The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis).

Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment).

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

Safety of continuous propofol sedation for endoscopic procedures in elderly patients.

OBJECTIVE: to evaluate safety of continuous propofol sedation in elderly patients who undergo endoscopic procedures and investigate risk factors to develop complications in the geriatric population. MATERIAL AND METHODS: patients who received endoscopist-directed propofol sedation were classified into two groups according to age. Group I: > 80 years; Group II: < 80 years. Propofol was administered by continuous intravenous infusion to achieve deep sedation. Arterial oxygen saturation, heart rate, blood pressure, and electrocardiographic records were monitored during the procedure. Therapy and complications secondary to sedation were recorded. RESULTS: one thousand two-hundred and ninety-five endoscopic procedures (gastroscopies, colonoscopies and endoscopic ultrasonographies) were included. The dose of propofol was lower and therapy was more frequently performed in Group I. There were no differences between sedation-related complications in both groups (Group I: 15.4%, Group II: 14%; p:n.s.). Patients in Group I showed greater tendency to develop severe oxygen desaturation in the colonoscopy and endoscopic ultrasonography procedures. In the univariate analysis, a higher dose of propofol was associated with the appearance of complications (157.4 ± 84.4 vs 121.3 ± 89.6 mg) in elderly patients but it was not associated with severe oxygen desaturation. CONCLUSIONS: continuous propofol sedation during endoscopic procedures in elderly patients > 80 years is as safe as in younger patients.

Seguridad de la sedación con perfusión continua de propofol en procedimientos endoscópicos en ancianos / No disponible

Objetivo: evaluar la seguridad de la sedación con perfusión continua de propofol en ancianos a los que se les realizan procedimientos endoscópicos e investigar los factores de riesgo para el desarrollo de complicaciones en la población anciana. Diseño experimental: estudio observacional prospectivo de cohortes. Pacientes: pacientes sedados mediante perfusión continua administrada por el propio endoscopista divididos en dos grupos: Grupo I: ≥ 80 años; Grupo II: < 80 años. El propofol fue administrado mediante perfusión continua para conseguir sedación profunda. Durante la exploración se monitorizó: saturación arterial de oxígeno, presión arterial y registro electrocardiográfico. Se registró además si se realizó terapéutica endoscópica y las complicaciones relacionadas con la sedación que se produjeron. Resultados: se incluyeron 1.295 procedimientos endoscópicos (gastroscopias, colonoscopias y ecoendoscopias). La dosis de propofol fue inferior y la endoscopia fue terapéutica con mayor frecuencia en el Grupo I. No hubo diferencias en la aparición de complicaciones relativas a la sedación entre ambos grupos. (Grupo I: 15,4%, Grupo II: 14%; p:n.s.). Los pacientes del Grupo I tuvieron una mayor tendencia a desarrollar desaturación grave durante la colonoscopia y ecoendoscopia. En el análisis univariante, en los pacientes ancianos, el incremento en la dosis de propofol se asoció con la aparición de complicaciones (157,4 ± 84,4 vs 121,3 ± 89,6 mg) pero no con la desaturación grave. Conclusiones: la sedación con perfusión continua de propofol en procedimientos endoscópicos en pacientes >= 80 años es tan segura como en pacientes más jóvenes(AU)

Objective: to evaluate safety of continuous propofol sedation in elderly patients who undergo endoscopic procedures and investigate risk factors to develop complications in the geriatric population. Material and methods: patients who received endoscopist-directed propofol sedation were classified into two groups according to age. Group I: ≥ 80 years; Group II: < 80 years. Propofol was administered by continuous intravenous infusion to achieve deep se - dation. Arterial oxygen saturation, heart rate, blood pressure, and electrocardiographic records were monitored during the procedure. Therapy and complications secondary to sedation were recorded. Results: one thousand two-hundred and ninety-five endoscopic procedures (gastroscopies, colonoscopies and endoscopic ultrasonographies) were included. The dose of propofol was lower and therapy was more frequently performed in Group I. There were no differences between sedation-related complications in both groups (Group I: 15.4%, Group II: 14%; p:n.s.). Patients in Group I showed greater tendency to develop severe oxygen desaturation in the colonoscopy and endoscopic ultrasonography procedures. In the univariate analysis, a higher dose of propofol was associated with the appearance of complications (157.4 ± 84.4 vs 121.3 ± 89.6 mg) in elderly patients but it was not associated with severe oxygen desaturation. Conclusions: continuous propofol sedation during endoscopic procedures in elderly patients >= 80 years is as safe as in younger patients(AU)

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy.

Propofol sedation by non-anesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anaesthesiologist administration of propofol for GI endoscopy.

Propofol sedation by non-anaesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anaesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.The guideline is published simultaneously in the Journals Endoscopy and European Journal of Anaesthesiology.

