Amiloidosis por cadenas livianas de inmunoglobulina con compromiso gástrico al debut: revisión de la literatura basada en un caso clínico / Gastric AL amyloidosis as initial manifestation: literature review from a case report

Systemic amyloidosis comprises a group of diseases characterized by low molecular weight subunit protein deposit in organs, including the gastrointestinal tract. The most frequent clinical manifestations are gastrointestinal bleeding, malabsorption syndrome, protein-losing enteropathy and chronic intestinal dysmotility. The diagnosis is confirmed with gastrointestinal tissue biopsy positive to Congo red stain or recognizing the amyloid fibrils by electron microscopy. The treatment is based in the management of gastrointestinal symptoms and chemotherapeutic drugs, including melphalan and prednisone or cyclophosphamide, bortezomib and prednisone. The bone marrow transplant is reserved for 70-year-old patients or younger without advanced comorbidities. We present a case of a patient with weight loss, anorexia, nausea and early satiety.

La amiloidosis sistémica a un conjunto de enfermedades caracterizadas por el depósito de subunidades fibrilares proteicas de bajo peso molecular en órganos, incluyendo el sistema digestivo. Sus manifestaciones clínicas más frecuentes son la hemorragia digestiva, síndrome malabsortivo, gastro-enteropatía perdedora de proteínas y dismotilidad gastrointestinal crónica. El diagnóstico se confirma con una biopsia de tejido gastrointestinal positiva a tinción rojo Congo o la visualización de fibrillas de amiloide mediante microscopia electrónica. El tratamiento está basado el manejo de los síntomas gastrointestinales y el oncológico, donde destacan esquemas quimioterapéuticos que incluyen melfalan y prednisona o ciclofosfamida, bortezomib y prednisona. El trasplante de médula ósea está reservado a pacientes menores de 70 años sin comorbilidades avanzadas. Presentamos en este artículo el caso de un paciente con baja de peso, anorexia, náuseas y saciedad precoz.

Alternativas terapéuticas para el manejo de la ectasia vascular gástrica antral (GAVE) / Alternatives for the treatment of gastric antral vascular ectasia (GAVE)

Gastric antral vascular ectasia is an unusual cause of upper gastrointestinal bleeding. The most frequent clinical presentation is iron deficiency anemia in a female patient older than 60 years. A third of patients have liver cirrhosis or a connective tissue disease, especially those related to Raynaud’s syndrome and scleroderma. The severity of this condition is variable, in some cases iron supplements are enough, while in other transfusion requirements are permanent. Currently the therapies most frequently reported in literature are argon plasma coagulation, radiofrequency ablation and endoscopic band ligation of antral mucosa. This article aims to review the available evidence for the management of this condition.

La ectasia vascular gástrica antral es una causa infrecuente de hemorragia digestiva alta cuya forma de presentación más habitual es la anemia ferropriva en una mujer mayor de 60 años. Un tercio de los pacientes tiene antecedente de cirrosis hepática o enfermedades del tejido conectivo relacionadas al síndrome de Raynaud o esclerodermia. El compromiso es de intensidad variable, sin embargo, en casos graves los pacientes pueden requerir transfusiones en forma permanente. En la actualidad las terapias más frecuentemente reportadas en la literatura son la termocoagulación con argón plasma, la ablación con radiofrecuencia y la ligadura de mucosa antral con bandas elásticas. El objetivo principal de este artículo es revisar la evidencia disponible para el manejo de esta condición.

Aceptación y adherencia de una pauta de preparación de colon el mismo díadel examen en población chilena / Patients’ acceptance and adherence to total or partial split dose bowel preparation for colonoscopy in chilean population

Colon preparation is more effective if it is partially or totally administered the same day of the colonoscopy. Objective: To know acceptance of a preparation guideline for the same day of the procedure and adherence to this guideline once it is implemented in a digestive endoscopy center. Methods: First, the importance of a preparation guideline for the same day was explained and adult patients and accompanying persons with preparation in the previous day were asked if they would be willing to prepare for the colonoscopy 4-5 h before the procedure. In the second stage, adult patients were surveyed who received instructions to prepare using polyethylene glycol solution (3 litres) the same day of the procedure. Results: 160 people were surveyed in phase one. 86 percent was willing to get up at 4 am to drink the solution, without statistical correlation with the other variables studied. 42.7 percent would prefer to split the doses and 39 percent would drink all the same day. 102 people were surveyed in phase two. 92 percent drank the preparation totally or partially the same day of the procedure (69 percent and 25 percent, respectively). 82 percent drank at least 80 percent of the dose. 51.5 percent described the preparation process as quite or very unpleasant. 45 percent would prefer colonoscopy preparation in the previous day. Conclusions: In our experience, most patients would accept preparation in the same day of the procedure and adhere to this, however, almost 50 percent would prefer to take it the previous day, in a future procedure.

