Revista Española de Enfermedades Digestivas

Virtual chromoendoscopy as an adjuvant to capsule endoscopy: a step ahead?

Virtual chromoendoscopy can be a useful software tool in capsule endoscopy

Background: capsule endoscopy (CE) has revolutionized the study of small bowel. One major drawback of this technique is that we cannot interfere with image acquisition process. Therefore, the development of new software tools that could modify the images and increase both detection and diagnosis of small-bowel lesions would be very useful. The Flexible Spectral Imaging Color Enhancement (FICE) that allows for virtual chromoendoscopy is one of these software tools. Aims: to evaluate the reproducibility and diagnostic accuracy of the FICE system in CE. Methods: this prospective study involved 20 patients. First, four physicians interpreted 150 static FICE images and the overall agree-ment between them was determined using the Fleiss Kappa Test. Second, two experienced gastroenterologists, blinded to each other results, analyzed the complete 20 video streams. One interpreted conventional capsule videos and the other, the CE-FICE videos at setting 2. All findings were reported, regardless of their clinical value. Non-concordant findings between both interpretations were analyzed by a consensus panel of four gastroenterologists who reached a final result (positive or negative finding). Results: in the first arm of the study the overall concordance between the four gastroenterologists was substantial (0.650). In the second arm, the conventional mode identified 75 findings and the CE-FICE mode 95. The CE-FICE mode did not miss any lesions identified by the conventional mode and allowed the identification of a higher number of angiodysplasias (35 vs 32), and erosions (41 vs. 24). Conclusions: there is reproducibility for the interpretation of CE-FICE images between different observers experienced in conventional CE. The use of virtual chromoendoscopy in CE seems to increase its diagnostic accuracy by highlighting small bowel erosions and angiodysplasias that weren't identified by the conventional mode.

**Carbon dioxide vs. air insufflation in ileo-colonoscopy and in gastroscopy plus ileo-colonoscopy: a comparative study**

Introduction: insufflation with carbon dioxide (CO2) during endoscopies compared to air is associated with a decrease in abdominal discomfort after the examination, because CO2 is readily absorbed through the small intestine and eliminated by the lungs. Aims: the objective of this randomized clinical trial was to assess the effect of CO2 insufflation on pain and abdominal distension after an ileo-colonoscopy (I) and after an ileo-colonoscopy plus gastroscopy (I+G). Material and methods: we included a total of 309 patients in the study and all endoscopies were performed under sedation with propofol. Two hundred fourteen patients underwent an I (132 with CO2 / 82 with air) and 95 underwent an I+G (53 with CO2 / 42 with air). Abdominal pain was studied at 10, 30 and 120 minutes of exploration and abdominal perimeter difference before and after the procedure. Results: both in group I and in group I+G, the use of CO2 translated into an average of abdominal pain significantly lower (p < 0.05). Similarly, a smaller increase in waist circumference was found among group I and group I+G, in patients where CO2 was used (p < 0.05). Conclusion: the insufflation of CO2 instead of air during the performance of endoscopy significantly reduces the discomfort and abdominal pain after an ileo-colonoscopy and after a gastroscopy + ileo-colonoscopy.

Introducción: la insuflación con dióxido de carbono (CO2) durante las endoscopias digestivas comparado con el aire, se asocia a una disminución de las molestias abdominales después de la exploración, ya que el CO2 es fácilmente absorbido por el intestino delgado y eliminado por los pulmones. Objetivo: el objetivo de este ensayo clínico aleatorizado fue valorar el efecto de la insuflación de CO2 sobre el dolor y la distensión abdominal después de una ileo-colonoscopia (I) y después de una íleo-colonoscopia + gastroscopia (I+G). Material y métodos: se incluyeron un total de 309 pacientes en el estudio y todas las endoscopias fueron realizadas bajo sedación con propofol. A 214 pacientes se les realizó una I (132 con CO2 / 82 con aire) y a 95 se les realizó una I+G (53 con CO2 / 42 con aire). Se estudió el dolor abdominal a los 10, 30 y 120 min de la exploración y la diferencia de perímetro abdominal antes y después del procedimiento. Resultados: tanto en el grupo I como en el grupo I+G, se objetivó una media de dolor abdominal en los pacientes en los que se utilizó CO2 significativamente menor que en los que se utilizó aire (p < 0,05). Y de igual modo se objetivó un menor incremento en el perímetro abdominal para el grupo I y para el I+G en los pacientes en que se utilizó CO2 frente a los que se utilizó aire (p < 0,05). Conclusión: la insuflación de CO2 en vez de aire durante la realización de la exploración endoscópica, reduce significativamente el disconfort y el dolor abdominal después de una ileo-colonoscopia y después de una íleo-colonoscopia + gastroscopia.