Fractura-luxación de columna cervical tras accidente de tráfico. Presentación de un caso / Fracture-luxation of the cervical spine after a car accident. Report of a case

En la actualidad en los servicios de urgencias hospitalarios es frecuente la atención a pacientes con sintomatología cervical tras accidente de tráfico. Aunque en la mayoría de los casos las lesiones son leves no por ello debemos descuidar su atención tanto en el nivel extrahospitalario como en el hospitalario. En el presente trabajo describimos el caso de una paciente, mujer de 48 años de edad, que tras sufrir un accidente de tráfico con vuelco del vehículo refería dolor a nivel de columna cervical. A la exploración objetivamos paresia de extremidad superior izquierda y parestesias en extremidad superior derecha. La Tomografía Axial Computadorizada cervical de urgencias, ante la imposibilidad de la completa visualización de la columna cervical en la radiología simple, nos confirmó el diagnóstico de fractura-luxación de la columna cervical en el nivel C7-D1 (AU)

Nowadays, Hospitals´Casualty Departments frequently assist cervical injured patients due to traffic accidents. Although most of them are not severe, we must not underestimate both out-patients and in-patients ones. This report describes the case of a 48 year-old woman who complained of cervical spine pain after her car turned upside down in a traffic accident. Exploration showed paresia in upper left limb and paresthesia in the upper right one. Since the simple X-ray could not show full vision of spinal cord, casualty Computed Tomography (CT) confirmed a spinal cord fracture dislocation diagnosis at level C7-D1 (AU)

[Primary linitis plastica of the rectum]. / Linitis plástica de recto primaria.

Linitis plastica of the rectum is an uncommon entity that is difficult to diagnose due to the lack of mucosal lesions on endoscopy, the low diagnostic yield of biopsy and non-specific findings of barium radiology and computerized tomography. Rectal endoscopic ultrasonography has had a radical impact on the differential diagnosis of stenosing lesions of the rectum, among them linitis plastica, allowing diagnosis of this lesion even in patients with negative results of biopsy.

Factors predicting mortality in severe acute pancreatitis.

UNLABELLED: Acute pancreatitis (AP) is a common disorder in which ensuing serious complications may lead to a fatal outcome in patients. BACKGROUND/AIMS: To describe a large series of patients with severe AP (SAP) who were admitted to our hospital and to identify factors predicting mortality. PATIENTS AND METHODS: In a retrospective study, all patients with SAP diagnosed between February 1996 and October 2000 according to the Atlanta criteria were studied. RESULTS: Out of a total of 363 AP patients, 67 developed SAP. The mean age of the patients was 69; the commonest etiology was biliary; 55.2% developed necrosis; the commonest systemic complication was respiratory failure (44.7%), followed by acute renal failure (35.8%) and shock (20.9%). A total of 31.3% of the patients died. Factors significantly related to mortality were age, upper digestive tract bleeding, acute renal failure, respiratory failure and shock by univariate analysis. However, pseudocysts seemed to have a protective effect. By multivariate analysis, independent prognostic factors were age, acute renal failure and respiratory failure. CONCLUSIONS: Patients with SAP mainly died due to systemic complications, especially acute renal failure and respiratory failure. Necrosis (in the absence or presence of infection) was not correlated with increased mortality. A pseudocyst was found to be a protective factor, probably because the definition itself led to the selection of patients who had survived multiorgan failure.

Usefulness of carbohydrate-deficient transferrin and trypsin activity in the diagnosis of acute alcoholic pancreatitis.

OBJECTIVE: The aim of this study was to assess if carbohydrate-deficient transferrin (CDT) and trypsin activity differentiate acute alcoholic pancreatitis from nonalcohol-related pancreatitis, and as a secondary goal to evaluate its use in comparison to healthy controls. METHODS: Serum levels of CDT and trypsin activity were measured in frozen sera from 70 nonconsecutive patients with acute pancreatitis and in 16 healthy controls. RESULTS: Causes of pancreatitis were gallstones in 51%, chronic alcoholism in 23%, and other or unknown causes in 26% of the patients. Serum CDT was significantly higher in alcoholic pancreatitis than in the nonalcoholic disease (p < 0.0001) with a median (interquartile range) of 30.8 U/L (23.6-41.7 U/L) in chronic alcoholism, 16.7 U/L (13.05-21.1 U/L) in gallstones, 17.5 U/L (15.9-21.6 U/L) in unknown cause, 19.3 U/L (15.1-27.7 U/L) in other etiologies, and 16.1 U/L (12.1-18.8 U/L) in controls. At a cutoff over 22.5 U/L, CDT showed a sensitivity of 87.5% and a specificity of 85.2%. Serum levels of trypsin activity were significantly higher (p = 0.0007) in alcoholic pancreatitis, median 165 U/L (76-405 U/L) than in nonalcoholic pancreatitis, median 73 U/L (46.5-100.5 U/L). At a cutoff value over 152 U/L, the sensitivity of trypsin activity was 60% with a specificity of 100%. In the multivariate analysis, patient's age (< or = 44 yr), CDT (>22.5 U/L), and trypsin activity (>152 U/L) enabled correct prediction of acute alcoholic pancreatitis in 98% of the cases. CONCLUSION: Serum CDT and trypsin activity are of clinical utility in differentiating alcoholic from nonalcoholic acute pancreatitis.

