Crohn's disease and Sweet's syndrome: an uncommon association.

Sweet's syndrome or acute febrile neutrophilic dermatosis (SS) is characterized by the sudden onset of painful erythematous lesions (papules, nodules, and plaques) together with fever and neutrophilia. The lesions are typically located on hands, arms, upper trunk, neck and face, showing an asymmetric distribution. Acute phase reactants are usually elevated and dermal infiltration of neutrophils without vasculitis is seen on skin biopsies. It is considered as a marker of systemic disease in over half of the cases, and is associated with infections, inflammatory bowel disease, autoimmune connective tissue disorders and various neoplasias. Its association with Crohn's disease (CD) is unusual and it appears mainly in association with colonic involvement. Fewer than 50 cases have been published in the medical literature since its first description in 1964, some concurrent with the first episode of CD. We present two patients with Crohn's disease and Sweet's syndrome diagnosed in our department at the time of CD diagnosis, as well as their response to treatment, subsequent course of the disease, and a review of the scientific literature.

Enfermedad de Crohn y síndrome de Sweet: una asociación infrecuente / No disponible

El síndrome de Sweet o dermatosis neutrofílica febril aguda(SS) se caracteriza por la aparición brusca de lesiones eritematosas,(pápulas, nódulos y placas) dolorosas, junto con fiebre y neutrofilia,siendo de presentación poco frecuente. Las lesiones se localizanpreferentemente en manos, brazos, parte superior deltronco, cuello y cara, con distribución asimétrica. Suele haber elevaciónde reactantes de fase aguda y en las biopsias cutáneas seidentifica una infiltración dérmica de neutrófilos sin vasculitis. Seconsidera un marcador de enfermedad sistémica en más de la mitadde los casos, asociándose a infecciones, enfermedad inflamatoriaintestinal, conectivopatías autoinmunes y diversas neoplasias.Su asociación con la enfermedad de Crohn (EC) es poco habitual,asociado sobre todo a afectación colónica. Se han publicadomenos de 50 casos en la literatura médica desde su primera descripciónen 1964, algunos de ellos simultáneos con el primer brotede la EC. Presentamos dos pacientes con enfermedad deCrohn y síndrome de Sweet diagnosticados en nuestro servicio enel momento del diagnóstico de la EC, así como su respuesta al tratamiento,evolución posterior y revisión de la literatura científica(AU)

The uncommon Sweet’s syndrome or acute febrile neutrophilicdermatosis (SS) is characterized by the sudden onset of painfulerythematous lesions (papules, nodules, and plaques) togetherwith fever and neutrophilia. The lesions are typically located onhands, arms, upper trunk, neck and face, showing an asymmetricdistribution. Acute phase reactants are usually elevated and dermalinfiltration of neutrophils without vasculitis is seen on skinbiopsies. It is considered as a marker of systemic disease in overhalf of the cases, and is associated with infections, inflammatorybowel disease, autoimmune connective tissue disorders and variousneoplasias.Its association with Crohn’s disease (CD) is unusual and it appearsmainly in association with colonic involvement. Fewer than50 cases have been published in the medical literature since itsfirst description in 1964, some concurrent with the first episodeof CD. We present two patients with Crohn’s disease and Sweet’ssyndrome diagnosed in our department at the time of CD diagnosis,as well as their response to treatment, subsequent course ofthe disease, and a review of the scientific literature(AU)

Treatment of irritable bowel syndrome with probiotics. An etiopathogenic approach at last?

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.

Treatment of irritable bowel syndrome with probiotics. An etiopathogenic approach at last?

Irritable bowel syndrome (IBS) is the most common functionaldigestive disorder, and may affect 11-20% of the adult populationin 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 pathophysiologyof IBS, but the etiology still remains uncertain or obscure,perhaps multifactorial. Abnormalities in colonic microflora haverecently been suggested in such patients, as has abnormal smallintestinebacterial overgrowth (SIBO), or in particular a significantreduction in the amount of intraluminal Bifidobacteria or Lactobacilli,with consequences like the production of colonic gas, andmotility or sensitivity disturbances of the intestinal tract. The disorderis difficult to treat, and the wide spectrum of non-drug anddrug treatments shows our ignorance about the cause of the condition.Newer drugs, both pro- and anti-serotonin, have failed toshow long-term efficacy or have been withdrawn due to concernsabout harmful effects.Recent research has provided increasing support for the ideathat disturbances of intestinal microbiota occur in patients withIBS, and that such abnormalities may contribute to IBS symptoms.Studies in Scandinavian countries in the last ten years emphasizethe role of probiotics in the modulation of intestinal microbiota,and as a consequence in the regulation of the motilityand hypersensitivity of the digestive tract. Although results betweenstudies are difficult to compare because of differences instudy design, probiotic dose, strain, and duration of therapy, somestudies show symptom improvement...(AU)

