Revista Española de Enfermedades Digestivas

Hepatitis C virus: five-year follow-up of patients with sustained virological response

Five-year follow-up of patients with chronic C hepatitis and sustained virological response

Objective: to assess persistence of sustained viral response at 5 years of follow-up in patients with chronic viral hepatitis C treated with pegylated interferon and ribavirin. Design: a descriptive study. Patients: from August 2001 to May 2004, all patients treated at our center with pegylated interferon and ribavirin who achieved a sustained viral response were consecutively enrolled (93 patients). Demographic, histological, biochemical, and virological data were collected during treatment and 5 years after achievement of the sustained viral response. Eighty-six percent of patients enrolled (n = 80) attended the control visit at 5 years. Results: mean age of enrolled patients was 41 years (standard deviation = 10 years), and 30.1% (n = 28) were women. Liver biopsy had been performed before treatment in 68.8% of patients (n = 64), showing no or mild fibrosis in 62.3% (F0 and F1) and significant fibrosis and cirrhosis in 37.7% (F ≥ 3). Genotype distribution was: 58.1% genotype 1 (n = 54); 8.6% genotype 2 (n = 8); 24.7% genotype 3 (n = 23); 7.5% genotype 4 (n = 7), and indeterminate in one patient. Only one patient experienced virological recurrence. All other patients had negative HCV RNA levels and, in the absence of other liver diseases, normal ALT levels. Conclusion: in patients treated with pegylated interferon and ribavirin with sustained viral response, long-term recurrence rate was very low.

Objetivo: evaluar la persistencia de respuesta viral sostenida a los 5 años de seguimiento en pacientes con hepatitis crónica por virus C tratados con interferón pegilado y ribavirina. Diseño: estudio descriptivo. Pacientes: desde agosto de 2001 hasta mayo de 2004, se incluyeron de forma consecutiva todos los pacientes de nuestro centro tratados con interferón pegilado y ribavirina que alcanzaron respuesta viral sostenida (93 pacientes). Se recogieron datos demográficos, histológicos, bioquímicos y virológicos durante el tratamiento y a los 5 años de haber obtenido la respuesta viral sostenida. Se presentaron a la visita de control a los 5 años un 86% de los pacientes incluidos (n = 80). Resultados: los pacientes incluidos presentaron una edad media de 41 años (desviación estándar = 10 años); mujeres 30,1% (n = 28). En el 68,8% de los pacientes (n=64) se había realizado biopsia hepática previa al tratamiento, que mostraba ausencia de fibrosis o fibrosis leve en un 62,3% (F0 y F1) y fibrosis significativa o cirrosis en un 37,7% (F≥3). La distribución por genotipos fue: 58,1% genotipo 1 (n = 54); 8,6% genotipo 2 (n = 8); 24,7% genotipo 3 (n = 23); 7,5% genotipo 4 (n = 7) e indeterminado en un caso. Sólo uno de los pacientes presentó recurrencia virológica. El resto de pacientes presentaron niveles de ARN-VHC negativo y, en ausencia de otra hepatopatía, niveles de ALT normales. Conclusión: en pacientes tratados con interferón pegilado y ribavirina con respuesta viral sostenida la tasa de recurrencia a largo plazo es muy baja.

Impact of endoscopic ultrasonography on the management of a prospective cohort of 700 consecutive patients referred for diagnostic endoscopic ultrasonography

Background: endoscopic ultrasonography (EUS) is a high accuracy technique for the study of many digestive diseases. The degree of knowledge about the impact of EUS on the management of these patients is inadequate. Aim: to determine the therapeutic impact of endoscopic ultrasonography (EUS) on a prospective cohort of patients. Methods: all patients referred for EUS over a period of 2 years were prospectively evaluated in order to asses: 1. EUS provides new information not previously known; 2. theoretic impact of EUS on patient management; 3. real impact of EUS on final therapy; 4. changes in the aggressiveness of the therapeutic decision after EUS. Results: 700 patients were included. Preoperative assessment of digestive tumors was the commonest indication. EUS provided "new information" in the 89% of the patients. With regard to endoscopist opinion, these findings should alter the management in 79% of patients ("theoretic impact"). However, EUS prompted a change in the management in 67% of patients ("real impact"). Final therapy post-EUS was less aggressive in 34% of patients. Changes in therapeutic decision were associated with EUS findings, alcohol intake and age ≥ 57 years old. Conclusions: 1) EUS findings, advanced age, and alcohol intake are associated with a change in the management in 2 out of every 3 patients referred for EUS. 2) Therapeutic decision (post-EUS) is less aggressive in a third of these patients, what should represent a significant economic saving.

