endoesophageal brachyterapy technique and we comment on the literature.

La braquiterapia endoesofágica es una técnica útil en el tratamiento paliativo de la disfagia secundaria al cáncer de esófago avanzado. Ofrece buenos resultados en cuanto a control de la disfagia y calidad de vida. Presentamos el caso de una paciente con cáncer de esófago avanzado con resolución completa de su disfagia después de dicho tratamiento. Describimos la técnica y resultados de la literatura.

Fármacos biológicos en la enfermedad inflamatoria intestinal: indicación y cuidados

Gastritis enfisematosa con gas venoso portal: tratamiento conservador en abdomen agudo de causa infrecuente

Pneumoperitoneo tras TAC-colonoscopia en paciente con colitis ulcerosa

Leiomyosarcoma of the inferior vena cava: feasibility of surgical resection. a report of two cases

Colangitis aguda como presentación de un hepatocarcinoma con trombosis tumoral de la vía biliar

Apendicitis de muñón: ¿una realidad infravalorada?

Gastroesophageal reflux disease and dental erosion correlation: a new theory from ancient time

Encuesta sobre el uso de la cápsula endoscópica para pacientes con sospecha o diagnóstico de enfermedad de Crohn en España

Disfagia baja como forma de presentación de un quiste de duplicación de cardias