[Effectiveness, safety, and tolerability of intragastric balloon in association with low-calorie diet for the treatment of obese patients]. / Efectividad, seguridad y tolerancia del balón intragástrico asociado a una dieta hipocalórica para la reducción de peso en pacientes obesos.

INTRODUCTION: the endoscopic placement of an intragastric balloon (IGB) in association with a low-calorie diet is an option for the treatment of obesity. The aim of the present study was to evaluate its effectiveness, safety, and tolerance. MATERIAL AND METHODS: thirty-eight patients with no contraindications for IGB were included in this prospective study from March 2004 to January 2007. Balloon removal was performed 6 months later. Weight and body mass index (BMI) were evaluated after IGB removal and at 6 months and 1 year thereafter. Tolerance and complications during treatment were evaluated. Patients filled out a questionnaire to evaluate their subjective perception of treatment. RESULTS: mean weight loss after 6 months on balloon treatment was 14.10 kg (0-46), and mean BMI reduction was 5.23 kg/m2 (0-18). At 12 months after balloon removal 48.4% of patients maintained their weight loss or kept loosing weight. Most common early symptoms included nausea (71.1%) and vomiting (57.9%) with a good response to symptomatic treatment. Complications were seen in 7 patients (18.4%): digestive intolerance in 4 patients, with early removal in 3 of them; moderate esophagitis in 2 patients; and gastric perforation complicated with septic shock and death in 1 patient. CONCLUSIONS: 1. IGB in association with low-calorie diet is an effective, safe, and well tolerated treatment for morbid obese patients.2. Almost half of patients maintained their weight loss after one year from balloon removal.

Efectividad, seguridad y tolerancia del balón intragástrico asociado a una dieta hipocalórica para la reducción de peso en pacientes obesos / No disponible

Introducción: la implantación de un balón intragástrico (BI)por vía endoscópica asociado a una dieta hipocalórica es una alternativaen el tratamiento de la obesidad. El objetivo de nuestroestudio es evaluar su efectividad, seguridad y tolerancia.Material y métodos: se incluyen de manera prospectiva 38pacientes sin contraindicaciones para la implantación del BI, desdemarzo de 2004 hasta enero de 2007. La retirada del balón serealizó 6 meses después de la implantación. Evaluamos el peso eíndice de masa corporal (IMC) tras la retirada del balón, a los 6 y12 meses postretirada, así como la tolerancia y aparición de complicacionesdurante el tratamiento. Tras la retirada del balón serealizó un cuestionario a cada paciente evaluando la percepciónsubjetiva al tratamiento.Resultados: después de 6 meses de tratamiento la pérdida depeso media fue de 14,10 kg (0-46) y la reducción media del IMCfue de 5,23 kg/m2 (0-18). A los 12 meses postretirada del balónel 48,4% de pacientes mantiene o sigue perdiendo peso. Los síntomasprecoces más frecuentes fueron náuseas (71,1%) y vómitos(57,9%), con buena respuesta a tratamiento sintomático. Presentaroncomplicaciones 7 pacientes (18,4%): intolerancia digestivaen 4 pacientes, requiriendo retirada precoz del balón en 3 deellos; esofagitis moderada en 2 pacientes; y perforación gástricacomplicada con shock séptico y exitus en 1 paciente.Conclusiones:1. El balón intragástrico asociado a una dieta hipocalórica puedeconsiderarse un tratamiento efectivo, seguro y bien toleradopara el tratamiento de pacientes con obesidad mórbida.2. La pérdida de peso se mantiene en casi la mitad de los pacientesal año tras la retirada del balón

