Early colorectal cancer diagnosed after endoscopic resection: Conservative treatment is safe in most of the cases. Proposal for a risk-based management / Cáncer colorrectal inicial tras resección endoscópica: el tratamiento conservador es seguro en la mayoría de los casos. Propuesta de un manejo basado en los factores de riesgo

Introduction Endoscopic resection offers advantages over surgical resection for early colorectal cancer (ECC). However, there might be a presumed risk of recurrence. We aimed to determine the risk of recurrence after endoscopic removal of ECC. Methods A single-centre series of endoscopic resections for ECC. Patients were stratified according to four risk factors: positive resection margins, Haggitt 4, lymphatic/vascular invasion and tumour budding. Results We included 127 patients. Haggitt classification was grade 4 in 54.0%. Positive margins were found in 43 (33.9%), 16 (12.6%) had lymphatic or vascular invasion, and 5 (4.0%) had high grade budding. In 82 (64.5%) endoscopic excision was the definitive treatment, 45 (35.4%) underwent surgery. Six patients (13.3%) had residual tumour on specimen and/or node metastases. Postoperative complications occurred in ten (22.2%). At a median follow-up of 63 months, none of the 82 patients treated with endoscopic resection alone had recurrence. After stratifying patients according to risk factors, those who had residual tumour also had ≥2 risk factors. Conclusions Endoscopic follow up might be a valid option for patients with ECC. A risk-adjusted management seems prudent (AU)

Introducción La resección endoscópica ofrece claras ventajas frente a la cirugía en el tratamiento del cáncer de colon inicial (ECC). Sin embargo, existe un riesgo de recurrencia tanto a nivel del lecho de polipectomía como a nivel ganglionar. El objetivo del estudio es determinar el riesgo de recurrencia tras la resección endoscópica del ECC. Métodos Serie retrospectiva unicéntrica de resecciones endoscópicas de ECC. Se analizaron cuatro factores de riesgo en la pieza de polipectomía: el margen de resección afecto, Haggitt 4, invasión linfovascular y la presencia de budding tumoral. Resultados Se incluyeron 127 pacientes: Haggitt 4 en el 54%, margen de resección afecto en el 33,9%, infiltración linfática o vascular en el 12,6% y budding tumoral de alto grado en el 4%. En 82 pacientes (64,5%), la resección endoscópica fue el tratamiento definitivo. En 45 (35,4%) se realizó una colectomía oncológica. Seis pacientes (13,3%) presentaron tumor residual en el lecho de la polipectomía y/o a nivel de los ganglios linfáticos. La morbilidad postoperatoria fue del 22% y la mortalidad del 0%. Tras un seguimiento medio de 63 meses, ninguno de los 82 pacientes del grupo de polipectomía presentó recurrencia tumoral. Tras dividir a los pacientes según el número de factores de riesgo presentes, aquellos que presentaron tumor residual en la pieza de colectomía presentaban a su vez ≥ 2 factores de riesgo. Conclusiones El seguimiento endoscópico puede ser una opción válida en los pacientes con ECC. El manejo de estos pacientes debe ajustarse al riesgo individual, en función del número de factores de riesgo (AU)

Insertion of self-expanding metal stent for treatment of malignant obstruction in a pregnant woman.

Colorectal cancer (CRC) is the second most frequent cancer both in incidence and mortality in women, especially in those over 60 years of age. Diagnosis in women at gestational age is rare, so its incidence during pregnancy is low. However, an increase in its diagnosis is expected during the next years because of the raise in the average age of pregnancy.In most cases, the diagnosis is delayed because symptoms related to CRC can be attributed to pregnancy itself. Up to 30 % of CRC cases may present as an intestinal obstruction. In this situation, the main objective is to solve the clinical emergency in the safest way for mother and fetus, together with performing an accurate diagnostic approach to offer the best possible therapeutic management knowing the limitations and difficulties related to pregnancy. The self-expanding metallic stent (SEMS) can be particularly useful in colon obstruction in a pregnant patient with CRC because it allows solving the acute condition providing time to perform a more accurate staging study and to prepare the patient for surgery, thus reducing both post-surgical morbidity and mortality.We report on the case of a patient who early in the second trimester of pregnancy presented with an acute colonic obstruction due to CRC which was successfully managed with the placement of a self-expanding metal stent.

