Revista Española de Enfermedades Digestivas

Pancreatic stents in ERCP. Where are we?

Pancreatic stent insertion after an unintentional guidewire cannulation of the pancreatic duct during ERCP

RESUMEN Introducción: en los intentos de canulación del colédoco durante la colangiopancreatografía retrógrada endoscópica (CPRE) la guía puede entrar en el conducto pancreático. No está definido qué maniobra es más eficaz para canular la vía biliar y prevenir la pancreatitis tras pasar la guía al Wirsung. Objetivo: estudiar la tasa de canulación coledociana y de pancreatitis post-CPRE cuando en la primera ocasión en que la guía pasó al conducto pancreático de forma involuntaria se insertó una prótesis pancreática. Material y métodos: análisis retrospectivo de pacientes a los que se realizó una CPRE para drenaje biliar e incluidos de forma prospectiva en una base de datos. Tras la inserción involuntaria de una guía en el conducto pancreático se insertó una prótesis plástica recta de 5 Fr y 4 cm de longitud, sin topes internos para facilitar su expulsión. El colédoco se intentó canular por encima de la prótesis. En los pacientes mayores de 60 años se realizó una esfinterotomía pancreática antes de insertar la prótesis. Resultados: en un grupo de 154 CPRE se insertaron 46 prótesis pancreáticas (29,8%) y en estos casos el colédoco se canuló en el 95,6% (44/46) de las ocasiones. Se realizaron 21/46 (45,6%) esfinterotomías pancreáticas. Hubo 1/46 (2,17%) pancreatitis leves. La mayoría de las prótesis se expulsaron de forma espontánea. Conclusiones: en este estudio, la inserción de una prótesis pancreática plástica cuando la guía ha pasado al conducto pancreático de forma involuntaria en los intentos de canulación del colédoco ayudó a canular la vía biliar en la mayoría de las ocasiones, sin que la inserción de las prótesis produjera efectos adversos.

ABSTRACT Introduction: the guidewire (GW) may enter the pancreatic duct during common bile duct (CBD) cannulation attempts in endoscopic retrograde cholangiopancreatography (ERCP). After GW passage into the pancreas, the most effective maneuver for CBD cannulation and pancreatitis prevention has not been determined. Aim: to study CBD cannulation and post-ERCP pancreatitis rates when a pancreatic stent is inserted after an unintentional GW cannulation of the pancreatic duct. Material and methods: a retrospective analysis of patients undergoing ERCP for biliary drainage that were included prospectively into a database. After unintentional GW cannulation of the pancreatic duct, a straight 5-Fr and 4-cm long plastic stent was inserted. The stents had no internal flaps to facilitate expulsion. CBD cannulation attempts were made above the stent. A pancreatic sphincterotomy was performed in patients older than 60 years before stent insertion. Results: a total of 46 pancreatic stents were inserted during 154 ERCP (29.8%) procedures. In the stent group, CBD cannulation was accomplished in 44/46 (95.6%) subjects. A total of 21/46 (45.6%) pancreatic sphincterotomies were performed. Only 1/46 (2.17%) mild pancreatitis cases were observed and most stents were spontaneously expelled. Conclusions: in this study, the CBD was eventually reached with the insertion of a plastic pancreatic stent after an unintentional GW passage into the pancreatic duct while attempting a CBD cannulation. No adverse events were observed following pancreatic stent insertion.

HLA-DQ distribution and risk assessment of celiac disease in a Spanish center

ABSTRACT Aims: celiac disease is a multisystem immune-mediated disease triggered by gluten in genetically susceptible individuals. The HLA-DQ2 and/or HLA-DQ8 heterodimers are encoded by the main genetic predisposing factors and their presence is required for the development of the immunological response that leads to the disease. However, the HLA-conferred risk can differ within different countries. The aim of the study was to analyze the risk of Spanish children to develop celiac disease according to their HLA-DQ genotype. Methods: a retrospective observational case-control study was performed using a sample of 475 celiac patients and 628 controls. Results: children carrying the HLA-DQ2.5 had the highest disease risk, especially those with two HLA-DQB1*02 alleles. A similar high risk was observed in HLA-DQ8 homozygous individuals. A risk conferred by HLA-DQ8 in heterozygosity and HLA-DQ2.2 was also found and two patients with celiac disease carried the HLA-DQ7.5 haplotype as the only HLA risk factor. Conclusions: there are four genetic risk categories according to the HLA-DQ genotype. The HLA-DQ7.5 genotype does not confer risk but should not be used to rule out celiac disease when a high suspicion of the disease exists. These findings could be relevant to determine when to perform serological screening in asymptomatic subjects at risk of celiac disease.