Introduction: the endoscopic placement of an intragastricballoon (IGB) in association with a low-calorie diet is an option forthe treatment of obesity. The aim of the present study was to evaluateits effectiveness, safety, and tolerance.Material and methods: thirty-eight patients with no contraindicationsfor IGB were included in this prospective study fromMarch 2004 to January 2007. Balloon removal was performed 6months later. Weight and body mass index (BMI) were evaluatedafter IGB removal and at 6 months and 1 year thereafter. Toleranceand complications during treatment were evaluated. Patientsfilled out a questionnaire to evaluate their subjective perception oftreatment.Results: mean weight loss after 6 months on balloon treatmentwas 14.10 kg (0-46), and mean BMI reduction was 5.23kg/m2 (0-18). At 12 months after balloon removal 48.4% of patientsmaintained their weight loss or kept loosing weight. Mostcommon early symptoms included nausea (71.1%) and vomiting(57.9%) with a good response to symptomatic treatment. Complicationswere seen in 7 patients (18.4%): digestive intolerance in 4patients, with early removal in 3 of them; moderate esophagitis in2 patients; and gastric perforation complicated with septic shockand death in 1 patient.Conclusions:1. IGB in association with low-calorie diet is an effective, safe,and well tolerated treatment for morbid obese patients.2. Almost half of patients maintained their weight loss after one year from balloon removal (AU)

Diagnóstico precoz del cáncer colorrectal. ¿Programas de reducción de demora diagnóstica o, mejor, de cribado? / Early diagnosis of colorectal cancer. Diagnostic delay reduction or rather screening programs?

No disponible

Tratamiento con antidepresivos en los trastornos funcionales digestivos / Antidepressant therapy in functional gastrointestinal disorders

Los datos disponibles basados en ensayos clínicos aleatorizados o metaanálisis acerca de la eficacia terapéutica de los psicofármacos y concretamente los antidepresivos (ATD) en los trastornos funcionales digestivos (TFD) son recientes y aún relativamente limitados. Su empleo se fundamenta en la frecuente asociación de ansiedad, depresión o neurosis en los pacientes con TFD que consultan, y en su efectividad demostrada en el alivio del dolor crónico, sea cual sea su localización u origen, desde hace más de 30 años. Los ATD, incluso a dosis bajas por debajo del rango antidepresivo, son antinociceptivos por su efecto neuromodulador central y periférico, lo que es totalmente independiente de las acciones anticolinérgica, espasmolítica o antidepresiva. Ello se demostró en el animal de experimentación y en el ser humano, y es mediado por adrenorreceptores-a, al igual que sucede con otro fármaco antinociceptivo como es clonidina. La elección terapéutica de uno u otro ATD dependerá tanto de la evidencia demostrada de su actividad analgésica (en general mayor con los tricíclicos que con los más modernos inhibidores selectivos de la recaptación de la serotonina [ISRS]) como de la presencia de efectos adversos medicamentosos relacionados con su empleo, no sólo los anticolinérgicos sino singularmente la posibilidad de hipotensión o cardiotoxicidad, que deberían evitarse. Es decir, primarán la eficacia demostrada y la seguridad de su empleo. En el campo concreto del dolor torácico no coronario, de probable origen esofágico y no relacionado con el reflujo gastroesofágico, los ATD se demostraron eficaces, en especial la mianserina y la trazodona, y el efecto se mantiene a largo plazo en cerca del 75% de los pacientes tratados. Los tricíclicos también se han mostrado eficaces en el tratamiento del dolor abdominal de pacientes con SII, con una odds ratio de 4,2 y un número necesario de pacientes a tratar de 3,2 en comparación con el placebo. En cambio, en la dispepsia funcional (DF) no disponemos aún de evidencia de calidad como para recomendar el empleo terapéutico de los ATD

The available evidence from randomized clinical trials or meta-analyses on the therapeutic efficacy of psychotropic drugs and, specifically, of antidepressants, in functional gastrointestinal disorders (FGD), are recent and still fairly limited. The use of these drugs is based on the frequent association of anxiety and depression or neurosis in patients with FGD who seek medical care and on the demonstrated efficacy of these drugs in relieving chronic pain, whatever its origin or localization, for more than 30 years. Antidepressants, even in doses under the antidepressant range, are antinociceptive due to their central and peripheral neuromodulatory effect, which is completely independent of anticholinergic, spasmolytic or antidepressant effects. This has been demonstrated in both animals and humans and, as occurs with another antinociceptive drugs such as clonidine, is mediated by alpha-adrenoreceptors. The choice of antidepressant depends both on the evidence of its analgesic activity (in general greater with tricyclic antidepressants than with the more modern selective serotonin reuptake inhibitors) and on the presence of drug-related adverse effects, which include not only anticholinergic adverse effects but also the possibility of hypotension or cardiotoxicity, which should be avoided. The main selection criteria are demonstrated efficacy and safety. Antidepressants have been shown to be effective in the specific field of non-coronary chest pain probably originating in the esophagus unrelated to gastroesophageal reflux disease, especially mianserin and trazodone, and the effect is maintained in the long term in nearly three-quarters of treated patients. Tricyclic antidepressants have also been shown to be effective in the treatment of abdominal pain in patients with irritable bowel syndrome, with an OR of 4.2 and an NNT of 3.2 in comparison with placebo. In contrast, there is insufficient evidence to recommend the use of antidepressants in functional dyspepsia

