Formación en Ecografía de los Médicos Residentes de Aparato Digestivo: encuesta y proyecto docente de la Asociación Española de Ecografía Digestiva / Training in Ultrasound for Resident Physicians in Gastroenterology: a survey and training project by the Spanish Association of Digestive Ultrasound (Asociación Española de Ecografía Digestiva - AEED)

Antecedentes: el programa de formación de la Especialidad de Aparato Digestivo, que deben seguir los Médicos Internos y Residentes de Aparato Digestivo, obliga a que estos dominen la ecografía digestiva diagnóstica y terapéutica. Métodos: la Asociación Española de Ecografía Digestiva ha realizado una encuesta a los 93 Servicios de Aparato Digestivo con programa de formación de Médicos Internos y Residentes de Aparato Digestivo para conocer la situación exacta de la docencia en ecografía digestiva. Resultados: solo 31 de los 93 (33%) Servicios de Aparato Digestivo podían dar formación en Ecografía Digestiva. Un 33% (48 de 148) de los Médicos Internos y Residentes de Aparato Digestivo no recibían una formación específica en ecografía digestiva, y otro 31% (46 de 148) recibían una formación específica pero en condiciones mejorables. Estas deficiencias afectaban a todas las Comunidades Autónomas de España, 8 de las cuales carecían totalmente de Servicios de Aparato Digestivo con capacidad para formar en Ecografía Digestiva. Conclusiones: existe un déficit importante de Servicios de Aparato Digestivo que puedan dar formación en Ecografía Digestiva a los Médicos Internos y Residentes de Aparato Digestivo y ello provoca una notable desigualdad formativa. Hasta que se pueda revertir esta situación, la Asociación Española de Ecografía Digestiva ha diseñado un proyecto formativo en Ecografía Digestiva dirigido a dar una docencia adecuada a todos los Médicos Internos y Residentes de Aparato Digestivo que lo necesiten

Background: the training program of the gastroenterology specialty that is mandatory for resident physicians, obliges them to be proficient in diagnostic and therapeutic digestive ultrasound tools. Methodology: the Asociación Española de Ecografía Digestiva (AEED) performed a survey of the 93 Departments of Gastroenterology with training programs for resident physicians in gastroenterology, in order to assess the exact situation of training in digestive ultrasound in Spain. Results: only 31 of the 93 (33%) Departments of Gastroenterology were able to provide training in Digestive Ultrasound. Moreover, 33% (48 out of 148) of the residents in gastroenterology did not receive specific training in digestive ultrasound. Whereas, 31% (46 out of 148) had received some specific training, but with ample room for improvement. These deficiencies were spread throughout the Spanish regions (Autonomous Communities) in an uneven manner, with almost half totally lacking gastroenterology departments that were capable of providing digestive ultrasound training. Conclusions: there is a significant deficit of gastroenterology departments capable of providing training in digestive ultrasound to residents, causing a significant training inequality. Until this situation can be reversed, the AEED has designed a training project in digestive ultrasound aimed at providing adequate training to all residents in gastroenterology as required

Training in Ultrasound for Resident Physicians in Gastroenterology: a survey and training project by the Spanish Association of Digestive Ultrasound (Asociación Española de Ecografía Digestiva - AEED).

BACKGROUND: the training program of the gastroenterology specialty that is mandatory for resident physicians, obliges them to be proficient in diagnostic and therapeutic digestive ultrasound tools. METHODOLOGY: the Asociación Española de Ecografía Digestiva (AEED) performed a survey of the 93 Departments of Gastroenterology with training programs for resident physicians in gastroenterology, in order to assess the exact situation of training in digestive ultrasound in Spain. RESULTS: only 31 of the 93 (33%) Departments of Gastroenterology were able to provide training in Digestive Ultrasound. Moreover, 33% (48 out of 148) of the residents in gastroenterology did not receive specific training in digestive ultrasound. Whereas, 31% (46 out of 148) had received some specific training, but with ample room for improvement. These deficiencies were spread throughout the Spanish regions (Autonomous Communities) in an uneven manner, with almost half totally lacking gastroenterology departments that were capable of providing digestive ultrasound training. CONCLUSIONS: there is a significant deficit of gastroenterology departments capable of providing training in digestive ultrasound to residents, causing a significant training inequality. Until this situation can be reversed, the AEED has designed a training project in digestive ultrasound aimed at providing adequate training to all residents in gastroenterology as required.