Evaluación de la reproducibilidad del diagnóstico microscópico del adenoma serrado de sésil de colon / Assessing the reproducibility of the microscopic diagnosis of sessile serrated adenoma of the colon

Introducción: el adenoma serrado sésil (ASS) es una lesión descrita recientemente y que puede estar relacionada con el desarrollo de hasta un 15% de los cánceres colorrectales (CCR). Objetivo: determinar la eficacia de los criterios morfológicos para el diagnóstico del ASS evaluando el grado de acuerdo entre patólogos. Material y métodos: se estudió la concordancia entre dos patólogos para el diagnóstico de las lesiones serradas de colon en 195 lesiones (187 pólipos hiperplásicos y 7 adenomas serrados). De cada lesión se recogió el tamaño, la localización, la morfología y la forma de obtención de la muestra. Los dos patólogos eran desconocedores del diagnóstico inicial, las características macroscópicas y la localización de las lesiones. Los posibles diagnósticos fueron: ASS, adenoma serrado tradicional (AST), pólipo hiperplásico (PH), pólipo serrado, adenoma tubular o formas mixtas. Las dudas diagnósticas debían describirse. La concordancia entre los dos observadores se evaluó mediante el índice kappa (k). También se evaluó la influencia de las variables recogidas de las lesiones en el grado de acuerdo en el diagnóstico. Resultados: el acuerdo global para el diagnóstico histológico fue pobre (k = 0,14). También lo fue el acuerdo para el diagnóstico de ASS (k = 0,23). La concordancia para el diagnóstico de ASS mejoró con el tamaño > 5 mm (k = 0,64) y para la localización proximal (k = 0,43). Conclusión: en un contexto clínico real, los criterios morfológicos existentes para la identificación del ASS pueden ser de difícil aplicación(AU)

Introduction: sessile serrated adenoma (SSA) is a recently described lesion that may be related to the development of up to 15% of colorectal cancers (CRCs). Objective: to determine the accuracy of morphological criteria for the diagnosis of SSA by assessing concordance between pathologists. Material and methods: concordance between two pathologists in the diagnosis of serrated lesions of the colon was studied for 195 lesions (187 hyperplastic polyps and 7 serrated adenomas). Size, location, morphology, and sampling method were collected of each lesion. Both pathologists were unaware of the previous diagnosis, macroscopic characteristics, and location of lesions. Possible diagnoses were: SSA, traditional serrated adenoma (TSA), hyperplastic polyp (HP), serrated polyp, tubular adenoma, or mixed lesions. Diagnostic doubts had to be described. Concordance between both observers was assessed using the kappa index (k). The influence of collected variables on concordance degree was also evaluated. Results: overall agreement on the histological diagnosis was poor (k = 0.14), and so was agreement on the diagnosis of SSA (k = 0.23). Concordance in the diagnosis of SSA improved with size > 5 mm (k = 0.64) and proximal location (k = 0.43). Conclusion: in a real clinical setting, the existing morphological criteria for SSA identification may be difficult to use(AU)

Metástasis en colon de un carcinoma lobulillar de mama / No disponible

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[Persistence of a magic-religious ritual to treat indigestion among patients attending a gastroenterology outpatient clinic]. / Persistencia de una práctica de medicina mágico-religiosa para la cura del empacho entre los enfermos que acuden a consultas externas de digestivo.

