Revista Española de Enfermedades Digestivas

Adult celiac disease: a common, significant health problem worldwide

Coeliac disease: clinical features in adult populations

Introduction: coeliac disease (CD) is a chronic disease of the small intestine, which is caused by gluten intolerance, producing malabsorption of nutrients and vitamins. Clinical manifestations of CD in adults are highly variable, including intestinal and extra-intestinal symptoms. The disease may also occur in individuals who are asymptomatic. Objective: our objective is to describe the incidence and clinical manifestations of CD in adults. Material and methods: a retrospective study was carried out in patients diagnosed of CD between January 1990 and December 2008. Diagnosis was based on serologic tests and duodenal biopsy, which were compatible with CD in all of them. Results: sixty eight adult patients were diagnosed of CD in this period. Mean age was 33 (18-65) years and 50 (74%) were women. The clinical manifestations were diarrhoea in 38 (55%), abdominal pain in 27 (40%), loss of weight in 15 (22%), dyspepsia in 13 (19%). Analytical results showed a slight increase of transaminases in 26 (38%), ferropenic anaemia in 33 (48.5%) cases, sub-clinical hypothyroidism in 3 (4.5%) patients, and folic acid deficiency in 16 (23.5%) cases. Almost all patients were diagnosed between 2000 and 2008: 60 (87%). Population-based incidence of CD in adults had increased from 0.7-2/100,000 per year in the nineties to 3.5-10.3/100,000 in the last years. Conclusions: CD can appear at any age and with a wide manifestation spectrum, which can be atypical in some cases. Patients with ferropenic anaemia and a negative response to treatment or those with an unexplained increase in transaminases should be screening for CD. Atypical manifestations and low suspect index can delay diagnosis even during years. There is a marked increase in the incidence-rates of CD in adults over time.

Introducción: la enfermedad celiaca (EC) es una enfermedad crónica que afecta al intestino delgado, causada por intolerancia al gluten cuyas manifestaciones clínicas son muy variables incluyendo síntomas extraintestinales y formas asintomáticas. Objetivo: nuestro objetivo es describir la incidencia y manifestaciones clínicas de la EC del adulto. Métodos: estudio retrospectivo de los pacientes mayores de 18 años diagnosticados de EC entre enero-1990 y diciembre-2008 mediante test serológicos y biopsia duodenal. Resultados: se incluyeron 68 pacientes con una mediana de edad de 33 años (18-65); 50 (74%) mujeres. Las manifestaciones clínicas fueron: diarrea en 38 (55%), dolor abdominal en 27 (40%), pérdida de peso en 15 (22%), dispepsia en 13 (19%) y 3 dermatitis herpetiforme. Los principales datos analíticos fueron: aumento de transaminasas en 26 (38%), anemia ferropénica en 33 (48,5%), hipotiroidismo subclínico en 3 (4,5%) y déficit de ácido fólico en 16 (23,5%) casos. Casi todos los pacientes han sido diagnosticados entre los años 2000 y 2008: 60 (87%). La incidencia de EC en adultos ha aumentado desde 0,7-2/100.000 habitantes por año en la década de los 90 hasta 10,3/100.000 habitantes por año en 2008. Conclusiones: la EC puede aparecer a cualquier edad con un amplio espectro de manifestaciones clínicas, las cuales pueden ser atípicas en muchos casos. En aquellos pacientes con anemia ferropénica y respuesta negativa al tratamiento o con elevación inexplicable de transaminasas se debe realizar cribado para EC. Las manifestaciones atípicas y un bajo índice de sospecha, pueden retrasar el diagnóstico durante años. Existe un aumento marcado en la incidencia de EC en los adultos en los últimos años.