Curación de la hepatitis autoinmune asociada a hepatitis C con antivirales de acción directa / Healing of autoimmune hepatitis associated with hepatitis C virus infection treated with direct-acting antivirals

La aparición de los nuevos antivirales de acción directa (AAD) para el tratamiento del virus de la hepatitis C (VHC) supone un gran avance para pacientes con hepatitis autoinmune e infectados, ya que hasta el momento no se disponía de opciones terapéuticas libres de interferón. Presentamos el caso de una paciente con infección por VHC que sufrió una HAI desencadenada por interferón, sin conseguir suspender el tratamiento inmunosupresor durante años. Gracias a los AAD, se alcanzó una respuesta viral sostenida y, posteriormente, una remisión clínica completa de su enfermedad autoinmune, sin tratamiento actualmente

The use of direct-acting antivirals (DAA) for the hepatitis C virus (HCV) has yielded a significant improvement in the treatment of autoimmune hepatitis (AIH) associated with HCV infection. Interferon was the cornerstone of HCV therapy before the introduction of these agents into the clinical practice. Herein, we report the case of an HCV-infected patient who developed an interferon-induced AIH and since then, has received immunosuppressive therapy. Administration of DAA resulted in a sustained virologic response (SVR) and clinical AIH remission which allowed a discontinuation of immunosuppressive treatment

Healing of autoimmune hepatitis associated with hepatitis C virus infection treated with direct-acting antivirals.

The use of direct-acting antivirals (DAA) for the hepatitis C virus (HCV) has yielded a significant improvement in the treatment of autoimmune hepatitis (AIH) associated with HCV infection. Interferon was the cornerstone of HCV therapy before the introduction of these agents into the clinical practice. Herein, we report the case of an HCV-infected patient who developed an interferon-induced AIH and since then, has received immunosuppressive therapy. Administration of DAA resulted in a sustained virologic response (SVR) and clinical AIH remission which allowed a discontinuation of immunosuppressive treatment.

Switching from endoscopic submucosal dissection to salvage piecemeal knife-assisted snare resection to remove a lesion: a preoperative risk score from the beginning

Background and aims: endoscopic submucosal dissection (ESD) in the Western setting remains a challenge. Therefore, other simplified techniques such as knife-assisted snare resection (KAR) have been reported to overcome this issue. Methods: patients who underwent an ESD for the treatment of gastrointestinal neoplasms were included in a retrospective cross-sectional observational study. Factors associated with the end of ESD as a salvage p-KAR were identified and a logistic regression model was developed. Results: a total of 136 lesions in 133 patients were analyzed. Operator experience of under 50 cases and the combination of lesion size > 30 mm and colorectal location were independent predictive factors for switching to a salvage p-KAR according to the multivariate logistic regression analysis. We developed a risk scoring system based on these four variables (experience, size, location and the combination of size and location) with a receiver operating characteristic curve of 0.81 (95% CI: 0.74-0.89). The diagnostic accuracy of the score for a cut-off point ≥ 5 had a sensitivity of 0.79 (95% CI: 0.66-0.93) and a specificity of 0.71 (95% CI: 0.61-0.80). Conclusion: a simple predictive score system that includes four preoperative factors accurately predicts ESD to finish as a p-KAR. A careful selection of cases considering these variables could be useful to achieve better outcomes in the Western setting

No disponible

Switching from endoscopic submucosal dissection to salvage piecemeal knife-assisted snare resection to remove a lesion: A preoperative risk score from the beginning.