La preparación de colon es más efectiva si es administrada parcial o totalmente el mismo día de la colonoscopia. Objetivo: Conocer la aceptación a una pauta de preparación al menos en parte el mismo día de la colonoscopia y adherencia a esta una vez implementada en un Centro de Endoscopia Digestiva. Métodos: Primero se explicó la importancia de una pauta de preparación el mismo día y se encuestó a pacientes adultos y acompañantes a estudio endoscópico con preparación exclusiva el día anterior si estarían dispuestos a realizar preparación para colonoscopia 4-5 h antes de la prueba. En la segunda fase se encuestó a pacientes adultos a los que se había indicado preparación con solución de polietilenglicol (3 litros) el mismo día del procedimiento. Resultados: En la fase 1 se encuestó a 160 personas. El 86 por ciento aceptaría levantarse a las 4 AM para tomar la preparación, sin relación estadística con las demás variables estudiadas. El 42,7 porciento preferirían tomar la dosis en forma repartida y 39 por ciento preferían beber todo el mismo día. En la fase 2 se encuestó a 102 personas. El 92 porciento tomó la preparación total o parcialmente el mismo día del examen (69 por ciento y 25 por ciento respectivamente). El 82 porciento tomó al menos 80 por ciento de la cantidad indicada. El 51,5 porciento calificó el proceso de la preparación como bastante o muy desagradable. El 45porciento preferiría en colonoscopias futuras la preparación el día anterior. Conclusiones: En nuestro medio, la mayoría de los pacientes aceptarían la pauta de preparación el mismo día de la prueba y adhieren a esta, aunque casi la mitad preferiría tomarla el día anterior en el futuro.

Reactivación de Citomegalovirus en crisis de enfermedad inflamatoria intestinal: un análisis retrospectivo / Cytomegalovirus reactivation in inflammatory bowel disease: a retrospective analysis

Cytomegalovirus (CMV) is considered an agent involved in reactivation of inflammatory bowel disease (IBD). In our country there are no studies or guidelines to standardize CMV search in that setting. Objective: To describe the prevalence of CMV infection in hospitalized patients with IBD. Methods: Retrospective analysis of patients hospitalized due to IBD crisis from June 2007 to June 2009 at a university health center. Electronic cards, laboratory data, and endoscopic study were reviewed. CMV reactivation was diagnosed by means of antigenemia assay, and/or histopathology. Results: 88 IBD crises were identified (74 patients), in 52 a CMV study was requested (47 with antigenemia assay). Mean age was 38.5 years-old, 54 percent female, ulcerative colitis 67.3 percent, Crohn disease 32.7 percent. IBD crisis were classified as follows; severe 57.7 percent, moderate or mild 42.3 percent. The CMV diagnosis test was positive in 5 cases (9.6 percent), all of them were severe crisis (16.6 percent in severe crisis versus 0 percent in moderate/mild crisis, p = 0.055). In the group of steroid resistant disease the CMV antigenemia was positive in 66.6 percent versus 2.17 percent of non-steroid resistant patients (p = 0.0002). Test to detect CMV performed after the third day of hospitalization were positive in 36.36 percent versus those performed earlier, which were positive in 2.43 percent (p = 0.004). Conclusion: High prevalence of CMV infection in cases of severe IBD crisis was detected, specifically in a subgroup of steroid-resistant patients and three days after hospital admission. These findings suggest the importance to search CMV in this subgroup of patients.

