Revista Española de Enfermedades Digestivas

Liver hydatidosis in the present decade

Profile of patients with hepatic hydatid disease not treated surgically

Background: hepatic hydatid disease (HHD) is still an important health problem in certain areas of Spain where it is endemic. The treatment of HHD is usually surgical but certain patients are found to be ineligible after assessment for surgery (asymptomatic disease, comorbidity, patient refusal, or other). Material and methods: description of patients assessed in the Department of Surgery for hepatic hydatid disease. Results: in a group of 70 patients with HHD, 27 patients were not treated surgically (mean age: 72.7 years [range: 47-97], 14 women [51.8%]). The number of cysts presented by these patients was 33, with 1.22 cyst/patient (range: 1-4). The cyst size was 5.5 cm (range: 2.1-12.5 cm). The cysts, according to the WHO classification, were CE1: 3 patients, CE3B: 5 patients, CE4: 10 patients and CE5: 9 patients. The form of presentation was: symptomatic in 9 patients, although only 6 were attributable to HHD (22%) and asymptomatic in 18 patients. In these cases, imaging was performed for study of tumor extension in 6 patients and diverse medical reasons in 12. Only two therapeutic interventions were performed: endoscopic retrograde cholangiopancreatography (ERCP) with insertion of a bile duct stent, and puncture-aspiration-injection-re-aspiration (PAIR), both in patients who did not wish to undergo surgery. Ten patients had surgical indications: CE1 (3 patients), CE3B (5 patients), CE4 (1 patient), and CE5 (1 patient). The reasons why the patients did not undergo surgical treatment were: refusal (9 patients) and advanced neoplasm (1 patient). Surgery was judged necessary in 5 patients. In the mean follow-up period of 17 months (range: 1-37), no surgery was performed. Conclusions: there were various causes for not performing surgical intervention of HHD after medical evaluation: asymptomatic patients, older patients, patients with multiple pathologies and oncologic patients. Usually, they were patients who voluntarily chose not to undergo surgery.

Introducción: la hidatidosis hepática (HH) es todavía un problema sanitario importante en ciertas áreas endémicas en España. El tratamiento es habitualmente quirúrgico pero ciertos pacientes, tras ser valorados por los Servicios de Cirugía, no son intervenidos por un variado conjunto de causas (asintomático, comorbilidades, negativa del paciente,...). Material y métodos: descripción de pacientes valorados en el Servicio de Cirugía de hidatidosis hepática y no intervenidos. Resultados: hemos atendido a 70 pacientes con HH. De ellos, 27 pacientes no fueron intervenidos. Edad media: 72,7 años (rango: 47-97). Catorce eran mujeres (51,8%). El número de quistes que presentaban era 33, con 1,22 quistes/paciente (rango: 1-4). El tamaño del quiste fue 5,5 cm (rango: 2,1-12,5 cm). Los quistes, según la clasificación OMS, eran CE1: 3 pacientes, CE3B: 5, CE4: 10 y CE5: 9. La forma de presentación fue: 9 pacientes sintomáticos, aunque solo 6 atribuibles a la HH (22%) y 18 asintomáticos. En estos se realizó la prueba de imagen por: estudio de extensión de neoplasia (6 pacientes) y en 12 por variadas razones médicas. Solo hemos realizado dos actuaciones terapéuticas: CPRE y colocación de prótesis biliar y una punción-aspiración-inyección-reaspiración (PAIR), ambas en pacientes que no querían ser intervenidos. Diez pacientes tenían indicación quirúrgica: CE1 (3 pacientes), CE3B (5), CE4 (1), y CE5 (1). Las razones porque no se intervinieron fueron: negativa del paciente (9) y neoplasia avanzada (1). Creemos que la cirugía era necesaria en cinco pacientes. En el seguimiento medio efectuado de 17 meses (rango: 1-37) no hemos realizado ninguna cirugía. Conclusiones: las causas de no intervención de HH tras valoración médica son múltiples: pacientes asintomáticos, enfermos ancianos, pluripatólogicos y oncológicos. Habitualmente es el paciente el que voluntariamente decide no intervenirse.