BACKGROUND AND AIMS: endoscopic submucosal dissection (ESD) in the Western setting remains a challenge. Therefore, other simplified techniques such as knife-assisted snare resection (KAR) have been reported to overcome this issue. METHODS: patients who underwent an ESD for the treatment of gastrointestinal neoplasms were included in a retrospective cross-sectional observational study. Factors associated with the end of ESD as a salvage p-KAR were identified and a logistic regression model was developed. RESULTS: a total of 136 lesions in 133 patients were analyzed. Operator experience of under 50 cases and the combination of lesion size > 30 mm and colorectal location were independent predictive factors for switching to a salvage p-KAR according to the multivariate logistic regression analysis. We developed a risk scoring system based on these four variables (experience, size, location and the combination of size and location) with a receiver operating characteristic curve of 0.81 (95% CI: 0.74-0.89). The diagnostic accuracy of the score for a cut-off point ≥ 5 had a sensitivity of 0.79 (95% CI: 0.66-0.93) and a specificity of 0.71 (95% CI: 0.61-0.80). CONCLUSION: a simple predictive score system that includes four preoperative factors accurately predicts ESD to finish as a p-KAR. A careful selection of cases considering these variables could be useful to achieve better outcomes in the Western setting.

Esophageal motor disorders are frequent during pre and post lung transplantation. Can they influence lung rejection?

Background: lung transplantation (LTx) is a viable option for most patients with end-stage lung diseases. Esophageal motor disorders (EMD) are frequent in candidates for LTx, but there is very little data about changes in esophageal motility post-LTx. Aim: the aim of our study was to assess esophageal motor disorders by high resolution manometry (HRM) both pre-LTx and six months post-LTx in patients with and without organ rejection. Study: HRM (Manoscan(r)) was performed in 57 patients both pre-LTx and six months post-LTx. HRM plots were analyzed according to the Chicago classification 3.0. Results: EMD were found in 33.3% and in 49.1% of patients pre-LTx and post-LTx, respectively, and abnormal peristalsis was more frequently found post-LTx (p = 0.018). Hypercontractile esophagus was frequently found post-LTx (1.8% and 19.3% pre-LTx and post-LTx, respectively). Esophagogastric junction (EGJ) morphology changed significantly pre-LTx and post-LTx; type I (normal) was more frequent post-LTx (63-2% and 82.5% respectively, p = 0.007). EMD were more frequent post-LTx in both the non-rejection and rejection group, although particularly in the rejection group (43.2% and 69.2% respectively, p = 0.09). EMD such as distal spasm, hypercontractile esophagus and EGJ outflow obstruction were also observed more frequently post-LTx in the rejection group. Conclusion: significant changes in esophageal motility were observed pre-LTx and particularly post-LTx; hypercontractile esophagus was a frequent EMD found post-LTx. EMD were more frequent in the group of patients that experienced organ rejection compared to the non-rejection group. EMD leading to an impaired esophageal clearance should be considered as an additional factor that contributes to LTx failure

No disponible

Esophageal motor disorders are frequent during pre and post lung transplantation. Can they influence lung rejection?

BACKGROUND: lung transplantation (LTx) is a viable option for most patients with end-stage lung diseases. Esophageal motor disorders (EMD) are frequent in candidates for LTx, but there is very little data about changes in esophageal motility post-LTx. AIM: the aim of our study was to assess esophageal motor disorders by high resolution manometry (HRM) both pre-LTx and six months post-LTx in patients with and without organ rejection. STUDY: HRM (Manoscan®) was performed in 57 patients both pre-LTx and six months post-LTx. HRM plots were analyzed according to the Chicago classification 3.0. RESULTS: EMD were found in 33.3% and in 49.1% of patients pre-LTx and post-LTx, respectively, and abnormal peristalsis was more frequently found post-LTx (p = 0.018). Hypercontractile esophagus was frequently found post-LTx (1.8% and 19.3% pre-LTx and post-LTx, respectively). Esophagogastric junction (EGJ) morphology changed significantly pre-LTx and post-LTx; type I (normal) was more frequent post-LTx (63-2% and 82.5% respectively, p = 0.007). EMD were more frequent post-LTx in both the non-rejection and rejection group, although particularly in the rejection group (43.2% and 69.2% respectively, p = 0.09). EMD such as distal spasm, hypercontractile esophagus and EGJ outflow obstruction were also observed more frequently post-LTx in the rejection group. CONCLUSION: significant changes in esophageal motility were observed pre-LTx and particularly post-LTx; hypercontractile esophagus was a frequent EMD found post-LTx. EMD were more frequent in the group of patients that experienced organ rejection compared to the non-rejection group. EMD leading to an impaired esophageal clearance should be considered as an additional factor that contributes to LTx failure.