Metformin modifies glutamine metabolism in an in vitro and in vivo model of hepatic encephalopathy

ABSTRACT Aim: to analyze the effect of metformin on ammonia production derived from glutamine metabolism in vitro and in vivo. Methods: twenty male Wistar rats were studied for 28 days after a porto-caval anastomosis (n = 16) or a sham operation (n = 4). Porto-caval shunted animals were randomized into two groups (n = 8) and either received 30 mg/kg/day of metformin for two weeks or were control animals. Plasma ammonia concentration, Gls gene expression and K-type glutaminase activity were measured in the small intestine, muscle and kidney. Furthermore, Caco2 were grown in different culture media containing glucose/glutamine as the main carbon source and exposed to different concentrations of the drug. The expression of genes implicated in glutamine metabolism were analyzed. Results: metformin was associated with a significant inhibition of glutaminase activity levels in the small intestine of porto-caval shunted rats (0.277 ± 0.07 IU/mg vs 0.142 ± 0.04 IU/mg) and a significant decrease in plasma ammonia (204.3 ± 24.4 µg/dl vs 129.6 ± 16.1 µg/dl). Glucose withdrawal induced the expression of the glutamine transporter SLC1A5 (2.54 ± 0.33 fold change; p < 0.05). Metformin use reduced MYC levels in Caco2 and consequently, SLC1A5 and GLS expression, with a greater effect in cells dependent on glutaminolytic metabolism. Conclusion: metformin regulates ammonia homeostasis by modulating glutamine metabolism in the enterocyte, exerting an indirect control of both the uptake and degradation of glutamine. This entails a reduction in the production of metabolites and energy through this pathway and indirectly causes a decrease in ammonia production that could be related to a decreased risk of HE development.

Clinical-endoscopic relevance of incidental colorectal lesions detected by PET-CT

RESUMEN Objetivo: establecer la proporción de lesiones incidentales en colon detectadas por PET-TC y su correlación con los hallazgos endoscópicos. Sugerir el valor máximo de captación estándar (SUVmax) que pueda discriminar lesiones benignas de malignas en nuestra serie. Métodos: estudio retrospectivo de 3.000 pacientes sometidos a PET-TC entre 2011 y 2015 para estadificación o respuesta a tratamiento de neoplasias. Se incluyeron pacientes con captación incidental en colon. Los criterios de exclusión fueron: colonoscopia incompleta, mal preparada o no realizada; enfermedad inflamatoria intestinal; tratamiento con metformina. Resultados: se incluyeron 71 pacientes (69% varones, edad media 65,77 ± 11,2) con captación colónica por PET-TC y endoscopia posterior. La tasa de lesiones incidentales por PET-TC fue del 1,73% y se describieron 52 captaciones en 50 pacientes. La localización de las captaciones fue: recto (19,23%), colon sigmoide (34,62%), descendente (13,46%), transverso (1,92%), ascendente (19,23%), ciego (9,62%) y anastomosis ileocólica (1,92%). Los hallazgos en 35 colonoscopias patológicas (71,15%) correspondieron a cinco neoplasias (13,51%), dos lesiones inflamatorias (5,4%) y 30 pólipos (81,1%). Se hallaron diferencias significativas en el SUVmax de neoplasias (11,7 g/ml; p = 0,03) y pólipos (9,26 g/ml; p = 0,04), respecto a lesiones inflamatorias (10,5 g/ml) y endoscopias normales (6,05 g/ml). No hubo diferencias en función del tamaño de los pólipos ni de la presencia o no de displasia de alto grado (p = 0,12 y 0,33). La localización de las lesiones por PET-TC y endoscopia presentó muy buena concordancia (k 0,90; IC 95% 0,86-0,93). Conclusiones: existe una buena correlación entre los hallazgos identificados por PET-TC y los endoscópicos. En nuestro estudio, un SUVmax > 11 g/ml sugiere patología maligna, ayudándonos a priorizar el estudio endoscópico.

