Revista Española de Enfermedades Digestivas

Disruptive therapeutic innovation and the opportunity to eliminate a chronic disease: the issue of chronic hepatitis C in Spain

Value and innovation of direct-acting antivirals: long-term health outcomes of the strategic plan for the management of hepatitis C in Spain

Objective: To assess the long-term healthcare costs and health outcomes in association with the access to new direct-acting antivirals (DAAs), during the first year of the National Strategic Plan for Chronic Hepatitis C (SPCHC) in patients with chronic hepatitis C (CHC) in Spain. Methods: A decision tree and a lifetime Markov model were developed to simulate the natural history, morbidity, and mortality of a cohort of 51,900 patients with CHC before (pre-DAA strategy) and after (post-DAA strategy) access to DAAs, following SPCHC approval. The percentage of patients treated, transition probabilities, disease management costs, health state utility values, sustained virologic response rates and treatment costs were obtained from the literature and published data from Spain. The results were expressed in terms of costs (€, 2016), quality-adjusted life years (QALYs) and prevention of clinical events, with an annual discount rate of 3%. Results: The post-DAA strategy would prevent 8,667 cases of decompensated cirrhosis, 5,471 cases of hepatocellular carcinoma, 1,137 liver transplants and 9,608 liver-related deaths. The cohort of 51,900 patients would require investments of 1,606 and 1,230 million euros with the post-DAA and pre-DAA strategies, respectively. This would produce 819,674 and 665,703 QALYs. Conclusions: The use of new DAA-based treatments in CHC patients during the first year after the implementation of the SPCHC significantly reduced long-term morbidity and mortality and increased quality of life; demonstrating that this plan is an efficient use of public health resources.

Methylation status of the estrogen receptor 1 promoter predicts poor prognosis of acute-on-chronic hepatitis B liver failure

Background: Acute-on-chronic hepatitis B liver failure (ACHBLF) is an acute deteriorating liver disease and rapidly progresses to multiple organ failure. There is currently no adequate accurate predictive models of ACHBLF prognosis. Aims: To identify the methylation frequency of the estrogen receptor 1 (ESR1) promoter in ACHBLF and analyze the associated prognostic significance. Methods: Methylation-specific PCR (MSP) was used to determine the methylation frequency of the ESR1 promoter in peripheral blood mononuclear cells from a training and validation cohort of patients. The training cohort included 113 patients with ACHBLF, 73 with chronic hepatitis B (CHB) and 40 healthy controls (HCs). The validation cohort consisted of 37 patients with ACHBLF. Another 18 patients with pre-ACHBLF who progressed to ACHBLF were used to dynamically evaluate ESR1 promoter methylation changes associated with a severe clinical condition. Results: Death from ACHBLF was associated with hyperbilirubinemia, a higher score in the model for end-stage liver disease (MELD), a higher incidence of hepatic encephalopathy (HE) and an increased frequency of ESR1 promoter methylation during the 28 day follow-up. HE, MELD score and ESR1 promoter methylation were the independent risk factors associated with 28-day mortality from ACHBLF. The frequency of ESR1 promoter methylation was significantly higher than in patients with CHB and HCs. Albumin and the MELD score were significantly associated with ESR1 promoter methylation. Moreover, ESR1 promoter methylation frequency increased with ACHBLF progression. More importantly, ESR1 promoter methylation was an independent risk factor and had a high value to predict 28-day mortality from ACHBLF. Conclusions: Abnormal ESR1 methylation could be a prognostic biomarker for ACHBLF.

Can we rely on inflammatory biomarkers for the diagnosis and monitoring Crohn's disease activity?

Background: Small bowel capsule endoscopy (SBCE) is a very important tool in the diagnosis and monitoring of Crohn's disease (CD). The Lewis score (LS) and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) are used to quantify and standardize inflammatory activity observed in the SBCE. Aim: To evaluate the correlation between the LS and CECDAI scores and inflammation biomarkers (C-reactive protein [CRP] and erythrocyte sedimentation rate [ESR]). A secondary goal was to define thresholds for CECDAI based on thresholds already established for LS. Methods: This was a retrospective study of 110 patients with suspect or known CD, with involvement of small bowel. Linear regression was used to calculate thresholds of CECDAI corresponding to the thresholds already established for LS. A Pearson correlation (r) was used to calculate the correlation between the LS and CECDAI scores and biomarker levels. Only patients with exclusive involvement of the small bowel were selected (n = 78). Results: A moderate correlation was found between the endoscopic scores (r = 0.59, p < 0.001). CECDAI scores of 5.57 and 7.53 corresponded to scores of 135 and 790 in LS, respectively. There was a statistically significant correlation between CRP and the LS (r = 0.28, p = 0.014) and CECDAI (r = 0.29, p = 0.009). There was also a significant correlation between ESR and CECDAI (r = 0.29, p = 0.019), but not with LS. Conclusion: There is a moderate correlation between the two scores. This study allowed the calculation of thresholds for CECDAI based on those defined for LS. We found a weak correlation between SBCE endoscopic activity and inflammatory biomarkers.