Antecedentes: la ultrasonografía endoscópica (USE) es una técnica de gran precisión para el estudio de diferentes patologías digestivas. El grado de conocimiento sobre el impacto de la USE en el tratamiento de estos pacientes es escaso. Objetivo: determinar el impacto terapéutico de la USE en una cohorte prospectiva de pacientes. Material y métodos: estudio que evalúa de forma prospectiva a todos los pacientes remitidos para USE en un periodo de 2 años. Se analiza: a) si la USE aporta información no conocida previamente; b) el impacto teórico de la USE en el tratamiento; c) el impacto final/real de USE en el tratamiento; d) la variación en la decisión terapéutica tras realizar la USE. Resultados: se incluyeron 700 pacientes. La indicación más frecuente de USE era el estudio preoperatorio de tumores digestivos. La USE aportó "información nueva" en el 89% de los casos. En opinión del ecoendoscopista estos hallazgos deberían suponer un cambio terapéutico en el 79% de los pacientes ("impacto teórico"). Sin embargo, el tratamiento sólo se modificó en el 67% de los casos ("impacto real"). La estrategia terapéutica post-USE fue menos agresiva en el 34% de los casos. Los cambios en la actitud terapéutica se asociaban con los hallazgos de USE, ingesta de alcohol y edad > 57 años. Conclusiones: - Los hallazgos de la USE, la edad avanzada y el consumo de alcohol, se asocian con un cambio terapéutico en 2 de cada 3 pacientes remitidos a una unidad de USE. - La decisión terapéutica final (post-USE) es menos agresiva en un tercio de estos pacientes, lo que podría representar un ahorro económico significativo.

PillCam^© Colon Capsule for the study of colonic pathology in clinical practice: Study of agreement with colonoscopy

Introduction: several studies have pointed out the effectiveness of the PillCam© colon capsule endoscopy (CCE) compared with the colonoscopy in the study of the colonic pathology. Aims and methods: the objective of our study was to assess the agreement in the diagnosis of CCE with conventional colonoscopy as well as its sensitivity and specificity, and to describe the findings of the CCE in our clinical practice. Consecutive patients with abdominal symptoms were included in the study. The CCE was performed as previously reported (with PEG and sodium phosphate as laxative agents). The nature and location of the findings, colonic transit time, complications, cleanliness degree and consistency with diagnostic colonoscopy, when performed, were analyzed. Results: a total of 144 subjects (67 women and 77 men); (52.17±16.71 years) with the following indications were included: screening of Colorectal cancer (88 patients), control after polipectomy (24), incomplete colonoscopy (7), rectal bleeding (10), anemia (8), diarrhea (7). The CCE exploration was complete in 134/144 cases (93%), with no case of retention. The preparation was good-very good in 88/134 (65,6%), fair in 26/134 (19,4%) and poor in 20/134 (15%) of the cases. The average colonic transit was of 140.76 min (9-603). Any adverse effect was notified. In 44 cases a colonoscopy was carried out after CCE (results were hidden from another endoscopist). Compared to colonoscopy, the rate of agreement was 75,6%, the sensitivity was 84% and the specificity 62,5%, PPV was 77,7% and NPV was 71,4 %. The colonic findings in 134 CCE were: in 34 cases CCE it did not show lesions, diverticulosis in 63 explorations, polyps in 43, angiodysplasias in 15, Crohn's Disease in 9 and ulcerative colitis in other 8 cases. Conclusions: the CCE is an effective and reliable technique for the detection of lesions in colon, and because of its high agree-ment with the colonoscopy, it could be useful in clinical practice. Further studies with large seria and cost-effectiveness analysis are needed to confirm these data.