Colestasis tras la colocación de un TIPS en paciente con colangitis esclerosante primaria; una complicación infrecuente / Cholestasis after TIPS placement in a patient with primary sclerosing cholangitis: an uncommon complication

Presentamos el caso de un paciente con colangitis esclerosante primaria que presentó un síndrome colestásico de rápida evolución, con hiperbilirrubinemia grave tras colocar un TIPS que se resolvió con una prótesis biliar mediante CPRE. Hasta la fecha no se han descrito casos similares en la literatura, ya que se trata de una complicación rara y, por otro lado, la experiencia con el TIPS en pacientes con CEP es limitada. Las causas de hiperbilirrubinemia tras realizar un TIPS son muy variadas y es crucial realizar un diagnóstico diferencial para instaurar un tratamiento precoz (AU)

We present the case of a patient with primary sclerosing cholangitis who presented a rapidly evolving cholestatic syndrome, with severe hyperbilirubinemia after placing a TIPS. It was resolved with a biliary prosthesis inserted by ERCP. To date, no similar cases have been described in the literature, as it is a rare complication and, on the other hand, the experience with TIPS in patients with PSC is limited. The causes of hyperbilirubinemia after TIPS placement are very varied and it is crucial to perform a differential diagnosis to establish an early treatment (AU)

Cholestasis after TIPS placement in a patient with primary sclerosing cholangitis: an uncommon complication.

We present the case of a patient with primary sclerosing cholangitis who presented a rapidly evolving cholestatic syndrome, with severe hyperbilirubinemia after placing a TIPS. It was resolved with a biliary prosthesis inserted by ERCP. To date, no similar cases have been described in the literature, as it is a rare complication and, on the other hand, the experience with TIPS in patients with PSC is limited. The causes of hyperbilirubinemia after TIPS placement are very varied and it is crucial to perform a differential diagnosis to establish an early treatment.

Extrinsic esophageal compression by the vertebral body.

A 78-year-old woman with hypertension, diabetes, dyslipidemia, and revascularized ischemic heart disease was diagnosed with gastric adenocarcinoma in 2011, with suspected bilateral adrenal metastatic disease, and was treated with subtotal gastrectomy and palliative chemotherapy. A follow-up gastroscopy in 2015 identified a protruding, erosive mid-esophageal lesion suggestive of extrinsic compression or ulcerated submucosal lesion, which had not been described previously. Follow-up was advised, and the lesion persisted after three months. The patient had no esophageal symptoms, and subsequent thoracoabdominal CT scans found no bony abnormalities in the cervicothoracic spine or mediastinal changes. Endoscopic ultrasound was recommended given the patient's cancer history.

Compresión esofágica extrínseca por cuerpo vertebral / Extrinsic esophageal compression by the vertebral body

No disponible

How the Body Position Can Influence High-resolution Manometry Results in the Study of Esophageal Dysphagia and Gastroesophageal Reflux Disease.