INTRODUCTION: Knowledge of popular medicine is essential to the practice of integrated medicine. Empacho (stomach upset) is a known folk illness that has been the object of several studies, especially in Iberoamerica and among the Hispanic population in the United States. In the Autonomous Community of Valencia (Spain) a magic-religious ritual known as "trencar lenfit" (TE) is still performed. This ritual has no apparent equivalent among the numerous remedies described for this illness. OBJECTIVES: To study the frequency and characteristics of the practice of TE among patients attending the gastroenterology outpatient clinic of a district hospital. PATIENTS AND METHOD: The geographical area was the region of La Safor (Valencian Community) with three main nuclei (Gandia, where the hospital is situated, Oliva and Tavernes de Valldigna) and 28 smaller municipalities. Random interviews were performed in patients attending a second consultation over a period of 5 months. RESULTS: Of 539 patients interviewed, 320 (59.4%) had undergone TE at some time in their lives and 25.0% had undergone this ritual in the previous 10 years. In 95.9% of cases, the person performing the ritual was a woman. Of the patients who had undergone TE, 40 (12.5%) knew how to perform the ritual, 35 of which were women (p < 0.0001). No significant differences were found between sexes but users were younger (51.8 +/- 15.9 versus. 55.5 +/- 17.7 years +/- SD, p < 0.05). Small municipalities and Oliva showed a frequency of 65.6% versus. 54.0% in Gandia and Tavernes (p < 0.005). Use was greater among natives of the Valencian Community (66.0%) compared with those from other parts of Spain (25.0%) (p < 0.0001). Patients who completed primary or secondary school showed greater use of TE (60.5% and 72.1%, respectively) than the illiterate (42.1%), those who had completed a 3-year higher education course (48.4%) and university graduates (36.0%) (p < 0.001). TE was more frequent among consumers of medicinal herbs than among non-consumers (69.0% versus. 54.3%) (p < 0.001). No relationship was found among TE and the use of alcohol, medication in general and smoking. However, an association was found between the use of psychotropic drugs (69.8% versus. 55.4%) (p < 0.005). No clear association was found with broad diagnostic group or with the functional/organic nature of the digestive disorder studied. Variables found to be significant on univariate analysis remained significant in multivariate analysis (logistic regression). CONCLUSION: The present study confirms the high use of TE among patients attending the gastroenterology outpatient clinic of La Safor and their belief in this ritual. "Experts" in performing TE were widely available, and were almost exclusively women. The profile of maximal use of TE corresponds to a man or woman, aged less than 60 years, a native of the Valencian Community, with primary or secondary school education, residing in particular municipalities (usually small) and consumer of psychotropic drugs and medicinal herbs.

Persistencia de una práctica de medicina mágico-religiosa para la cura del empacho entre los enfermos que acuden a consultas externas de digestivo / Persistence of a magic-religious ritual to treat indigestion among patients attending a gastroenterology outpatient clinic

Introducción: El conocimiento de la medicina popular resulta básico para el ejercicio de una medicina integrada. El empacho es una enfermedad conocida de la medicina popular cuyo estudio ha motivado diversas publicaciones, especialmente en el área iberoamericana y entre la población hispana de Estados Unidos. En la Comunidad Valenciana persiste un ritual de medicina mágico-religiosa conocido como trencar l’enfit (TE) (romper el empacho), sin paralelismo aparente entre los múltiples remedios descritos para esta dolencia. Nuestro objetivo ha sido estudiar la frecuencia y las características de la práctica de TE entre los pacientes que acuden a consultas externas de digestivo de un hospital comarcal. Pacientes y método: El ámbito geográfico fue la comarca de La Safor (Comunidad Valenciana), con 3 núcleos principales (Gandia, sede del hospital, Oliva y Tavernes de Valldigna) y 28 municipios menores. Se realizaron entrevistas de forma aleatoria a los pacientes que acudían a segundas visitas, durante 5 meses. Resultados: De los 539 pacientes entrevistados, 320 (59,4%) habían realizado TE en algún momento de su vida y un 25,0% en los 10 últimos años. La persona que realizaba el ritual fue en un 95,9% de los casos mujer. De los pacientes que habían practicado TE, 40 (12,5%) sabían realizar el ritual; de éstos 35 eran mujeres (p < 0,0001). No hubo diferencias significativas entre sexos, pero fueron más jóvenes los usuarios (media de edad ± desviación estándar: 51,8 ± 15,9 frente a 55,5 ± 17,7 años; p < 0,05). Las poblaciones pequeñas y Oliva presentaron una frecuencia del 65,6%, frente al 54,0% de Gandia y Tavernes (p < 0,005). El uso fue mayor entre las personas originarias de la Comunidad Valenciana (66,0%) que entre las procedentes de otros lugares de España (25,0%) (p < 0,0001). Los pacientes con estudios primarios o EGB-bachillerato presentaron el uso máximo de TE (el 60,5 y el 72,1%, respectivamente), frente a los analfabetos (42,1%), titulados medios (48,4%) y titulados superiores (36,0%) (p < 0,001). Los consumidores de hierbas medicinales habían practicado TE más que quienes no las consumían (el 69,0 frente al 54,3%; p < 0,001). No se encontró relación de la utilización del TE con el consumo de alcohol, tabaco y medicamentos en general, pero sí con el de psicofármacos (el 69,8 frente al 55,4%; p < 0,005). No hubo relación clara con los grandes grupos diagnósticos ni con el carácter funcional/orgánico de la enfermedad digestiva estudiada. El análisis multivariante (regresión logística) confirmó la asociación independiente de las variables significativas en el estudio univariante. Conclusión: Se corrobora una elevada utilización y considerable vigencia de TE entre los pacientes que acuden a consultas externas de digestivo de La Safor. Se constata una amplia difusión de las personas «expertas» en la realización de TE, con predominio casi absoluto del sexo femenino. El perfil de máximo uso de TE se podría acercar al siguiente: varón o mujer, menor de 60 años, de origen valenciano, con estudios medios-primarios, residente en determinadas poblaciones (en general, pequeñas), consumidor/a de psicofármacos y de hierbas medicinales