Factors related to survival in hepatocellular carcinoma in the geographic area of Sabadell (Catalonia, Spain)

Background: hepatocellular carcinoma (HCC) is a very frequent tumor. Screening for the disease is effective, but the prognostic factors are difficult to evaluate. Objectives: 1. To determine epidemiological data and the clinical course of HCC in our setting. 2. To compare patient survival according to whether screening is performed or not. 3. To evaluate survival prognostic factors. Patients and methods: data on the epidemiology and clinical course of patients diagnosed with HCC were collected on a prospective basis (January 2004-December 2006). Two groups were considered according to whether screening had been performed (group A) or not (group B). Results: a total of 110 patients were diagnosed with HCC (70% males). The most common etiology of cirrhosis was hepatitis C (56.1%), and 69% presented mild liver failure (Child-Pugh grade A). The median follow-up was 1.8 years. Fifty-one percent had been subjected to screening. The diagnosis of HCC was established by imaging techniques in 48.2% of the cases, and by histological criteria in 51.8%. The median tumor size was 23 mm in group A and 28 mm in group B (p = 0.005). Treatment with curative intent was provided in 72% of the cases in group A and in 48% in group B (p = 0.011). The median overall survival was 1.99 years-2.67 years in group A and 1.75 years in group B (p = 0.05). The multivariate analysis of overall survival showed the type of treatment (OR = 2.82 95%CI: 1.3-6.12, p = 0.009) and liver function (OR = 1.71 95%CI: 1.1-2.68, p = 0.020) to be independent predictors of survival. Conclusions: screening allows the diagnosis of smaller lesions and a higher percentage of curative treatments. The degree of liver function and the provision of curative treatment are independent predictors of survival.

Introducción: el carcinoma hepatocelular (CHC) es un tumor muy prevalente. Su cribado es eficaz, pero los factores pronósticos son difíciles de evaluar. Objetivos: 1. Conocer datos epidemiológicos y evolución clínica en nuestra área. 2. Comparar la supervivencia de los pacientes según si seguían cribado o no. 3. Evaluar los factores pronósticos de supervivencia. Pacientes y métodos: se recogieron prospectivamente (enero 2004-diciembre 2006) datos epidemiológicos y evolución clínica de pacientes diagnosticados de CHC. Se estudiaron dos grupos en función del cribado (grupo A = cribado, grupo B = sin cribado). Resultados: 110 pacientes fueron diagnosticados de CHC (70% hombres). La etiología más frecuente de la cirrosis fue por virus C en 56,1%, eran Child A el 69%. El seguimiento mediano fue de 1,8 años. El 51% estaban en programa de cribado. El diagnóstico de CHC fue mediante pruebas de imagen en el 48,2% y 51,8% por criterios histológicos. El tamaño tumoral mediano fue 23 mm en el grupo A y de 28 mm en el B (p = 0,005). El tratamiento con intención curativa fue del 72% en el A y del 48% en el B (p = 0,011). La supervivencia global mediana fue de 1,99 años: grupo A. 2,67 años y grupo B 1,75 años (p = 0,05). El análisis multivariado de la supervivencia global evidenció que el tipo de tratamiento -OR = 2,82 (IC 95%: 1,3-6,12) (p = 0,009)- y la funcionalidad hepática -OR = 1,71 (IC 95%: 1,1-2,68) (p= 0,020)- predicen independientemente la supervivencia. Conclusiones: el cribado permite el diagnóstico de lesiones de menor tamaño y mayor porcentaje de tratamientos curativos. De forma independiente el grado de función hepática y la realización de un tratamiento curativo predicen la supervivencia.

HLA-DQ typing in the diagnostic algorithm of celiac disease

Objective: celiac disease (CD) is an immune-mediated chronic inflammatory disease associated with HLA-DQ2 and DQ8 molecules. We evaluated the role of HLA in the CD diagnostic algorithm in order to contribute to the development of practical indications for the use of HLA typing. Material and methods: we selected 317 subjects typed for DR-DQ genes. CD was present in 123 patients, and 89 were included in the study; a control sample of 70 healthy individuals was recruited. Results: 64% of patients with CD carried DQ2 heterodimer (α5β2), 13.5% carried DQ8 heterodimer without DQ2, 21.4% only showed β2 chain and 1.1% were positive for DQ2 α5 chain. The only presence of α5 chain did not predispose to CD, while DQB1*02 allele resulted more frequent than in other reports, pointing out the intrinsic correlation between β2 chain and CD. In the case-control study we observed a progression of increased risk, ranging from 1:7 for HLA-DQ2 homozygous to 1:85 for DQ8 heterozygous subjects. Overall, 8,6% of first degree family members were affected, exclusively in presence of HLA-DQ2, -DQ8 or DQB1*02, and CD was significantly more frequent among siblings than parents. Finally, considering the different patterns of clinical presentation among the HLA-DQ risk classes identified we found no relationship between CD clinical presentation and HLA-DQ risk categories. Conclusions: our results strengthen the evidence that HLA-DQ status strongly influences the development of CD and demonstrate that knowledge of a patient's HLA-DQ genotype allows to establish clinically relevant genetic risk profiles.

Role of tight junctions in hepatitis C virus infection

Giant hepatocellular carcinoma

Rectal ulcer secondary to a fecal impaction due to pomegranate seed bezoar

Pseudomyxoma retroperitonei: report of 2 cases and review of the literature

Pseudomyxoma peritonei is a rare clinical condition that is characterized by the presence of mucinous ascitis. It is believed to originate predominately from a mucinous neoplasm of the appendix including a heterogeneous group of tumours ranging from indolent to malignant. It was first described in the late 19th century. Pseudomyxoma retroperitonei is extremely rare with only 33 cases having been reported since the first description in the middle of the 20th century. We report two additional cases of pseudomyxoma retroperitonei and present a review of the literature.

Whipple´s disease

Small bowel giant cavernous hemangioma diagnosed by capsule endoscopy

Role of contrast-enhanced ultrasound in clinical staging of pancreatic cancer

Severe thrombocytopenia in liver transplantation

Recurrent hepatotoxicity associated with etanercept and adalimumab but not with infliximab in a patient with rheumatoid arthritis

Primary biliary sarcoidosis mimicking Klatskin tumor: case report and review of literature

Intestinal obstruction secondary to endoscopic capsule retention