Anti-tissue transglutaminase antibodies (IgA and IgG) in both Crohn's disease and autoimmune diabetes

Objective: a strong association has been observed between celiac disease, generally its silent clinical form, and autoimmune disorders. A potential correlation with inflammatory bowel disease has also been suggested. Anti-tissue transglutaminase antibodies have been detected in Crohn's disease. We investigated the prevalence of celiac disease in patients with autoimmune diabetes and in Crohn's disease patients and also evaluated the correlation between anti-transglutaminase antibody positivity and the clinical status of these diseases. Methods: anti-tissue transglutaminase and anti-endomysium antibodies were assessed by enzyme-linked immunosorbent assay and indirect immunofluorescence, respectively. Upper digestive endoscopy and duodenal biopsy were indicated for cases with positive serology. Results: anti-transglutaminase antibodies were detected in five diabetic patients (prevalence of 11.1%), only one serum sample was positive for IgG isotypes. Nine of thirty-three patients with Crohn's disease had low positive levels for IgA anti-transglutaminase. Anti-endomysium antibodies were detected only in celiac patients. Celiac disease was confirmed in all diabetic patients submitted to duodenal biopsies who presented both anti-transglutaminase and anti-endomisyum antibodies positivity. In Crohn's disease, its clinical status and the diagnosis of celiac disease were not associated with positive anti-transglutaminase result. Conclusions: the prevalence of celiac disease was high in diabetic patients. Anti-tissue transglutaminase antibodies were sensitive and specific markers of celiac disease in this diabetic group, while these antibodies were of limited value for celiac disease screening in patients with Crohn's disease.

Colorectal cancer and its delayed diagnosis: have we improved in the past 25 years?

Objective: to determine the current delay in diagnosing colorectal cancer (CRC) and establish whether there has been any improvement in the past 25 years in the same healthcare setting using the same methods. Patients and method: 152 patients undergoing surgery at our unit were personally interviewed during their hospital stay to determine the delay incurred for the diagnosis and treatment of their CRC. SPSS software was used for univariate and multivariate analysis of the data obtained. Results: the study population was comprised of 152 patients of mean age 71 years (SD 10; range 36 to 90 years), 82 men and 70 women (53.9 and 46.1% respectively; p > 0.05). The diagnostic delay for CRC at our unit currently runs at 7.28 months despite the fact that in 58% of patients the disease produced obvious symptoms such as rectal bleeding. Although this delay in diagnosis is reduced over that observed 25 years ago, the difference is statistically not significant in terms of both doctor-attributed or patient-attributed delay (doctor-attributed delay was 3.28 months in 1985 versus 1.89 at present and patient-attributed delay was 3.18 months versus today's 2.75; p > 0.05). Unlike the situation 25 years ago, no link was detected between diagnostic delay and tumor stage. Paradoxically, stage D disease was diagnosed earlier (at 5.71 months) than stage A disease (at 11.16 months) (p < 0.05). Conclusion: the diagnostic delay for CRC at our centre is 7.28 months. This delay is excessive for a disease that produces evident symptoms in 90% of patients. Over the last 25 years little improvement has been noted in the overall delay in diagnosing CRC, although the delay attributed to the care provider has significantly improved. No relationship was detected between diagnostic delay and disease stage upon diagnosis. We feel the high prevalence of CRC, the failure of campaigns to increase awareness of early symptoms and no real improvement in its prognosis justify the introduction of large-scale colonoscopy screening for this disease.