Introduction: Knowledge of popular medicine is essential to the practice of integrated medicine. Empacho (stomach upset) is a known folk illness that has been the object of several studies, especially in Iberoamerica and among the Hispanic population in the United States. In the Autonomous Community of Valencia (Spain) a magic-religious ritual known as «trencar l’enfit» (TE) is still performed. This ritual has no apparent equivalent among the numerous remedies described for this illness. Objectives: To study the frequency and characteristics of the practice of TE among patients attending the gastroenterology outpatient clinic of a district hospital. Patients and method: The geographical area was the region of La Safor (Valencian Community) with three main nuclei (Gandia, where the hospital is situated, Oliva and Tavernes de Valldigna) and 28 smaller municipalities. Random interviews were performed in patients attending a second consultation over a period of 5 months. Results: Of 539 patients interviewed, 320 (59.4%) had undergone TE at some time in their lives and 25.0% had undergone this ritual in the previous 10 years. In 95.9% of cases, the person performing the ritual was a woman. Of the patients who had undergone TE, 40 (12.5%) knew how to perform the ritual, 35 of which were women (p < 0.0001). No significant differences were found between sexes but users were younger (51.8 ± 15.9 versus. 55.5 ± 17.7 years ± SD, p < 0.05). Small municipalities and Oliva showed a frequency of 65.6% versus. 54.0% in Gandia and Tavernes (p < 0.005). Use was greater among natives of the Valencian Community (66.0%) compared with those from other parts of Spain (25.0%) (p < 0.0001). Patients who completed primary or secondary school showed greater use of TE (60.5% and 72.1%, respectively) than the illiterate (42.1%), those who had completed a 3-year higher education course (48.4%) and university graduates (36.0%) (p < 0.001). TE was more frequent among consumers of medicinal herbs than among non-consumers (69.0% versus. 54.3%) (p < 0.001). No relationship was found among TE and the use of alcohol, medication in general and smoking. However, an association was found between the use of psychotropic drugs (69.8% versus. 55.4%) (p < 0.005). No clear association was found with broad diagnostic group or with the functional/organic nature of the digestive disorder studied. Variables found to be significant on univariate analysis remained significant in multivariate analysis (logistic regression). Conclusion: The present study confirms the high use of TE among patients attending the gastroenterology outpatient clinic of La Safor and their belief in this ritual. «Experts» in performing TE were widely available, and were almost exclusively women. The profile of maximal use of TE corresponds to a man or woman, aged less than 60 years, a native of the Valencian Community, with primary or secondary school education, residing in particular municipalities (usually small) and consumer of psychotropic drugs and medicinal herbs

[Consumption of medicinal herbs in patients attending a gastroenterology outpatient clinic]. / Consumo de hierbas medicinales en los pacientes de consultas externas de digestivo.

