Revista Española de Enfermedades Digestivas

¿Las pruebas no invasivas, sustituirán a la biopsia hepática para el diagnóstico y seguimiento de la esteatohepatitis no alcohólica (EHNA)?

Utilidad de un índice de puntuación como predictor de fibrosis hepática en pacientes obesos sometidos a cirugía bariátrica

Objective: to evaluate the usefulness of a non-invasive clinical score to predict liver fibrosis in the steatosis associated with morbid obesity. Patients and methods: we included 88 patients, who underwent bariatric surgery in the Sanitary Area of León, Spain, and who showed a liver biopsy with steatosis greater than 5%. This is a retrospective study in which the rate of fibrosis is calculated from tests performed during the preoperative period, and is then compared to data from intraoperative hepatic biopsies. The analysis population was grouped according to the presence of advanced fibrosis in the liver biopsy (grade 3-4) or its absence (grade 0-2). The cutoff used for diagnosing advanced fibrosis was 0.676 (high cutoff point), and the cutoff point to exclude advanced fibrosis was -1.455 (low cutoff). Results: the prevalence of advanced fibrosis in the histological samples was 5.5%, and 65.9% of patients had no fibrosis. The cutoff for a low negative predictive value was 100%, and sensitivity was 100%. The cutoff point for a high positive predictive value was 1.7%, and specificity was 31.3%. Conclusions: this scoring system for morbidly obese patients eligible for bariatric surgery allows to identify those without advanced fibrosis, but cannot predict who may have advanced fibrosis.

Objetivo: evaluar la utilidad de un índice de puntuación clínica no invasivo para predecir fibrosis hepática en la esteatosis asociada a la obesidad mórbida. Pacientes y métodos: se incluyeron 88 pacientes, intervenidos de cirugía bariátrica en el área sanitaria de León, que presentaron en la biopsia hepática una esteatosis mayor del 5%. Se trata de un estudio retrospectivo en el que se calculó el índice de fibrosis a partir de los datos analíticos del preoperatorio, y se comparó su resultado con los datos de la biopsia hepática intraoperatoria realizada. Para el análisis los pacientes fueron agrupados según presentaban en la biopsia hepática fibrosis avanzada (grado 3-4) o no (grado 0-2). El punto de corte usado para diagnosticar fibrosis avanzada fue 0,676 (punto de corte alto), y el punto de corte para excluir fibrosis avanzada fue -1,455 (punto de corte bajo). Resultados: la prevalencia de fibrosis avanzada en las muestras histológicas fue del 5,5% y el 65,9% de los pacientes no presentaban fibrosis. Para el punto de corte bajo el valor predictivo negativo fue del 100% y la sensibilidad del 100%. Para el punto de corte alto el valor predictivo positivo fue del 1,7% y la especificidad del 31,3%. Conclusiones: el sistema de puntuación analizado permite, en los pacientes con obesidad mórbida candidatos a cirugía bariátrica, detectar aquellos sin fibrosis avanzada, pero no permite predecir aquellos que pueden tener una fibrosis avanzada.

Manejo quirúrgico del cáncer colorrectal hereditario: cirugía basadas en el análisis molecular y los antecedentes familiares

The importance of colorectal cancer (CRC) is increasing. A proportion show a hereditary component, as in Lynch syndrome and Familial Adenomatous Polyposis, and a recently defined entity as well, namely, Familial Colorectal Cancer type X. The high probability to develop CRC in these groups may, at the time of recognition, change surgical management, including its timing or even the surgical technique. In some cases prophylactic surgery can play an important role. The possibility of using tools that allow recognition of the aforementioned syndromes, including microsatellite instability, immunohistochemistry for DNA mismatch repair system proteins, and especially their mutations, is on the basis of therapeutic strategies that differ from those employed in sporadic CRC cases.

Dilatación de la esfinterotomía biliar para la extracción de coledocolitiasis difíciles

Background and aim: endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy (BS) is the usual method for extracting common bile duct stones. However, following BS and by means of extraction balloons and Dormia baskets a complete bile duct clearance cannot be achieved in all cases. We present a study on the impact that hydrostatic balloon dilation of a previous BS (BSD) may have in the extraction rate of choledocholithiasis. Patients and methods: a prospective study which included 91 consecutive patients diagnosed with choledocholithiasis who underwent ERCP. For stone removal, extraction balloons and Dormia baskets were used, and when necessary BSD was employed. Results: complete bile duct clearance was achieved in 86/91 (94.5%) patients. BSD was used in 30 (33%) cases. In these cases, extraction was complete in 29/30 (97%); 23 (76%) patients in the BSD group had anatomic difficulties or bleeding disorders. The most frequently used hydrostatic balloon diameter was 15 mm (60%). There were 7 (7.6%) complications: two self-limited hemorrhage episodes in the BSD group and one episode of cholangitis, one of pancreatitis, and three of bleeding in the group in which BSD was not used. Conclusions: BSD is a very valuable tool for extracting common bile duct stones. In our experience, there has been an increase in the extraction rate from 73% (Rev Esp Enferm Dig 2002; 94: 340-50) to 94.5% (p = 0.0001, OR 0.1, CI 0.05-0.45), with no increase in complications.