Coeliac disease in China: a field waiting for exploration

Background: no systematic studies on the prevalence of coeliac disease (CD) have been reported from China. In western populations CD is more common in patients with insulin dependent diabetes mellitus (IDDM) and in diarrhoea-predominant irritable bowel syndrome (D-IBS). We have screened patients with these conditions presenting to the outpatient department of a large hospital of "Traditional Chinese Medicine" (TCM) in Nanjing, Jiangsu province, P.R. China. Methods: we tested sera of 78 unrelated Han Chinese patients (5 IDDM and 73 D-IBS), using ELISA serological tests for IgG anti-gliadin antibodies (IgG-AGA) and IgA anti-tissue transglutaminase antibodies (IgA-tTG). Results: six out of 78 patients (7.7%) were positive for IgG-AGA (two men and four women) and two (2.6%) were positive for IgA-tTGs. One of the latter patients was negative for IgG-AGA. Besides, one patient had a dubious IgA-tTG antibody and a positive IgG-AGA. None of the six patients agreed to undergo duodenal biopsy. Two out of these six patients followed a gluten-free diet for one year. In one patient the diarrhoea ceased and his body weight increased. Another stopped losing weight. Conclusions: this study previously published as a letter in GUT (Wu J, Xia B, von Blomberg BME, Zhao C, Yang XW, Crusius JBA, Peña AS. Coeliac disease: emerging in China? Gut 2010; 59(3): 418-9) demonstrated that CD may exist in the Jiangsu province of P.R. China. The present article draws attention to the difficulties of following a standard protocol in China such as established in western countries and highlights important factors less well known in the west in relation to the development of CD in China. Wheat production became significant in China between 1600 and 1300 B.C. After the Han dynasty (500-200 B.C.), wheat was one of the main cereals in China. One the major wheat fields in China is located in the Jiangsu province where the research for this article was performed. A review of Chinese literature shows that the predominant HLA-DQ CD risk alleles and haplotypes are present in the Jiangsu province. Genetic background, food consumption, and the results of our study suggest that CD should actively be investigated in P.R. China.

Usefulness of colonoscopy in ischemic colitis

Background: the ischemic colitis is intestinal the most frequent cause of ischemia. With this work we determine the demographic and clinical characteristics, and the usefulness of the colonoscopy in the patients with ischemic colitis diagnosed in our centre in relation to a change of therapeutic attitude. Method: retrospective study in which were selected 112 patients diagnosed with ischemic colitis by colonoscopy and biopsy, in a period of five years. It was analyzed: age, sex, reason for examination, factors of cardiovascular risk, endoscopic degree of ischemia, change in the therapeutic attitude, treatment and outcome. Results: the average age was of 73.64 ± 12.10 years with an equal incidence in women (50.9%) and the men (49.1%). The associated factors were the HTA (61.1%), tobacco (37.2%) and antecedents of cardiovascular episode (52.2%). The most frequent reason for colonoscopy was rectorrhagia (53.6%) followed of the abdominal pain (30.4%), being urgent the 65.3%. Colonoscopy allowed a change in the therapeutic attitude in the 50 increasing in the urgent one to the 65.75%. Global mortality was of 27.67%. The serious ischemic colitis (25%) was more frequent in men (64.3%) in urgent indication (85.71%) and attends with high mortality (53.57%). Surgical treatment in the 57.14% was made with a good evolution in the 50%, whereas the patients with mild or moderate ischemic colitis had a better prognosis (favourable evolution in 80.95%) with smaller requirement of the surgical treatment (4.76%), p < 0.05. Conclusion: the colitis ischemic are more frequent in the older age. The most frequent symptoms are the rectorrhagia and the abdominal pain. The colonoscopy is a useful technique to evaluate the gravity and it induces a change of attitude according to the result of the same one. The evidence of a serious colitis supposed an increase of the necessity of surgery and worse prognosis.