Safety of continuous propofol sedation for endoscopic procedures in elderly patients

Objective: to evaluate safety of continuous propofol sedation in elderly patients who undergo endoscopic procedures and investigate risk factors to develop complications in the geriatric population. Material and methods: patients who received endoscopist-directed propofol sedation were classified into two groups according to age. Group I: > 80 years; Group II: < 80 years. Propofol was administered by continuous intravenous infusion to achieve deep sedation. Arterial oxygen saturation, heart rate, blood pressure, and electrocardiographic records were monitored during the procedure. Therapy and complications secondary to sedation were recorded. Results: one thousand two-hundred and ninety-five endoscopic procedures (gastroscopies, colonoscopies and endoscopic ultrasonographies) were included. The dose of propofol was lower and therapy was more frequently performed in Group I. There were no differences between sedation-related complications in both groups (Group I: 15.4%, Group II: 14%; p:n.s.). Patients in Group I showed greater tendency to develop severe oxygen desaturation in the colonoscopy and endoscopic ultrasonography procedures. In the univariate analysis, a higher dose of propofol was associated with the appearance of complications (157.4 ± 84.4 vs 121.3 ± 89.6 mg) in elderly patients but it was not associated with severe oxygen desaturation. Conclusions: continuous propofol sedation during endoscopic procedures in elderly patients ≥ 80 years is as safe as in younger patients.

Objetivo: evaluar la seguridad de la sedación con perfusión continua de propofol en ancianos a los que se les realizan procedimientos endoscópicos e investigar los factores de riesgo para el desarrollo de complicaciones en la población anciana. Diseño experimental: estudio observacional prospectivo de cohortes. Pacientes: pacientes sedados mediante perfusión continua administrada por el propio endoscopista divididos en dos grupos: Grupo I: ≥ 80 años; Grupo II: < 80 años. El propofol fue administrado mediante perfusión continua para conseguir sedación profunda. Durante la exploración se monitorizó: saturación arterial de oxígeno, presión arterial y registro electrocardiográfico. Se registró además si se realizó terapéutica endoscópica y las complicaciones relacionadas con la sedación que se produjeron. Resultados: se incluyeron 1.295 procedimientos endoscópicos (gastroscopias, colonoscopias y ecoendoscopias). La dosis de propofol fue inferior y la endoscopia fue terapéutica con mayor frecuencia en el Grupo I. No hubo diferencias en la aparición de complicaciones relativas a la sedación entre ambos grupos. (Grupo I: 15,4%, Grupo II: 14%; p:n.s.). Los pacientes del Grupo I tuvieron una mayor tendencia a desarrollar desaturación grave durante la colonoscopia y ecoendoscopia. En el análisis univariante, en los pacientes ancianos, el incremento en la dosis de propofol se asoció con la aparición de complicaciones (157,4 ± 84,4 vs 121,3 ± 89,6 mg) pero no con la desaturación grave. Conclusiones: la sedación con perfusión continua de propofol en procedimientos endoscópicos en pacientes ≥ 80 años es tan segura como en pacientes más jóvenes.

Occupational risk prevention in endoscopy units: a pending issue

The degree of Knower and compliance with occupational risk prevention measures in the Spanish gastrointestinal endoscopy units is unknown. Aim: 1. To assess compliance with occupational risk prevention measures in GIE units. 2. To determine which factors influence the fulfillment of occupational risk prevention measures. Methods: a validated survey was supplied to 300 GIE units, including questions on: 1. General occupational risk prevention measures; 2. occupational risk prevention measures during disinfection; 3. occupational risk prevention measures during examination. The following Hospital or GIE Unit characteristics were evaluated: Type of hospital according to the Spanish National Health Service; Number of hospital beds; Advanced diagnostic and therapeutic procedures performed and; Centers providing training in the field of endoscopy. Results: response: 196 GIE units (65%). 104 GIE units (53% CI95%: 46-60) fulfill less than 50% of the occupational risk prevention measures studied. The RR of less than 50% of the ORP measures being fulfilled is 1.975 times higher at public hospitals than at private facilities (CI95%: 1.11-3.52). None of the remaining factors analyzed proved to have a significant influence. Conclusions: compliance with occupational risk prevention measures in Spanish GIE units is inadequate and must be improved. Public hospitals in Spain comply with fewer occupational risk prevention measures than their private counterparts.