ABSTRACT Aim: to determine the proportion of incidental colon lesions detected by PET-CT and their correlation with the endoscopic and histological findings. In addition, to determine the maximum standardized uptake value (SUVmax) that can discriminate between benign and malignant lesions in our series of cases. Methods: this was a retrospective study of 3,000 patients evaluated by PET-CT for staging or response to treatment of primary neoplasms, between 2011 and 2015. Patients with incidental uptake in the colon were included in the study. Exclusion criteria included an incomplete, poorly prepared or abandoned Results: the study cohort comprised 71 patients evaluated by PET-CT and subsequently analyzed by endoscopy; 69% were male with a mean age of 65.77 ± 11.2. The rate of incidental colon lesions found by PET-CT was 1.73%, with 52 incidental colonic uptakes reported in 50 patients. The location of the uptake was the rectum (19.23%), sigmoid colon (34.62%), descending colon (13.46%), transverse colon (1.9%), ascending colon (19.23%), cecum (9.62%) and ileocolic anastomosis (1.92%). Thirty-five pathological colonoscopies (71.15%) were identified: the findings included five neoplasms (13.51%), two inflammatory lesions (5.4%) and 30 adenomatous polyps (81.1%). Significant differences were found between neoplastic SUVmax (11.7 g/ml; p = 0.03) and polyps (9.26 g/ml; p = 0.04) in relation to inflammatory lesions and normal endoscopies (6.05 g/ml). There were no differences in terms of the size of the polyps, nor the presence or absence of high grade dysplasia (p = 0.12 and 0.33). Both PET-CT and endoscopy proved consistent for locating lesions (k 0.9; CI 95% 0.86-0.93). Conclusion: there is a good correlation between the findings identified by PET-CT and the endoscopic study. In our study, a SUVmax > 11 g/ml suggests a malignant pathology, which aids the prioritization of an endoscopic study.

Factors associated with complications during endoscopic esophageal dilation

RESUMEN Antecedentes: las dilataciones endoscópicas se consideran el tratamiento de elección para las estenosis esofágicas, sin embargo, no se cuenta en nuestra región con estudios en los que se evalúe la seguridad de este procedimiento. Objetivo: evaluar la seguridad de las dilataciones esofágicas y los factores asociados a las complicaciones. Material y métodos: cohorte retrospectiva. Se incluyeron todos los pacientes referidos para dilatación esofágica entre enero de 2015 y junio de 2017. Se obtuvo la tasa de complicaciones y se determinó la asociación entre la no adherencia a la "regla de los tres" y el desarrollo de complicaciones. Se analizaron otros factores predictivos asociados al desarrollo de complicaciones. Resultados: se incluyeron 164 pacientes en los que se realizaron 474 dilataciones. La etiología más prevalente fue la estenosis de anastomosis quirúrgica. Se presentaron seis complicaciones: tres perforaciones (0,63%), dos sangrados (0,42%) y un episodio de dolor significativo que requirió observación posprocedimiento (0,21%). La dilatación endoscópica esofágica fuera de la "regla de los tres" no se encontró asociada a un mayor riesgo de complicaciones. La dilatación con balón fue el único factor predictivo para el desarrollo de complicaciones. Conclusiones: la dilatación esofágica es un procedimiento seguro. La no adherencia a la "regla de los tres" no parece estar asociada a un mayor riesgo de complicaciones, incluyendo la perforación esofágica.