Modelo para el aprendizaje y entrenamiento en la técnica de disección endocópica submucosa de tumores gástricos

Introduction: the elevated risk of complications and technical complexity of endoscopic submucosal dissection (ESD) has limited its implementation in our medical system. Objective: to design and evaluate a training program for learning the ESD technique. Methods: four endoscopists with no experience with ESD underwent a 4-step training program: 1) review of the existing literature, didactic material, and theoretical aspects of ESD; 2) ESD training in an ex-vivo animal model; 3) ESD training in an in-vivo animal model(supervised by ESD expert); and 4) ESD performance in a patient. A standard gastroscope and an ESD knife (IT, Flex or Hook-knife Olympus®) were employed. The classical ESD technique was performed: rising of the lesion, circumferential incision, and submucosal dissection. Results: ex-vivo animal model: 6 x swine stomach/esophagus -cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) and fundus/cardia (n = 1)-; size of resected specimen: 4-10 cm; ESD duration: 105-240 minutes; therapeutic success: 100%; complications: perforation (1/6: 16%) sealed with clips. In-vivo animal model: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size: 2-5 cm; duration: 40-165 minutes; success: 100%; complications: 0%. Patient: ESD of a gastric lesion located in the antrum/body; size: 3 cm; duration 210 minutes; a complete resection was achieved; no complications. Conclusions: the results of the present study support the usefulness of this model for learning ESD in our system.

Tratamiento con probióticos del síndrome de intestino irritable: ¿Por fin un enfoque etiopatogénico?

Irritable bowel syndrome (IBS) is the most common functional digestive disorder, and may affect 11-20% of the adult population in industrialized countries. In accordance with Rome III criteria (2006) IBS involves abdominal pain and bowel habit disturbance, which are not explained by structural or biochemical abnormalities. Several hypotheses attempt to account for the pathophysiology of IBS, but the etiology still remains uncertain or obscure, perhaps multifactorial. Abnormalities in colonic microflora have recently been suggested in such patients, as has abnormal small-intestine bacterial overgrowth (SIBO), or in particular a significant reduction in the amount of intraluminal Bifidobacteria or Lactobacilli, with consequences like the production of colonic gas, and motility or sensitivity disturbances of the intestinal tract. The disorder is difficult to treat, and the wide spectrum of non-drug and drug treatments shows our ignorance about the cause of the condition. Newer drugs, both pro- and anti-serotonin, have failed to show long-term efficacy or have been withdrawn due to concerns about harmful effects. Recent research has provided increasing support for the idea that disturbances of intestinal microbiota occur in patients with IBS, and that such abnormalities may contribute to IBS symptoms. Studies in Scandinavian countries in the last ten years emphasize the role of probiotics in the modulation of intestinal microbiota, and as a consequence in the regulation of the motility and hypersensitivity of the digestive tract. Although results between studies are difficult to compare because of differences in study design, probiotic dose, strain, and duration of therapy, some studies show symptom improvement. Lactobacilli are found among the normal bacterial flora of the gastrointestinal tract, and Lactobacillus plantarum (Lp) is one of the species frequently isolated from the human mucosa, which is capable of surviving the low pH of the stomach and duodenum, resisting the effect of bile acids in the upper small intestine when ingested, and temporarily colonizing the gastrointestinal tract by binding to the intestinal and colonic mucosa. Concurrent with colonization by Lp there is a decrease in bacterial groups with gas-producing ability, such as Veillonella spp. and Clostridia spp. Evidence has now accumulated to suggest the efficacy of certain probiotics like Lp299v, which may be capable of bringing about a significant reduction in pain, abdominal distension and flatulence, while increasing health-related quality of life in IBS.

Perforación de la vesícula biliar con absceso perivesicular comunicante: diagnóstico por ecografía

Necrosis gástrica masiva secundaria a ingesta de ácido clorhídrico

Pancreatitis y lupus eritematoso sistémico

Gastrointestinal symptoms in patients with SLE are common, specifically abdominal pain. However, the rate of pancreatic diseases is much lower and does not reach 5% according to published series in Europe and the USA. This association between SLE and pancreatic disease is basically at the expense of episodes of acute pancreatitis. An association with chronic pancreatitis is much more uncommon, and only four articles have been published showing this relationship. Three cases of SLE-associated pancreatitis are described, and disease onset, etiological factors, and clinical progression are analyzed. A review of the literature and a brief discussion about pathophysiological mechanisms and the role of corticosteroids are also included.

Los síntomas gastrointestinales en los pacientes con lupus eritematoso sistémico (LES) son comunes, específicamente el dolor abdominal. Sin embargo la tasa de enfermedades pancreáticas es mucho menor, una tasa que no alcanza ni al 5% según las series publicadas en Europa y EE. UU. Esta asociación entre enfermedades pancreáticas y LES es fundamentalmente a expensas de episodios de pancreatitis aguda. La asociación con pancreatitis crónica es muchísimo más infrecuente, teniendo en cuenta que tan sólo cuatro artículos han sido publicados reflejando esta asociación. Describimos tres casos de asociación entre pancreatitis y LES, analizando el debut de la enfermedad, los factores etiológicos y también la evolución clínica. Hemos realizado, además, una breve discusión de la fisiopatología y del papel de corticosteroides, así como una revisión de la literatura.

Colangiopancreatografía retrógrada endoscópica (CPRE)

Causa emergente de dolor abdominal y fiebre: tuberculosis intestinal

Bronquiolitis obliterante con neumonía organizada inducida por rapamicina en un paciente trasplantado hepático

Rotura espontánea del sarcoma hepático que parece un quiste hidatídico en adulto

Pioderma gangrenoso atípico en enfermedad inflamatoria del intestino: Un problema diagnóstico

Isquemia segmentaria de yeyuno como complicación de trombosis venosa mesentérica secundaria a déficit congénito de antitrombina III

Lipoma primario del colon simulador de un adenocarcinoma

Hemorragia digestiva secundaria a tumor del estroma gastrointestinal en dos pacientes con neurofibromatosis