[Development of Escherichia coli strands resistant to quinolones in stools of patients with liver cirrhosis submitted to selective bowel decontamination]. / Aparición de cepas de Escherichia coli resistentes a quinolonas en las heces de pacientes cirróticos sometidos a descontaminación intestinal selectiva.

BACKGROUND: Selective intestinal decontamination (SID) with norfloxacin in patients with cirrhosis may promote the development of quinolone-resistant (QR) gram-negative bacteria in stools. It is not known wether this fact may become a predisposing factor for the development of infections due to these bacteria. MATERIAL AND METHODS: We designed a prospective study to evaluate the incidence of Escherichia coli in stools at admission in patients with cirrhosis that had previously received norfloxacin as primary or secondary prophylaxis of spontaneous bacterial peritonitis (SBP) (group I, n = 28) vs those who did not (group II, n = 55). RESULTS: QR strains of E. coli were observed in 37.5 and in 1.47% of patients from groups I and II, respectively (p < 0.001). During admission, 36 patients underwent norfloxacin prophylaxis (group III), and 40 did not (group IV). Eleven patients from group III and one patient from group IV showed QR E. coli in stools. We observed 5 bacterial infections in group III and 14 in group IV (p = 0.0039). No patient with QR E. coli in stools developed infections due to this bacteria. CONCLUSION: The incidence of QR E. coli in stools of patients with cirrhosis is significantly increased in patients previously treated with prophylactic norfloxacin. However, this fact seems not to be associated with an increment in the prevalence of QR E. coli infections.

Development of quinolone-resistant strains of Escherichia coli in stools of patients with cirrhosis undergoing norfloxacin prophylaxis: clinical consequences.

BACKGROUND/AIM: Norfloxacin prophylaxis decreases the incidence of bacterial infections in high-risk cirrhotic patients, but may promote the development of quinolone-resistant gram-negative bacteria in stools, and eventually lead to infections due to these bacteria. The aim of the study was to evaluate the prevalence of quinolone-resistant strains of E. coli in stools on admission, and the characteristics of any nosocomial infections. METHODS: Eighty-three consecutively hospitalized cirrhotic patients were included in this prospective study. The presence of quinolone-resistant strains of E. coli in stools on admission, and the characteristics of any nosocomial infections were recorded. RESULTS: Fourteen out of 83 patients (16.8%) showed quinolone-resistant E. coli in stools (Group I), and 69 did not (Group II). Thirteen out of 14 from Group I (92.8%) and 17/69 (24.6) from Group II had received primary or secondary prophylaxis with norfloxacin (p<0.001). During hospitalization, 12/12 (100%) of patients from Group I and 25/66 (37.8%) of patients from Group II underwent norfloxacin prophylaxis. Three bacterial infections in patients from Group I, 3 from Group II patients receiving norfloxacin and 16 from Group II patients not receiving norfloxacin were recorded (p<0.05). No infections due to quinolone-resistant E. coli were observed in patients colonized with these bacteria. Treatment with norfloxacin induced the development of quinolone-resistant E. coli in 6/14 (42.8%) patients in a mean time of 18.5+/-9.8 days. CONCLUSIONS: The development of quinolone-resistant strains of E. coli is significantly associated with previous administration of norfloxacin prophylaxis. However, in our series this fact is not associated with an increased incidence of quinolone-resistant E. coli or other gram-negative infections.

Obesity: a prognostic factor of severity in acute pancreatitis.

This study was conducted to assess the prognostic value of obesity in acute pancreatitis and to determine the role played by obesity-associated diseases in the course of the disease. We prospectively studied 49 patients with acute pancreatitis who were divided into three groups according to their body mass index (BMI). There were 22 patients in group I (BMI < or = 25 kg/m2, normal or low weight); 15 in group II (BMI >25 and < or = 29 kg/m2, overweight); and 12 in group III (BMI >29 kg/m2, obese). Other anthropometric parameters also were measured. The severity of pancreatitis was assessed according to the Atlanta classification system. Systemic complications were significantly more common among obese than nonobese patients (p < 0.05). Patients with severe pancreatitis had a higher body-fat percentage, measured by the subscapular skin-fold thickness, and a larger abdominal circumference than patients with mild pancreatitis. Although hypertensive or diabetic patients developed more systemic complications, the multivariate analysis demonstrated that the presence of these underlying diseases did not modify the prognostic role of obesity in acute pancreatitis. We conclude that obesity is a prognostic factor of outcome in acute pancreatitis. Obesity-associated diseases do not vary the prognostic value of obesity. It seems that truncal adiposity is the kind of obesity related to worse outcome of acute pancreatitis.