Introducción: El citomegalovirus (CMV) puede participar en la reactivación de la enfermedad inflamatoria intestinal (EII). En nuestro medio no se ha estudiado el rol de CMV en pacientes hospitalizados por crisis de EII. Objetivo: Estimar la prevalencia de la reactivación de CMV en crisis de EII que requirieron hospitalización. Métodos: Análisis retrospectivo de pacientes hospitalizados en un centro de salud universitario por EII entre junio de 2007 y junio de 2009. Se revisaron registros clínicos electrónicos, laboratorio y estudio endoscópico. La reactivación de CMV se diagnosticó mediante antigenemia y/o histología. Resultados: Se identificaron 88 crisis de EII (74 pacientes), en 52 se solicitó estudio de CMV (47 con antigenemia). 67,3 por ciento fueron colitis ulcerosa; 32,7 por ciento enfermedad de Crohn. Edad promedio 38,5 años, 54 por ciento sexo femenino. La exacerbación fue catalogada como grave en 57,7 por ciento de los casos, moderada o leve en 42,3 por ciento. Se detectó reactivación de CMV en 5 pacientes (9,6 por ciento), los que se caracterizaron por presentar crisis grave (16,6 por ciento en crisis grave versus 0 por ciento en crisis leve/moderada, p = 0,055), refractariedad a corticoides (66,6 por ciento en corticorrefractarios versus 2,17 por ciento en sensibles a corticoides, p = 0,0002) y hospitalización mayor de 3 días (36,36 por ciento en hospitalización > 3 días versus 2,43 por ciento en estudio temprano, p = 0,004). Conclusión: En pacientes hospitalizados por crisis de EII es frecuente detectar evidencia de reactivación de CMV, la que se concentra en las crisis graves, corticorrefractarias y con hospitalización mayor de 3 días. Estos datos sugieren que la búsqueda de CMV debiera ser dirigida a este subgrupo de pacientes.

Análisis crítico de un artículo: La suspensión de inhibidores de la bomba de protones induciría síntomas de reflujo / Critically appraised article

Background & Aims: Rebound acid hypersecretion (RAHS) has been demonstrated after 8 weeks of treatment with a proton-pump inhibitor (PPI). IfRAHS induces acid-related symptoms, this might lead to PPI dependency and thus have important implications. Methods: A randomized, double-blind, placebo-controlled trial with 120 healthy volunteers was conducted. Participants were randomized to 12 weeks of placebo or 8 weeks of esomeprazole 40 mg/d followed by 4 weeks with placebo. The Gastrointestinal Symptom Rating Scale (GSRS) was filled out weekly. A score of >2 on 1 of the questions regarding heartburn, acid regurgitation, or dyspepsia was defined as a clinically relevant acid-related symptom. Results: There were no significant differences between groups in GSRS scores at baseline. GSRS scores for acid-related symptoms were significantly higher in the PPIgroup at week 10 (1.4 ± 1.4 vs 1.2 ± 0.9; P = .023), week 11 (1.4 ± 1.4 vs 1.2 ± 0.9; P = .009), and week 12 (1.3 ± 1.2 vs 1.0 ± 0.3; P = .001). Forty-four percent (26/59) of those randomized to PPI reported >1 relevant, acid-related symptom in weeks 9-12 compared with 15% (9/59; P < .001) in the placebo group. The proportion reporting dyspepsia, heartburn, or acid regurgitation in the PPIgroup was 13 of 59 (22%) at week 10,13 of59 (22%) at week 11, and 12 of 58 (21%) at week 12. Corresponding figures in the placebo group were 7% at week 10 (P = .034), 5% at week 11 (P = .013), and 2% at week 12 (P = .001). Conclusions: PPI therapy for 8 weeks induces acid-related symptoms in healthy volunteers after withdrawal. This study indicates unrecognized aspects of PPI withdrawal and supports the hypothesis that RAHS has clinical implications.

Manejo de várices gastroesofágicas: revisión de la evidencia y consenso: metodología y organización de las guías / Management of gastroesophageal varices: evidence-based review and consensus: methodology and organization of the guidelines

Introduction: There is plenty of scientific evidence regarding the management of esophageal varices, but sometimes it is contradictory. International consensuses carried out in America and Europe are evidence based, however these do not include a comprehensive analysis on the quality of the studies. The purpose of this review is to establish a national consensus, by means of relevant questions regarding the management of gastroesophageal varices, to provide detailed information on related evidence, thus, establishing reasonable behaviors based on the national scenario. Methodology: The guidelines are organized following 15 clinically relevant questions on the management of gastroesophageal varices, including primary prophylaxis, interventional pharmacological, endoscopical and radiological treatment of variceal hemorrhage until secondary prophylaxis. Quality assessment of the evidence supporting each asseveration will be descriptive and will be based mainly in the design of the studies, adapted from the recommendations of the U.S. Preventive Services Task Force. Then, the group of experts will make a recommendation for each intervention in response to each question. The consensus will be achieved by a Delphi approach of 2 rounds, and the third round will be achieved in the national consensus to be carried out in June 2010 during the Course on Advances in Gastroenterology, with the participation of the audience, using an electronic board where the questions will be answered in actual time. Preliminary results: The survey includes 15 open questions which were distributed among the 12 experts who will provide responses according to levels/degrees of evidence and recommendations. Conclusions: Definitive results of the national consensus will be presented during the Course on Advances in Gastroenterology 2010 and will be published in the Gastroenterología Latinoamericana journal. This methodology can be replicated in the future in other areas ...