Introducción: la colitis isquémica es la causa más frecuente de isquemia intestinal. Realizamos un estudio con el objetivo de analizar las características demográficas, clínicas y la utilidad de la colonoscopia en los pacientes diagnosticados de colitis isquémica en nuestro centro en relación a un cambio de actitud terapéutica. Método: estudio retrospectivo en el que se seleccionaron 112 pacientes diagnosticados de colitis isquémica mediante colonoscopia y biopsia, en un periodo de tiempo de cinco años. Se analizaron: edad, sexo, motivo de exploración, factores de riesgo cardiovascular, grado endoscópico de isquemia, cambio en la actitud terapéutica, tratamiento y evolución. Resultados: la edad media de nuestros pacientes fue de 73,6 ± 12,1 años con una incidencia similar en ambos sexos (50,9% mujeres y 49,1% hombres). Los factores de riesgo asociados fueron la hipertensión arterial (61,1%), el tabaco (37,2%) y antecedente de accidente cardiovascular previo (52,2%). El motivo más frecuente de realización de colonoscopia fue rectorragia (53,6%) seguido de dolor abdominal (30,4%), realizándose de forma urgente en el 65,3% de los casos. La colonoscopia permitió un cambio en la actitud terapéutica en el 50% de los casos, aumentando en la urgente al 65,75%. La mortalidad global fue del 27,67%. La colitis isquémica grave (25%) fue más frecuente en varones (64,3%), y cuando la indicación de colonoscopia fue urgente (85,71%) y cursó con mortalidad alta (53,57%). En estos se realizó tratamiento quirúrgico en el 57,14% de los casos con una evolución favorable en el 50%, mientras que los pacientes con colitis isquémica leve o moderada tuvieron un pronóstico mejor, con evolución favorable en el 80,95% de los casos y con menor requerimiento de tratamiento quirúrgico (4,76%, p < 0,05). Conclusión: la colitis isquémica es más frecuente en la edad avanzada. La sintomatología más común es la rectorragia y el dolor abdominal. La colonoscopia permite evaluar la gravedad e induce un cambio de actitud según el resultado de la misma. La evidencia de una colitis grave supuso un aumento de la necesidad de cirugía y peor pronóstico.

Are hepatocellular carcinoma surveillance programs effective at improving the therapeutic options?: ¿mejoran las opciones terapéuticas de estos pacientes?

Aim: to evaluate whether the current surveillance programs (ultrasonography and alpha-fetoprotein testing every six months) are successful in detecting patients in the early stages. Material and methods: the health records of all patients diagnosed with hepatocellular carcinoma in Donostia Hospital between 2003 and 2005 were reviewed retrospectively. Eighty-five patients (11 women and 74 men) were included in the study and demographic data, risk factors and clinical data were obtained. Patients were split into two groups according to whether or not they had been included in a surveillance program. Results: seventy per cent of patients of the surveillance group is diagnosed in early stage opposite to 26.7% of patients in no surveillance group (p < 0.05). Thirteen patients cannot receive curative treatment in spite of the diagnosis in early stage (9 in the surveillance group and 4 in the no surveillance group. The global sensibility of the surveillance program in our series is 95%. Conclusions: current hepatocellular carcinoma surveillance programs, which comprise six-monthly ultrasonography and alpha-fetoprotein tests, are highly sensitive and effective. These programs result in the detection of hepatocellular carcinoma in its early-stages, when potentially curative treatment may be offered.

Objetivo: determinar si la utilización en nuestro medio del programa de cribado de HCC establecido -alfa-fetoproteína (AFP) y ecografia semestral- en pacientes con hepatopatía crónica permite detectar pacientes en estadios precoces de la enfermedad. Material y métodos: Diseño experimental: estudio retrospectivo. Criterios diagnósticos de HCC: 2 o más técnicas de imagen con lesión hipervascular mayor de 2 cm o 1 técnica de imagen con lesión hipervascular mayor de 2 cm asociado a AFP mayor de 400 ng/ml. Pacientes: 85 pacientes diagnosticados de HCC en el Hospital Donostia entre los años 2003 y 2005. Datos analizados: información demográfica (sexo, edad), factores de riesgo (alcohol, virus de hepatitis, hemocromatosis, otras enfermedades asociadas), e información clínica (etiología de la hepatopatía, estadio de Child-Pugh, determinación de AFP, hallazgos radiológicos, criterios de resecabilidad, tratamiento recibido, evolución). Se divide la muestra en dos grupos según hubieran seguido o no un programa de cribado. Resultados: el 70% de los pacientes del grupo de cribado se diagnostican en estadio precoz frente al 26,7% del grupo de no cribado (p < 0,05). Trece pacientes no pueden recibir tratamiento curativo a pesar del diagnóstico en fase precoz (9 en el grupo de cribado y 4 en el de no cribado). La sensibilidad global del cribado en nuestra serie es del 95%. Conclusiones: en nuestro medio, el programa de cribado de hepatocarcinoma es eficaz en términos de aplicación de tratamientos curativos.