ABSTRACT Background: endoscopic dilation is considered as the treatment of choice for esophageal strictures. However, there are no studies in our region that have assessed the safety of the procedure. Objective: to assess the safety of esophageal dilation and the factors associated with the development of complications. Materials and methods: a retrospective cohort was studied. All patients referred for esophageal dilation between January 2015 and June 2017 were included in the study. A complication rate was obtained and the association between nonadherence to the "rule of 3" and the development of complications was determined. Other predictive factors associated with complication development were also analyzed. Results: a total of 164 patients that underwent 474 dilations were included in the study. Surgical anastomosis stricture was the most prevalent etiology. A total of six complications occurred, including three perforations (0.63%), two bleeding events (0.42%) and one episode of significant pain that required post-procedure observation (0.21%). Endoscopic esophageal dilation without adherence to the "rule of 3" was not associated with a higher risk of complications. Balloon dilation was the only predictive factor for complications. Conclusions: esophageal dilation is a safe procedure. Nonadherence to the "rule of 3" does not appear to be associated with a higher risk of complications, including esophageal perforation.

EUS-FNA cytological material from pancreatic lesions: the expression of cathepsins and its predictive value of malignancy

ABSTRACT Aims: To assess the expression of cathepsins in pancreatic samples obtained by endoscopic ultrasonography and fine needle aspiration (EUS-FNA) and to investigate their relationship with the staging of the pancreatic ductal adenocarcinoma (PDAC). Methods: We prospectively included patients with solid pancreatic masses, in which EUS-FNA were performed. Cathepsins B, L, S and H expression was determined in FNA samples. Results: Seventeen FNA were performed. All cytological material was from PDAC. Expression of cathepsins was predominantly low (B 65%, L 23%, S 76%, and H 41%). We found no correlation between the expression levels and the extension of the neoplasm. Conclusion: Expression of cathepsins in the cytological material of PDAC is diverse but still poor to be useful in the pre-operative diagnosis. There is no correlation between the expression levels of cathepsins and the extension of the PDAC.

Long-term results of linaclotide in the treatment of constipation-type irritable bowel syndrome

RESUMEN Antecedentes: el síndrome de intestino irritable tipo estreñimiento (SII-E) es una patología prevalente, compleja y multifactorial que representa un desafío tanto desde el punto de vista diagnóstico como terapéutico. Objetivo: evaluar la efectividad, seguridad y satisfacción de linaclotida en pacientes con SII-E. Métodos: estudio prospectivo, unicéntrico y observacional realizado en pacientes con diagnóstico de SII-E. Los pacientes recibieron tratamiento con linaclotida (Constella(r), Allergan Inc., Irvine, CA), 290 microgramos/24 horas, una cápsula 30 minutos antes del desayuno. La variable primaria de efectividad fue el número de deposiciones por semana. Las variables secundarias incluían el grado de satisfacción y el registro de la frecuencia e intensidad de los síntomas (dolor e hinchazón), medidos mediante una escala visual analógica (EVA) de once niveles (0-10), y recogidas mediante un diario que se entregó al paciente. Resultados: treinta pacientes, todas mujeres, fueron incluidas consecutivamente. La mediana del tiempo de seguimiento fue de 18 meses. La media (deviación estándar [DE]) de deposiciones por semana aumentó desde 0,9 (0,6) al inicio del estudio hasta 4,7 (3,7) al final del mismo (p < 0,0001). Resultados similares fueron observados con el dolor (5,7 [2,3] frente a 3,1 [2,8] al inicio y al final del estudio, respectivamente, p < 0,0001) y con la hinchazón (6,8 [1,6] frente a 2,9 [2,5] al inicio y final del estudio, respectivamente, p < 0,0001). El grado medio (DE) de satisfacción al final del estudio fue 6,7 (3,0). Conclusiones: el tratamiento con linaclotida en pacientes con SII-E en el entorno de la práctica clínica se ha mostrado eficaz y seguro a largo plazo.