[Antidepressant therapy in functional gastrointestinal disorders]. / Tratamiento con antidepresivos en los trastornos funcionales digestivos.

The available evidence from randomized clinical trials or meta-analyses on the therapeutic efficacy of psychotropic drugs and, specifically, of antidepressants, in functional gastrointestinal disorders (FGD), are recent and still fairly limited. The use of these drugs is based on the frequent association of anxiety and depression or neurosis in patients with FGD who seek medical care and on the demonstrated efficacy of these drugs in relieving chronic pain, whatever its origin or localization, for more than 30 years. Antidepressants, even in doses under the antidepressant range, are antinociceptive due to their central and peripheral neuromodulatory effect, which is completely independent of anticholinergic, spasmolytic or antidepressant effects. This has been demonstrated in both animals and humans and, as occurs with another antinociceptive drugs such as clonidine, is mediated by alpha-adrenoreceptors. The choice of antidepressant depends both on the evidence of its analgesic activity (in general greater with tricyclic antidepressants than with the more modern selective serotonin reuptake inhibitors) and on the presence of drug-related adverse effects, which include not only anticholinergic adverse effects but also the possibility of hypotension or cardiotoxicity, which should be avoided. The main selection criteria are demonstrated efficacy and safety. Antidepressants have been shown to be effective in the specific field of non-coronary chest pain probably originating in the esophagus unrelated to gastroesophageal reflux disease, especially mianserin and trazodone, and the effect is maintained in the long term in nearly three-quarters of treated patients. Tricyclic antidepressants have also been shown to be effective in the treatment of abdominal pain in patients with irritable bowel syndrome, with an OR of 4.2 and an NNT of 3.2 in comparison with placebo. In contrast, there is insufficient evidence to recommend the use of antidepressants in functional dyspepsia.

[Chronic diarrhea with uncommon etiology]. / Diarrea crónica de causa infrecuente.

Chronic diarrhea is a common syndrome. An etiological diagnosis is often reached through clinical history, physical examination and simple tests. In some cases, when the etiology is not found, the syndrome is called functional diarrhea, even though established criteria are often not fulfilled. We present the case of a patient with diarrhea for several months. The most common causes were ruled out through clinical history, physical examination, radiographic studies and laboratory tests, and the patient was diagnosed with functional diarrhea. Three months later, the patient presented a neck mass, and biopsy revealed medullary carcinoma of the thyroid. A review of recommendations for the systematic evaluation of chronic diarrhea is presented. A general approach should include careful history taking characteristics of diarrhea (onset, associated symptoms, epidemiological factors, iatrogenic causes such as laxative ingestion), a thorough physical examination with special attention to the anorectal region, and routine laboratory tests (complete blood count and serum chemistry). In addition, stool analysis including electrolytes (fecal osmotic gap), leukocytes, fecal occult blood, excess stool fat and laxative screening can yield important objective information to classify the diarrhea as: osmotic (osmotic gaps > 125 mOsm/Kg), secretory (osmotic gaps < 50 mOsm/Kg), inflammatory or steatorrheic. At this point in the evaluation, a specific diagnosis may be made. However, if diagnosis is not reached further specific examinations should be performed for each of the 4 types of diarrhea described above. A systematic approach to the evaluation of chronic diarrhea is warranted. Medullary thyroid carcinoma and other endocrine syndromes causing chronic diarrhea are very rare. Measurement of serum peptide concentrations should only be performed when clinical presentation and findings in stool or radiographic studies suggest this etiology.