Multiple non-metastatic gastrointestinal stromal tumors: Differential features

Introduction: gastrointestinal stromal tumors (GISTs) are specific, generally KIT (CD117)-positive, mesenchymal tumors of the digestive tract displaying KIT or PDGFRA gene mutations. Clinically, they tend to present as solitary tumors of the intestinal wall; more rarely, multiple tumors may occur in one or more organs. Objective: to review the morphological, immunohistochemical and molecular features of multiple, non-metastatic forms of GIST. Sources: review of the literature on Medline, and authors' own experience. Conclusions: multiples GISTs may occur in three different contexts: as spontaneous lesions (in both adults and children); due to familial GIST syndrome (autosomal dominant inheritance); or in association with specific syndromes (e.g. Carney's triad, Carney-Stratakis syndrome, type I neurofibromatosis). Outside these contexts, the existence of multiple GISTs is deemed to be the result of tumor metastasis, and therefore indicative of advanced-stage disease. Clinicians need to be aware of these variants, whose prognosis and treatment differ.

Introducción: los tumores del estroma gastrointestinal (GIST) son neoplasias mesenquimales del tubo digestivo que generalmente expresan el receptor KIT (CD117) y muestran mutaciones en los genes KIT o PDGFRA. Aunque la forma de presentación clínica habitual es como una neoplasia mural solitaria, excepcionalmente pueden presentarse formas múltiples en el mismo o diferente órgano. Objetivo: revisar las características morfológicas, inmunohistoquímicas y moleculares de las formas de GIST múltiples no metastásicos. Fuentes: revisión de la literatura en Medline y la propia experiencia. Conclusiones: los GIST múltiples pueden presentarse en tres contextos diferentes: lesiones espontáneas (del adulto o de la edad infantil); síndrome familiar propio (transmitido con herencia autosómica dominante); y lesiones asociadas a síndromes específicos (tríada de Carney, síndrome de Carney-Stratakis, y neurofibromatosis tipo I). Fuera de estos ámbitos, se interpreta que todo GIST múltiple es el resultado de siembras tumorales metastásicas y, por tanto, corresponde a enfermedad avanzada. Estas variantes deben ser conocidas por el clínico dado las connotaciones pronósticas y terapéuticas que ello conlleva.

Primary omental infarction as cause of non-surgical acute abdomen: imaging diagnose

Appendagitis in post-laparotomy hernia

Adenocarcinoma de recto y ano en paciente con enfermedad de Crohn tratado con infliximab

In the present paper, we report the case of a patient with long-standing Crohn´s disease and multiple complications that, after receiving treatment with infliximab, was diagnosed with an adenocarcinoma of the rectum and anus that required radical surgery, later presenting multiple metastases. In the discussion, characteristics and major risk factors for colorectal cancer in patients with inflammatory bowel disease will be largely reviewed, and current studies will be analyzed in connection with the appearance of neoplasms in patients being treated with biologics.

Presentamos el caso de un paciente con enfermedad de Crohn de larga evolución y con múltiples complicaciones de su enfermedad que, tras recibir tratamiento con infliximab, es diagnosticado de un adenocarcinoma de recto y ano que precisa cirugía radical, presentando posteriormente metástasis múltiples. Se repasarán durante la discusión las características y los factores de riesgo más importantes del cáncer colorrectal en pacientes con enfermedad inflamatoria intestinal, y se analizarán los trabajos existentes hasta la fecha en relación con la aparición de neoplasias en pacientes tratados con fármacos biológicos.

Liver diseases in pregnancy

Littré´s hernia: unusual find in inguino-scrotal hernial repair

Multifocal hepatic inflammatory pseudotumor: spontaneous regression in a diabetic patient

**Is Helicobacter pylori active infection increased or decreased in Crohn´s disease?**

Metastatic gastric adenocarcinoma with microangiopathic hemolytic anemia

Gastrointestinal metastasis from poorly differentiated neuroendocrine carcinoma

On time to veto the use of the word "appendagitis"?