Enteral nutrition is associated with a decreased risk of surgical intervention in Crohn's disease patients with spontaneous intra-abdominal abscess

Background: The impact of enteral nutrition (EN) on surgical risk in Crohn's disease (CD) patients suffering from spontaneous intra-abdominal abscess (IAA) was evaluated. Methods: CD patients diagnosed with spontaneous IAA from 2008 to 2015 were included in the study. The impact of EN on surgical risk was evaluated using both univariate and multivariate analyses. Results: A total of 87 patients were enrolled, 66 (75.9%) were male. The mean age at the development of an abscess was 30.2 ± 10.1 years and the median duration of illness from CD diagnosis until the development of an abscess was three (2-6) years. After a median follow-up of 1.9 (1.1-2.9) years, surgical intervention was performed in 42 patients (48.3%). Patients treated with EN were less likely to require surgical intervention (26.1% vs 56.3%, p = 0.01). Multivariate analysis showed that EN was an independent protective factor for the risk of surgery with a hazard ratio of 0.27 (95% confidence interval: 0.11-0.65, p = 0.004) after adjusting for abdominal pain, history of abdominal surgery, concomitant intestinal stenosis and prior use of antibiotics within three months. Conclusions: Surgical intervention is common for CD patients with IAA. Appropriate application of EN may help obviate the need for surgical treatment.

Hepatopulmonary syndrome: which blood gas analysis criteria and position should we use for diagnosis?

Introduction: Different blood gas criteria have been used in the diagnosis of hepatopulmonary syndrome (HPS). Patients and methods: Arterial blood gases were prospectively evaluated in 194 cirrhotic candidates for liver transplantation (LT) in the supine and seated position. Three blood gas criteria were analyzed: classic (partial pressure of oxygen [PaO2] < 70 mmHg and/or alveolar-arterial gradient of oxygen [A-a PO2] ≥ 20 mmHg), modern (A-a PO2 ≥ 15 mmHg or ≥ 20 mmHg in patients over 64) and the A-a PO2 ≥ threshold value adjusted for age. Results: The prevalence of HPS in the supine and seated position was 27.8% and 23.2% (classic), 34% and 25.3% (modern) and 22.2% and 19% (adjusted for age), respectively. The proportion of severe and very severe cases increased in a seated position (11/49 [22.4%] vs 5/66 [7.6%], p = 0.02). No difference was observed in the pre-LT, post-LT and overall mortality in patients with HPS, regardless of the criteria used. Conclusion: Obtaining blood gas measurements in the supine position and the use of modern criteria are more sensitive for the diagnosis of HPS. Blood gas analysis with the patient seated detects a greater number of severe and very severe cases. The presence of HPS was not associated with an increase in mortality regardless of blood gas criterion used.

Comparison of esophageal motility in gastroesophageal reflux disease with and without globus sensation

Backgrounds and aims: This study aimed to compare the esophageal motility between gastroesophageal reflux disease (GERD) patients with typical symptoms but without globus sensation and GERD patients only with globus symptoms. Methods: A total of 57 consecutive GERD patients diagnosed by endoscopy or by 24-hour pH monitoring between May 2013 and September 2015 were included retrospectively into the study. The patients were grouped based on the presence or absence of globus. Thirty patients presented with typical reflux symptoms but without globus were assigned to the typical GERD group and 27 patients only with globus symptom were assigned to the globus GERD group. All patients underwent esophageal high resolution manometry (HRM) and the differences in esophageal motility between the two groups were analyzed. Results: The globus GERD group showed a significantly greater lower esophageal sphincter (LES) length, LES basal pressure and upper esophageal sphincter (UES) residual pressure than that of the typical GERD group (3.47 ± 0.76 vs 2.65 ± 0.62 cm, 21.71 ± 9.68 vs 16.04 ± 8.49 mmHg, 7.30 ± 4.42 vs 4.12 ± 2.92 mmHg, all p < 0.05). There was no significant difference between the two groups in terms of the distal wave amplitude, mean wave duration, distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL), integrated relaxation pressure (IRP) and UES basal pressure. The incidence of esophageal dysmotility in the globus GERD group (33.3%) was higher than in the typical GERD group (23.3%). There was no significant difference in esophageal acid exposure of the non-erosive gastroesophageal reflux disease (NERD) patients between the two groups. Conclusions: Globus GERD patients have a higher UES residual pressure, longer LES length, higher LES basal pressure and greater esophageal dysmotility than typical GERD patients. HRM is useful in evaluating esophageal motility of GERD patients.