Objetivo: determinar la situación actual en cuanto al retraso diagnóstico del cáncer colorrectal (CCR) y analizar si se ha producido alguna mejora con respecto a lo acontecido hace 25 años en un mismo medio sanitario y con una misma metodología. Pacientes y método: se entrevistó personalmente a 152 pacientes durante su ingreso para tratamiento quirúrgico en nuestro Servicio con el fin de determinar el retraso acumulado para el diagnóstico y tratamiento de su CCR. Se realizó un análisis estadístico univariable y mutivariable mediante el software SPSS. Resultados: se incluyeron 152 pacientes con una edad media de 71 años con una desviación típica de 10 (edad mínima 36 y máxima 90 años), con un total de 82 varones y 70 mujeres (53,9 y 46,1% respectivamente; p > 0,05). El retraso diagnóstico del cáncer colorrectal en el momento actual en nuestro medio es de 7,28 meses, a pesar de que la mayoría de los pacientes cursa con sintomatología florida, como es la rectorragia en un 58% de pacientes. Aunque el retraso es menor que hace 25 años, la diferencia no llega a ser significativa en cuanto a retraso médico ni por parte del paciente (retraso médico 3,28 meses en 1985 frente a 1,89 en el momento actual y retraso del paciente de 3,18 en 1985 frente a 2,75 en la actualidad) (p > 0,05). A diferencia de lo que acontecía hace 25 años, no se ha encontrado relación entre retraso diagnóstico y estadio anatomopatológico, con el hecho paradójico de un menor retraso en estadio D (5,71 meses) que en A (11,16 meses) (p < 0,05). Conclusión: el retraso diagnóstico en el CCR es de 7,28 meses; cifra muy elevada para una patología que presenta sintomatología en el 90% de pacientes. En los últimos 25 años apenas ha variado el retraso global, aunque ha mejorado de forma importante el atribuible al médico. En nuestro estudio no se ha encontrado relación entre retraso diagnóstico y estadio anatomopatológico. Dada la alta prevalencia del cáncer colorrectal y la insuficiencia de las campañas para diagnóstico temprano del mismo en fase sintomática, con la ausencia de mejoría en cuanto al pronóstico, creemos necesaria la potenciación de programas de screening mediante colonoscopia.

Diagnostic accuracy and therapeutic impact of endoscopic ultrasonography in patients with intermediate suspicion of choledocholithiasis and absence of findings in magnetic resonance cholangiography

Background: endoscopic ultrasonography (EUS) and magnetic resonance cholangiography (MRC) are the elective tests in the diagnosis of choledocholithiasis. MRC is best accepted by patients, but its sensitivity might decrease in the evaluation of microlithiasis. Aim: to evaluate the diagnostic accuracy and therapeutic impact of EUS in a prospective cohort of patients with intermediate suspicion of choledocolithiasis and no findings in MRC (normal MRC). Material and methods: during a period of 24 months, all the patients with clinical intermediate suspicion of choledocholithiasis and normal MRC were included. Sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MRC and EUS were compared, and so their impact in the management of these patients. Results: seventy six patients were evaluated (lithiasis in 30% of them). Sensitivity and diagnostic accuracy of EUS (100%, 92%) were significantly higher than MRC values (0%, 70%) (p < 0.05). EUS findings (suspicion of choledocholithiasis) favored a significant change in therapeutic attitude (therapeutic ERCP was performed) in 38% of the patients (in which MRC had ruled out the presence of choledocholithiasis, and so, ERCP had not been performed) (p < 0.05). Conclusions: EUS allows the diagnosis of lithiasis in approximately 1/3 of patients with intermediate suspicion of choledocholithiasis and normal MRC. EUS findings involve a significant change in the management of these patients; this supports the use of EUS in clinical practice.

Antecedentes: la ultrasonografía endoscópica (USE) y la colangiografía por resonancia magnética nuclear (CRM) son las técnicas de elección para el diagnóstico de litiasis en la vía biliar. Aunque la CRM es mejor aceptada por los pacientes, la sensibilidad de esta para detectar litiasis de pequeño tamaño podría ser insuficiente. Objetivo: estudiar de forma prospectiva la precisión diagnóstica y el impacto terapéutico de la USE en los pacientes con sospecha intermedia de coledocolitiasis y CRM normal. Material y métodos: se incluyeron prospectivamente durante 24 meses todos los pacientes con sospecha clínica intermedia de coledocolitiasis y CRM negativa. Se comparó la sensibilidad, especificidad, precisión diagnóstica, valor predictivo positivo y negativo de CRM y USE, así como su impacto en el tratamiento. Resultados: se evaluaron 76 pacientes (litiasis en el 30%). La sensibilidad y precisión diagnóstica de USE (100%, 92%) eran significativamente superiores a las alcanzadas por la CRM (0%, 70%) (p < 0,05). Los hallazgos de la USE (sospecha de coledocolitiasis) propiciaron un cambio significativo en la actitud terapéutica (realización de CPRE terapéutica) en el 38% de los pacientes (CRM había descartado coledocolitiasis y contraindicado la CPRE) (p < 0,05). Conclusiones: en pacientes con sospecha intermedia de coledocolitiasis y CRM normal, la USE permite diagnosticar litiasis en aproximadamente una tercera parte de ellos. Los hallazgos endosonográficos permiten modificar significativamente la actitud terapéutica en estos pacientes, lo que apoya su utilización en la práctica clínica diaria.