Diarrea crónica de causa infrecuente / Chronic diarrhea with uncommon etiology

La diarrea crónica es un síndrome relativamente frecuente. El diagnóstico etiológico se realiza a menudo con anamnesis, exploración física y estudios básicos. En ciertos casos, cuando no se halla la causa, se etiqueta de diarrea funcional, muchas veces sin cumplir los criterios establecidos. Presentamos el caso de un paciente con diarrea de meses de evolución. Tras un estudio amplio, se descartaron las etiologías más frecuentes y se etiquetó de diarrea funcional. Tres meses después, presentó una masa cervical, cuya biopsia fue diagnóstica de cáncer medular de tiroides. Se presentan unas recomendaciones para la evaluación sistemática de la diarrea crónica. El abordaje inicial incluiría: una buena anamnesis que recoja las características de la diarrea, síntomas acompañantes, entorno epidemiológico, antecedentes patológicos y de toma de laxantes; exploración física completa, con examen anorrectal incluido, hemograma y bioquímica básica. Además, el estudio de heces que incluya electrólitos (hiato aniónico fecal), leucocitos, sangre oculta, grasa y laxantes permite clasificar la diarrea en osmótica (hiato aniónico > 125 mOsm/kg), secretora (hiato aniónico < 50 mOsm/kg), inflamatoria o esteatorrea. Llegado este punto podremos tener el diagnóstico etiológico de la diarrea. Sin embargo, si no lo hemos alcanzado, las siguientes exploraciones deben realizarse de acuerdo con cada uno de los 4 tipos de diarrea descritos anteriormente. Se necesita un abordaje sistemático para el diagnóstico etiológico de la diarrea crónica. El carcinoma medular de tiroides y otros síndromes endocrinos que pueden causar diarrea crónica son muy raros; sólo se debe solicitar la determinación de péptidos plasmáticos cuando la historia clínica, los hallazgos analíticos o los estudios radiológicos hagan pensar en uno de estos síndromes

Chronic diarrhea is a common syndrome. An etiological diagnosis is often reached through clinical history, physical examination and simple tests. In some cases, when the etiologyis not found, the syndrome is called functional diarrhea, even though established criteria are often not fulfilled. We present the case of a patient with diarrhea for several months. The most common causes were ruled out through clinical history, physical examination, radiographic studies and laboratory tests, and the patient was diagnosed with functional diarrhea. Three months later, the patient presented a neck mass, and biopsy revealed medullary carcinoma of the thyroid. A review of recommendations for the systematic evaluation of chronic diarrhea is presented. A general approach should include careful history taking characteristics of diarrhea (onset, associated symptoms, epidemiological factors, iatrogenic causes such as laxative ingestion), a thorough physical examination with special attention to the anorectal region, and routine laboratory tests (complete blood count and serumchemistry). In addition, stool analysis including electrolytes(fecal osmotic gap), leukocytes, fecal occult blood, excess stool fat and laxative screening can yield important objective information to classify the diarrhea as: osmotic (osmotic gaps > 125 mOsm/Kg), secretory (osmotic gaps < 50 mOsm/Kg), inflammatory or steatorrheic. At this point in the evaluation, a specific diagnosis may be made. However, if diagnosis is not reached further specific examinations should be performed for each of the 4 types of diarrhea described above. A systematic approach to the evaluation of chronic diarrhea is warranted. Medullary thyroid carcinoma and other endocrine syndromes causing chronic diarrhea are very rare. Measurement of serum peptide concentrations should only be performed when clinical presentation and findings in stoolor radiographic studies suggest this etiology

Criterios actuales en el diagnóstico del síndrome de intestino irritable: ¿Una herramienta útil?

El diagnóstico del síndrome del intestino irritable ya no es de exclusión, procedimiento que requiere un gran número de pruebas complementarias, desde luego costosas, casi siempre molestas para el paciente y, en ocasiones, incluso peligrosas por ser invasivas o exponer al paciente a radiación. En este sentido, en estos momentos existen las condiciones idóneas para responder a la pregunta del título del trabajo afirmando que son una herramienta perfectamente provechosa y beneficiosa, es decir, útil.Además, este enfoque, que motiva la manifestación del grado de enfermedad que siente el paciente, es una gran oportunidad para desarrollar la relación médico-enfermo debido a que algunas manifestaciones afectan a esferas muy íntimas de la persona. Es obvio que será imprescindible la intervención de médicos bien preparados para escuchar, preguntar, comprender y razonar, en lugar de 'tirar de bolígrafo' para pedir pruebas complementarias (AU)