Aspectos diagnósticos y terapéuticos de la afectación del intestino delgado en la hipertensión portal

Enteropathy is a lesser known complication of portal hypertension and consists of different changes in the mucosal layer of the small bowel which lead to the appearance of vascular and inflammatory lesions. It can be an important co-factor in the development of anemia in the cirrhotic population, and nowadays an easy and non-invasive diagnosis can be made thanks to capsule endoscopy. However, it is rarely considered in the management of patients with portal hypertension. Some aspects such as pathogenesis or incidence remain unclear and no specific recommendations are included in the guidelines regarding diagnosis or treatment. A review of the available literature was performed with regards to the most relevant aspects of this entity.

La enteropatía es la menos conocida de entre las complicaciones de la hipertensión portal y consiste en una serie de cambios en la mucosa del intestino delgado que dan lugar a la aparición de lesiones vasculares e inflamatorias sobre la misma. Aunque puede ser un cofactor importante en la anemia de la población cirrótica, y a pesar de que en la actualidad es posible realizar un diagnóstico de la misma de modo simple y no invasivo gracias a los estudios de cápsula endoscópica, es rara vez tenida en consideración en el manejo de los pacientes con hipertensión portal. Aspectos como su patogenia o su incidencia real siguen sin ser aclarados, y tampoco existen consenso ni recomendaciones en las guías de práctica clínica sobre su diagnóstico o tratamiento. Se ha realizado una revisión narrativa de la literatura disponible sobre los aspectos más importantes de esta entidad.

Immune mediated colitis caused by lung cancer treatment with atezolizumab

A bull horn fragment found on colonoscopy

Complete tubular colonic duplication in an adult: a rare incidental finding and the risk of colonoscopic perforation

Localized gastrointestinal amyloidosis presenting with protein-losing enteropathy and massive hemorrhage

Amyloidosis of the gastrointestinal tract is usually a systemic disease. Localized gastrointestinal amyloidosis without evidence of extraintestinal involvement or an associated plasma cell dyscrasia is uncommon and does not usually cause death. We report a case of a patient with localized gastrointestinal amyloidosis who presented with protein-losing enteropathy and a fatal upper gastrointestinal bleed.

Pseudotumor gástrico ulcerado con afectación pancreática por enfermedad relacionada con inmunoglobulina G4: descripción de un caso y revisión de la literatura

We report the case of a 67 year old male who presented with a nine year history of a gastric ulcer with symptoms of hematemesis and melena. Histological analysis identified fibrotic lesions and the accumulation of immunoglobulin G4-positive plasma cells with no evidence of malignancy. The lesion extended into the pancreas, where histological lesions and gastric lesions were also observed. This is a case of an ulcerated gastric ulcer and pseudo-tumor with pancreatic affection that is associated with immunoglobulin G4-related disease.

Presentamos el caso de un varón de 67 años con una úlcera gástrica de 9 años de evolución, con clínica de hematemesis y melenas, que a nivel histológico mostró lesiones de fibrosis y acúmulos de células plasmáticas con positividad para inmunoglobulina G4, sin evidencia de malignidad. Esta lesión alcanzaba al páncreas, donde se observaron lesiones histológicas superponibles a las gástricas. El diagnóstico final fue el de pseudotumor gástrico ulcerado con afectación pancreática por enfermedad relacionada con inmunoglobulina G4.

Chemoprevention of polyp recurrence with curcumin followed by silibinin in a case of multiple colorectal adenomas

Posicionamiento de GETTEMO sobre las técnicas endoscópicas bariátricas consideradas como medicina satisfactiva

Hemorragia digestiva alta masiva secundaria a lesión de Dieulafoy oculta en un divertículo duodenal

Dilatación gástrica aguda tras transgresión dietética

A rare cause of upper gastrointestinal bleeding in a patient with end stage renal disease: gastric amyloidosis

Real time visualization may be advisable to exclude aspiration in patients undergoing capsule endoscopy examination