En la actualidad desconocemos el grado de conocimiento y aplicación de medidas de prevención de riesgos laborales en las Unidades de Endoscopia Españolas. Objetivo: valorar la aplicación de la prevención de riesgos laborales en las unidades de endoscopia y establecer los factores que determinan su cumplimiento. Diseño: se pasó un cuestionario validado a 300 unidades de endoscopia. Se incluían preguntas sobre: Medidas generales de prevención de riesgos laborales, medidas de prevención durante la desinfección y medidas de prevención durante las exploraciones. Se valoraron el tipo de hospital en función de su adscripción al sistema público de salud, el tamaño de los hospitales según el número de camas, la realización o no de técnicas avanzadas y la realización de docencia de endoscopia o no. Se estimó el porcentaje de cumplimiento de cada medida con un intervalo de confianza del 95% y se realizó una regresión logística para determinar los factores que determinan su cumplimiento. Resultados: respondieron 196 unidades (65%). 104 (53% CI95%: 46-60) cumplían menos del 50% de las medidas de PRL estudiadas. Los Hospitales Españoles de titularidad pública tienen un RR 1,975 veces mayor (IC95%: 1.11-3.52) de aplicar menos del 50% de las medidas de PRL frente a los privados. El resto de los factores estudiados no mostraron influencia significativa. Conclusiones: la aplicación de medidas de prevención de riesgos laborales en las unidades de endoscopia españolas no es adecuada y debe ser mejorada. Los hospitales públicos cumplen con menor número de medidas que los privados.

Diarrhea in an immunocompromised patient: endoscopic findings

Image of pneumoperitoneum in patient with phytobezoar

Radiation rectitis diagnosed with narrow band imaging

Cystic dystrophy of the pancreas in patient with only one previous cyst

Case report: we describe the case of a 46-year-old patient with cystic dystrophy of the pancreas admitted for alcoholic pancreatitis in a state of alcohol deprivation. The patient's background includes two cases of acute pancreatitis and a computed tomography taken 18 months prior to admittance reveals a 9 mm cyst in the first duodenal portion. Magnetic resonance imaging and endoscopic ultrasonography were consistent with cystic dystrophy of the pancreas without stenosis, for which reason treatment with octreotide was initiated. Discussion: it is believed to be a disease caused by obstruction of the ducts of the heterotopic pancreas and is associated with alcoholic pancreatitis. Its treatment is still under debate, but it requires pancreatectomy as a last option. Conclusion: cystic dystrophy of the pancreas is a rare disease and an effort should be made to bring together all of the described cases to increase our understanding of the disease.

Introducción: la distrofia quística de páncreas en una enfermedad rara. Su diagnóstico es difícil y su tratamiento se halla en debate. Caso clínico: describimos el caso de un paciente de 46 años con distrofia quística de páncreas que ingresa por pancreatitis alcohólica en estado de deprivación alcohólica. Entre sus antecedentes destaca dos pancreatitis agudas y en un TC de 18 meses previo al ingreso un quiste de 9 mm en primera porción duodenal. Se realizó resonancia magnética y ecoendoscopia hallando imagen compatible con distrofia quística de páncreas sin estenosis, por lo que se inició tratamiento con octreótido. Discusión: se cree que se trata de una enfermedad causada por la obstrucción de los ductos del páncreas heterotópico y se asocia a pancreatitis alcohólica. Su tratamiento se encuentra todavía en debate pero requiere en última instancia de pancreatectomía. Conclusión: la distrofia quística de páncreas es una enfermedad rara y se debe intentar aunar todos los casos descritos para incrementar nuestro conocimiento sobre la enfermedad

Security of proton pump inhibitors

Right hepatic artery pseudoaneurisma following cholecystectomy

Hemoperitoneum after gallbladder perforation associated with hemodialysis

Autoimmune cholangitis IgG4

Jaundice due to simple giant cyst of the liver

Advances in the management of primary malignant melanoma of the rectum

A rare cause of severe coagulopathy, leading to extradural hematoma in an alcoholic patient

Reply: Clinical meaning of portal pneumatosis