Hepatotoxicity in 2011: advancing resolutely

Intraductal papillary mucinous neoplasm

Spontaneous esophageal rupture (Boerhaave's syndrome): An uncommon image

Posterolateral Bochdalek diaphragmatic hernia in adults

Bochdalek hernias (BHs) are produced in the posterolateral area of the diaphragm. They are generally congenital, appearing in childhood, but are also detected in asymptomatic adult patients seeking medical attention for other reasons. Computed tomography (CT) or magnetic resonance imaging (MRI) is used for the correct diagnosis of the hernia type and for its localization, facilitating its management and the choice of treatment. We describe three cases of Bochdalek hernia, two on the right side and one bilateral, which was larger on the right than left side. All of these hernias contained only omental fat. In one patient, the right kidney was adjacent to the diaphragmatic defect but remained within the abdomen. The patients showed no symptoms and were not surgically treated. Examination by multi-slice CT with the possibility of coronal and sagittal reconstruction should be considered the standard method for diagnosing this entity. MRI in T1 is highly valuable to evaluate fat-containing chest lesions. The incidental finding of BH in asymptomatic adults is increasing, thanks to the wider application of new imaging techniques.

Las hernias de Bochdalek se producen a través de la zona posterolateral del diafragma. Generalmente son congénitas y se presentan en la infancia, pero pueden verse también en la edad adulta en pacientes asintomáticos, que consultan por patologías diversas. El uso de tomografía computarizada o resonancia magnética permite el diagnóstico correcto del tipo y localización de la hernia, lo cual facilitará su manejo y la elección del tratamiento. Presentamos 3 casos clínicos, dos tenían una hernia de Bochdalek derecha, y, el otro caso es bilateral, siendo mayor la situada en el lado derecho. En todos nuestros casos, el contenido ha sido únicamente grasa omental. No obstante, en uno de ellos, el riñón derecho se situaba adyacente al defecto diafragmático, pero dentro del abdomen. Debido a la ausencia de sintomatología, nuestros pacientes no han sido tratados quirúrgicamente. La exploración mediante tomografía computarizada multicorte, con posibilidad de realizar reconstrucciones coronales y sagitales, debería ser considerada el método estándar para diagnosticar esta entidad. La resonancia magnética en T1 es muy valiosa en la evaluación de lesiones torácicas que contienen grasa. Para concluir, debemos resaltar que las hernias de Bochdalek en el adulto, asintomáticas, descubiertas de forma incidental, están siendo diagnosticadas cada vez con una mayor frecuencia gracias a los avances en las nuevas técnicas de imagen, permitiendo el diagnóstico correcto del tipo y localización de la hernia, lo cual facilitará su manejo y la elección del tratamiento.

Functional abdominal pain

Diagnosis, treatment and follow-up of gastric carcinoid tumors: Analysis of 14 cases

Biliopleural fistula after radiofrecuency ablation of hepatocellular carcinoma

Spontaneous intramural gastric haematoma in an anticoagulated patient

Endosonographic diagnosis of aberrant right subclavian artery that leads to disphagia lusoria

Gastric volvulus associated with cardiac tamponade

NOD2/CARD15 gene mutations in patients with inflammatory bowel disease in Valladolid

Association between Lynch syndrome and renal carcinoma