ABSTRACT Background: constipation-predominant irritable bowel syndrome (C-IBS) is a prevalent, complex and multifactorial disorder that represents a challenge in terms of diagnosis and therapeutic management. Objective: to evaluate the effectiveness, safety and treatment satisfaction of linaclotide in C-IBS patients. Methods: prospective, single-center and observational study conducted in patients diagnosed with C-IBS. The patients were treated with linaclotide (Constella(r), Allergan Inc., Irvine, CA), once-daily via an oral capsule of 290-µg, 30 minutes before breakfast. The primary effectiveness endpoint was the number of bowel movements per week. The secondary endpoints included treatment satisfaction and changes from baseline in frequency and severity of symptoms (abdominal pain and bloating). This was assessed via an 11-point visual analog scale (VAS) reported by the patients in a daily register. Results: thirty female patients were consecutively included. The median follow-up time was 18 months. The mean (standard deviation [SD]) number of weekly bowel movements significantly increased from 0.9 (0.6) at baseline to 4.7 (3.9) at the end of follow-up, p < 0.0001. Abdominal pain significantly decreased from 5.7 (2.3) at baseline to 3.1 (2.8) at the end of the follow-up period, p < 0.0001. Similarly, bloating significantly decreased from 6.8 (1.6) to 2.9 (2.5) at the beginning and end of the treatment period, respectively, p < 0.0001. The mean (SD) degree of satisfaction at the end of the study was 6.7 (3.0). Conclusions: long-term linaclotide treatment in patients with C-IBS is effective and safe in the clinical setting.

Recommendations to report and interpret HLA genetic findings in coeliac disease

Type V biliary cyst with cystolithiasis

Peroral endoscopic myotomy in pediatric jackhammer esophagus

ABSTRACT The jackhammer esophagus is a rare hypercontractile disorder and diagnosis is based on high-resolution manometry. Peroral endoscopic myotomy (POEM) of the spastic esophagus segments has been described. We report a pediatric patient with jackhammer esophagus that was treated endoscopically.

Sarcoidosis onset simulating a unique hepatic metastasis

RESUMEN La sarcoidosis es una enfermedad granulomatosa sistémica de etiología incierta, caracterizada por la formación de granulomas no necrotizantes. La afectación más frecuente es la pulmonar y mediastínica, aunque puede afectar a cualquier órgano. La afectación hepática ocurre en el 50-65% de los casos, pero suele ser subclínica o descubierta en el estudio de una alteración de las enzimas hepáticas. El debut de una sarcoidosis como una tumoración hepática aislada en muy inusual. La biopsia hepática suele ser necesaria para confirmar el diagnóstico y el diagnóstico diferencial debe establecerse con cualquier enfermedad hepática granulomatosa de carácter infeccioso o autoinmune y la exclusión de malignidad. Presentamos un caso clínico de una paciente diagnosticada de sarcoidosis hepática aislada simulando una lesión única hepática metastásica. La biopsia hepática fue diagnóstica.

ABSTRACT Sarcoidosis is a systemic granulomatous disease with an uncertain etiology, characterized by the production of non-necrotizing granulomas. The most frequent presentation is pulmonary and mediastinal, although it might affect any other organ. Hepatic alterations occur in 50 to 65% of the cases. Nevertheless, it is commonly subclinical or detected during a study of the alteration of liver enzymes. It is very unusual that disease onset occurs as an isolated hepatic tumor. A hepatic biopsy is usually required to confirm the diagnosis. A differential diagnosis must be established via any hepatic granulomatous disease, infectious or autoimmune disease as well as the exclusion of malignancy. We present a clinical case of a female diagnosed with an isolated hepatic sarcoidosis that simulated a unique hepatic metastatic lesion. The hepatic biopsy was diagnostic.

MRCP before ERCP: the added value in the management of common bile duct stones

Intramural esophageal dissection. A rare occurrence in pediatric eosinophilic esophagitis

Accuracy of malignancy criteria for an intraductal papillary mucinous neoplasm. Should we have blind faith in consensus guidelines?

A study of a pancreatic mass: not all is what it seems

A case report: asymptomatic esophageal eosinophilia after herpes simplex esophagitis. Controversies in the therapeutic approach

Cellulase, Coca-Cola®, pancreatin and ursodeoxycholic acid in the dissolution of gastric bezoars: why not all together?