BACKGROUND/AIMS: The body position can influence esophageal motility data obtained with high-resolution manometry (HRM). To examine whether the body position influences HRM diagnoses in patients with esophageal dysphagia and gastroesophageal reflux disease (GERD). METHODS: HRM (Manoscan) was performed in 99 patients in the sitting and supine positions; 49 had dysphagia and 50 had GERD as-sessed by 24-hour pH monitoring. HRM plots were analyzed according to the Chicago classification. RESULTS: HRM results varied in the final diagnoses of the esophageal body (EB) in patients with dysphagia (P = 0.024), the result being more distal spasm and weak peristalsis while sitting. In patients with GERD, the HRM diagnoses of the lower esophageal sphinc-ter (LES), the esophagogastric junction (EGJ) morphology, and EB varied depending on the position; (P = 0.063, P = 0.017, P = 0.041 respectively). Hypotensive LES, EGJ type III (hiatal hernia), and weak peristalsis were more frequently identified in the sitting position. The reliability (kappa) of the position influencing HRM diagnoses was similar in dysphagia and GERD ("LES diagnosis": dysphagia 0.32 [0.14-0.49] and GERD 0.31 [0.10-0.52], P = 0.960; "EB diagnosis": dysphagia 0.49 [0.30-0.69] and GERD 0.39 [0.20-0.59], P = 0.480). The reliability in "EGJ morphology" studies was higher in dysphagia 0.81 (0.68-0.94) than in GERD 0.55 (0.37-0.73), P = 0.020. CONCLUSIONS: HRM results varied according to the position in patients with dysphagia and GERD. Weak peristalsis was more frequently diagnosed while sitting in dysphagia and GERD. Hypotensive LES and EGJ type III (hiatal hernia) were also more frequently diagnosed in the sitting position in patients with GERD.

Endoscopic submucosal dissection (ESD) of antral subepithelial lesion suspected of malignancy.

Subepithelial gastric tumours comprise a heterogeneous group of lesions. Endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) is a useful approach but cannot always offer a definitive diagnosis to guide future therapeutic decisions. In the case we describe, biopsy samples of an antral subepithelial lesion and cytological analysis obtained with an EUS-FNA suggested the diagnosis of an adenocarcinoma. Endoscopic submucosal dissection (ESD) allowed en bloc resection of the tumour ensuring diagnosis and providing a definitive treatment.

Endoscopic submucosal dissection (ESD) of antral subepithelial lesion suspected of malignancy

Subepithelial gastric tumours comprise a heterogeneous group of lesions. Endoscopic ultrasonography with fine-needle aspiration (EUS-FNA) is a useful approach but cannot always offer a definitive diagnosis to guide future therapeutic decisions. In the case we describe, biopsy samples of an antral subepithelial lesion and cytological analysis obtained with an EUS-FNA suggested the diagnosis of an adenocarcinoma. Endoscopic submucosal dissection (ESD) allowed en bloc resection of the tumour ensuring diagnosis and providing a definitive treatment (AU)

No disponible

Fallo hepático agudo en paciente consumidora de productos de Herbalife y zumo de Noni / Fallo hepático agudo en paciente consumidora de productos de Herbalife y zumo de Noni

No disponible

How useful is esophageal high resolution manometry in diagnosing gastroesophageal junction disruption: causes affecting this disruption and its relationship with manometric alterations and gastroesophageal reflux.

BACKGROUND: High-resolution manometry (HRM) is a breakthrough in the morphological study of the gastroesophageal junction (GEJ) and its degrees of disruption. OBJECTIVES: a) Assessment of risk factors involved in the disruption of the GEJ in patients with gastroesophageal reflux (GER) symptoms; b) the relationship between the type of GEJ and GER demonstrated by 24 hours pH-monitoring; and c) identification of the alterations in the manometric parameters related to the morphology of the GEJ. METHODS: One hundred and fifteen patients with symptoms of GER studied with HRM and classified by the type of GEJ (type I: Normal; type II: Sliding; type III: Hiatal hernia). Twenty four hour pH-monitoring without proton pump inhibitors was performed in all of them. Epidemiological aspects, manometric parameters (Chicago 2012 classification) and the pH-monitoring results were evaluated. RESULTS: Age (OR 1.033 [1.006-1.060]; p = 0.16), BMI (OR 1.097 [1.022-1.176]; p = 0. 01) and abdominal perimeter (OR 1.034 [1.005-1.063]; p = 0.0215) were independent risk factors for the GEJ type III (area under the curve 0.70). Disruption of the GEJ was associated with a lower resting pressure (p = 0.006), greater length (p < 0.001) and greater esophageal shortening (p < 0.001). Abnormal acidic reflux was found in the total period (p = 0.015), standing (p = 0.022) and supine (p = 0.001) in patients with GEJ type II and III with respect to type I. CONCLUSIONS: Increased age, overweight and central obesity pose a higher risk of GEJ type III (hiatal hernia). The greater disruption of the GEJ is associated with lower resting pressure, esophageal shortening, and higher acid exposure in the pH-monitoring.