The consumption of medicinal herbs is one of the most important topics in alternative and complementary medicine. The widespread use of these substances among the general population gives rise to the possibility of therapeutic or toxic effects in patients seeking conventional medical assistance. To determine the frequency of medicinal herb use, the species consumed and the profile of medicinal herb consumers among patients with gastrointestinal disorders, patients attending the gastroenterology outpatient clinic of the Francesc de Borja district hospital (Gandía, Spain) over a 5-month period were interviewed and 539 valid questionnaires were obtained. A total of 34.7% of the interviewees had taken medicinal herbs at some time and 26.9% had used them in the last year. Self-prescription was reported by 67.1%. Medicinal herbs were mainly obtained in the pharmacy or herbalist's (74.7%). The results of medicinal herb therapy were considered good or excellent by 80.3% of the interviewees, average by 18.6% and poor by 1.1%. In the univariate analysis, medicinal herb consumption was positively associated with female sex (p < 0.001), a university education (p < 0.05), consumption of psychotropic drugs (p < 0.005), use of trencar l'enfit (TE, a common practice of magic medicine in Valencia) (p < 0.001), functional gastrointestinal disorders (p < 0.005) and a diagnosis of lower gastrointestinal disorder (p < 0.01). In the multivariate analysis, the variables that remained statistically significant were female sex (p < 0.005), university education (p < 0.01), use of TE and a diagnosis of lower gastrointestinal disorder. Fifty-seven botanical varieties were used. The most frequent varieties were Santolina chamaecyparissus (18.8%), Tilia platyphyllos (6.5%), Thymus vulgaris (6%), Equisetum ramosissimum (4.7%), Mentha pulegium (4.4%) and Valeriana officinalis (4.4%). The results show that consumption of medicinal herbs is frequent among patients attending the gastroenterology outpatient clinic of a district hospital. The probable profile of those showing maximum consumption is: female sex, university education, lower gastrointestinal disorder, functional gastrointestinal disorder, psychotropic drug consumption and use of TE.

[Autoimmune hepatitis and anti-Ro antibodies. Is there a link?]. / Hepatitis autoinmune y anticuerpos anti-Ro positivos. ¿Alguna relación?

Antinuclear antibodies (ANA) are considered to be markers of autoimmune disease. Several specific reactivities of ANA are known, among them the Ro (SS-a) complex. Although the presence of anti-Ro antibodies is widely known in systemic connective tissue diseases such as lupus erythematous or Sjögren's syndrome, few studies have attempted to link this finding with autoimmune hepatitis (AIH). We present a case of acute AIH in a 55-year-old woman who tested positive for anti-Ro 60 kD antibodies. The Ro (SS-A) antigen is a complex ribonucleoprotein whose structure is still the subject of debate. Two fractions, of 50 and 60 kD, have been identified. A review of the literature revealed frequencies of 21-34% for anti-Ro 52 kD and of 9-13-6% for anti-Ro 60 kD in AIH. Although no relationship has been demonstrated between this complex and the etiopathogenic mechanisms or clinical patterns of AIH, we propose that multicenter investigations with large series should be performed before the possible involvement of anti-Ro antibodies in these diseases is definitively ruled out.

[Agricultural occupation and strongyloidiasis. A case-control study]. / Actividad laboral agrícola y estrongiloidiasis. Estudio caso-control.

BACKGROUND: In the last few years, Strongyloides stercoralis has been repeatedly recovered from indigenous farmers in the Safor area (Valencia Community). The relationship between the different occupational activities, mainly farming, and the presence of strongyloidiasis was investigated. PATIENTS AND METHODS: A paired case-control study was designed. The investigation was conducted at Oliva Centro de Salud, from October 1997 to October 1999. Diagnosis was established when Strongyloides stercoralis was observed in any of the three serial fecal samples requested when eosinophilia was observed in the hemogram. Controls were persons matched by sex and age (+/- 5) years, with no eosinophilia in the hemogram and in whom the presence of the parasite was excluded in fecal samples. RESULTS: Participants in the study were 47 cases and their respective controls. Each group included 39 (83%) men and 8 (17%) women. Forty-five cases (95%) and 42 controls (89%) had been born in Safor. Only two cases had travelled to endemic areas. Farming was the main activity in 32 (68%) cases and 31 (66%) controls. The only occupational activity which showed influence on strongyloidiasis was working in ricefields, with an OR of 2.97 (95% CI: 1.16-7.71). Dermatologic symptoms were significant for pruritus, OR 7.39 (95% CI: 2.29-27.60). One case with hyperinfection and another with larva currens were diagnosed. CONCLUSION: In our area, working in ricefields and chronic pruritus are associated with chronic strongylodiasis.