Introducción: La evidencia científica en relación al manejo de las várices gastroesofágicas es abundante y muchas veces contradictoria. Los consensos internacionales realizados en América y Europa son basados en la evidencia, sin embargo, no incluyen un análisis detallado de la calidad de los estudios incluidos. El objetivo de la presente revisión es establecer un consenso a nivel nacional, a través de preguntas relevantes en el manejo de las varices gastroesofágicas, detallar la evidencia relacionada y establecer así conductas racionales, considerando la realidad nacional. Metodología: Las guías están organizadas en relación a 15 preguntas clínicas relevantes en el manejo de las várices gastroesofágicas que incluyen la profilaxis primaria, tratamiento farmacológico, endoscópico y radiológico intervencional de la hemorragia variceal hasta la profilaxis secundaria. La evaluación de la calidad de la evidencia que sustenta cada afirmación se realizará en forma descriptiva, fundamentándose primordialmente en el diseño de los estudios, adaptado de las recomendaciones realizadas por la U.S. Preventive Services Task Force. Luego el panel de expertos realizará una recomendación para cada intervención en respuesta a cada pregunta clínica. El consenso se realizará mediante una técnica Delfi de 2 rondas y la tercera ronda se realizará durante el consenso nacional a realizarse en el curso de avances en gastroenterología en junio de 2010 con participación de la audiencia mediante teclera electrónica con respuestas en tiempo real. Resultados preliminares: La encuesta incluye 15 preguntas abiertas distribuidas entre el panel de 12 expertos nacionales que deberán responder de acuerdo a la pauta de niveles de evidencia y grados de recomendación. Conclusión: Los resultados definitivos del consenso nacional serán expuestos durante el curso de avances en gastroenterología 2010 y publicados en la Revista Gastroenterología Latinoamericana. Esta metodología puede ser...

Análisis crítico de un artículo: Levofloxacino profiláctico en pacientes neutropénicos / Critically appraised article: Levofloxacin to Prevent Bacterial Infection in Patients with Cancer and Neutropenia

Background: The prophylactic use of fluoroquinolones in patients with cancer and neutropenia is controversial and is not a recommended intervention. Methods: We randomly assigned 760 consecutive adult patients with cancer in whom chemotherapy-induced neutropenia (<1000 neutrophils per cubic millimeter) was expected to occur for more than seven days to receive either oral levofloxacin (500 mg daily) or placebo from the start of chemotherapy until the resolution of neutropenia. Patients were stratified according to their underlying disease (acute leukemia vs solid tumor or lymphoma). Results: An intention-to-treat analysis showed that fever was present for the duration of neutropenia in 65 percent of patients who received levofloxacin prophylaxis, as compared with 85 percent of those receiving placebo (243 of 375 vs 308 of 363; relative risk, 0.76; absolute difference in risk, -20 percent; 95 percent confidence interval, -26 to -14 percent; P=0.001). The levofloxacin group had a lower rate of microbiologically documented infections (absolute difference in risk, -17 percent; 95 percent confidence interval, -24 to -10 percent; P <0.001), bacteremias (difference in risk, -16 percent; 95 percent confidence interval, -22 to -9 percent; P <0.001), and single-agent gram-negative bacteremias (difference in risk, -7 percent; 95 percent confidence interval, -10 to -2 percent; P <0.01) than did the placebo group. Mortality and tolerability were similar in the two groups. The effects of prophylaxis were also similar between patients with acute leukemia and those with solid tumors or lymphoma. Conclusions: Prophylactic treatment with levofloxacin is an effective and well-tolerated way of preventing febrile episodes and other relevant infection-related outcomes in patients with cancer and profound and protracted neutropenia. The long-term effect of this intervention on microbial resistance in the community is not known.