Utilidad de la manometría de alta resolución en el diagnóstico de la disrupción de la unión gastroesofágica: causas que influyen en su disrupción y asociación con reflujo gastroesofágico y alteraciones manométricas / How useful is esophageal high resolution manometry in diagnosing gastroesophageal junction disruption: Causes affecting this disruption and its relationship with manometric alterations and gastroesophageal reflux

Introducción: la manometría de alta resolución (MAR) constituye un gran avance en el estudio morfológico de la unión gastroesofágica (UGE) y en sus grados de disrupción. Objetivos: a) valoración factores de riesgo implicados en la disrupción de la UGE en pacientes con síntomas de reflujo gastroesofágico (RGE); b) la relación entre el tipo de UGE y RGE demostrado por pH-metría; y c) identificación de las alteraciones en los parámetros manométricos vinculados a la morfología de la UGE. Métodos: 115 pacientes con síntomas de RGE, estudiados con MAR y clasificados por el tipo de UGE (tipo I o normal; tipo II o deslizamiento; tipo III o hernia de hiato). En todos ellos se realizó pH-metría de 24 horas sin inhibidores de la bomba de protones. Se evaluaron aspectos epidemiológicos, parámetros manométricos (clasificación de Chicago 2012) y resultados de la pH-metría. Resultados: la edad (OR 1,033 [1,006-1,060]; p = 0,016), IMC (OR 1,097 [1,022-1,176]; p = 0,01) y perímetro abdominal (OR 1,034 [1,005-1,063]; p = 0,0215) fueron factores de riesgo independientes para la UGE tipo III (área bajo la curva 0,70). La disrupción de la UGE se asoció con una menor presión de reposo (p = 0,006), mayor longitud de la misma (p < 0,001) y mayor acortamiento esofágico (p < 0,001). Se encontró RGE patológico en el periodo total (p = 0,015), en bipedestación (p = 0,022) y supino (p = 0,001) en el canal distal en los pacientes con UGE tipo II y III respecto al tipo I. Conclusiones: la mayor edad, el sobrepeso y la obesidad central suponen mayor riesgo de desarrollar UGE tipo III (hernia de hiato). La mayor disrupción de la UGE se asocia con menor presión de reposo, mayor acortamiento esofágico y mayor exposición ácida en la pH-metría (AU)

Background: High-resolution manometry (HRM) is a breakthrough in the morphological study of the gastroesophageal junction (GEJ) and its degrees of disruption. Objectives: a) Assessment of risk factors involved in the disruption of the GEJ in patients with gastroesophageal reflux (GER) symptoms; b) the relationship between the type of GEJ and GER demonstrated by 24 hours pH-monitoring; and c) identification of the alterations in the manometric parameters related to the morphology of the GEJ. Methods: One hundred and fifteen patients with symptoms of GER studied with HRM and classified by the type of GEJ (type I: normal; type II: sliding; type III: hiatal hernia). Twenty four hour pH-monitoring without proton pump inhibitors was performed in all of them. Epidemiological aspects, manometric parameters (Chicago 2012 classification) and the pH-monitoring results were evaluated. Results: Age (OR 1.033 [1.006-1.060]; p = 0.16), BMI (OR 1.097 [1.022-1.176]; p = 0. 01) and abdominal perimeter (OR 1.034 [1.005-1.063]; p = 0.0215) were independent risk factors for the GEJ type III (area under the curve 0.70). Disruption of the GEJ was associated with a lower resting pressure (p = 0.006), greater length (p < 0.001) and greater esophageal shortening (p < 0.001). Abnormal acidic reflux was found in the total period (p = 0.015), standing (p = 0.022) and supine (p = 0.001) in patients with GEJ type II and III with respect to type I. Conclusions: Increased age, overweight and central obesity pose a higher risk of GEJ type III (hiatal hernia). The greater disruption of the GEJ is associated with lower resting pressure, esophageal shortening, and higher acid exposure in the pH-monitoring (AU)