Actividad laboral agrícola y estrongiloidiasis. Estudio caso-control / Farming occupation and strongyloidiasis. Case control study

Fundamento. En los últimos años Strongyloides stercoralis ha sido aislado repetidamente en agricultores autóctonos de la comarca de la Safor (Comunidad Valenciana). Se estudia la relación entre las distintas actividades laborales, principalmente las agrícolas, y la presencia de estrongiloidiasis.Sujetos y métodos. Se diseñó un estudio casocontrol apareado. El trabajo se ha desarrollado en el Centro de Salud de Oliva desde octubre de 1997 a octubre de 1999. En los casos el diagnóstico se estableció al observar Strongyloides stercoralis en alguna de las tres muestras seriadas de heces solicitadas ante la presencia de eosinofilias en el hemograma. Los controles eran personas de igual sexo y edad ñ 5 años, sin eosinofilia en el hemograma y en los que se excluyó la presencia del parásito en las muestras de heces. Resultados. Participaron 47 casos y sus respectivos controles. En cada grupo había 39 (83 por ciento) varones y 8 (17 por ciento) mujeres. Habían nacido en la Safor 45 (95 por ciento) casos y 42 (89 por ciento) controles. Sólo dos casos habían viajado a países endémicos. La agricultura era la actividad principal en 32 (68 por ciento) de los casos y en 31 (66 por ciento) de los controles. La única actividad en la que mostró influencias sobre la estrongiloidiasis fue el trabajo en arrozales, que obtuvo una odds ratio (OR) de 2,97 [intervalo de confianza (IC) 95 por ciento: 1,16-7,71]. Los síntomas dermatológicos resultaron significativos para el prurito, OR de 7,39 (IC 95 por ciento: 2,29-27,60). Fueron diagnosticados un caso con síndrome de hiperinfección y otro con larva currens. Conclusión. En nuestra zona el trabajo en arrozales y el prurito crónico muestran relación con la estrongiloidiasis crónica (AU)

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[Cryoglobulinemia following liver transplantation for cirrhosis secondary to hepatitis C virus infection]. / Crioglobulinemia tras trasplante hepático por cirrosis secundaria al virus de la hepatitis C.

Hepatitis C virus (HCV) infection has been linked with some extrahepatic immunologic abnormalities. Cryoglobulinemia is one of the most frequently reported. Nevertheless, there are only a few reports of cryoglobulinemia in the setting of liver transplantation. More studies are needed to clarify the frequency of post-OLT cryoglobulinemia in patients with HCV-related cirrhosis and its impact on OLT outcome. A case of a patient who underwent liver transplantation because of HCV end-stage liver disease and in whom cryoglobulinemia appeared 3 years after transplantation is reported. Treatment with cyclophosphamide and steroids was attempted but patient died of septicemia 3 years after liver transplantation.

[Cholestatic hepatitis caused by amoxycillin-clavulanic acid. Report of a new case]. / Hepatitis colestásica por amoxicilina-clavulánico. Presentación de un nuevo caso.

Toxic hepatitis is an infrequent secondary effect of amoxycillin-clavulanic acid with fewer than 30 well documented cases in the literature. Presentation is usually that of acute cholestasis several weeks after the initiation of treatment with this antibiotic. A new case of hepatic toxicity by amoxycillin-clavulanic acid is reported in a 47-years-old male who had taken this drug for a diarrhea syndrome. A brief review of the literature is made with special emphasis on the anatomopathologic aspects.