Development and validation of a faecal immunochemical test-based model in the work-up of patients with iron deficiency anaemia.

Objective: In patients with iron deficiency anaemia (IDA), the diagnostic yield of gastroscopy and colonoscopy (bidirectional endoscopy) in detecting neoplastic lesions is low. This study aimed to develop and validate a faecal immunochemical test (FIT)-based model to optimise the work-up of patients with IDA. Methods: Outpatients with IDA were enrolled in a prospective, multicentre study from April 2016 to October 2019. One FIT was performed before bidirectional endoscopy. Significant gastrointestinal lesions were recorded and a combined model developed with variables that were independently associated with significant colorectal lesions in the multivariate analysis. The model cut-off was selected to provide a sensitivity of at least 95% for colorectal cancer (CRC) detection, and its performance was compared to different FIT cut-offs. The data set was randomly split into two groups (developed and validation cohorts). An online calculator was developed for clinical application. Results: The development and validation cohorts included 373 and 160 patients, respectively. The developed model included FIT value, age, and sex. In the development and validation cohorts, a model cut-off of 0.1375 provided a negative predictive value of 98.1 and 96.7% for CRC and 90.7 and 88.3% for significant colorectal lesions, respectively. This combined model reduced the rate of missed significant colorectal lesions compared to FIT alone and could have avoided more than one-fourth of colonoscopies. Conclusion: The FIT-based combined model developed in this study may serve as a useful diagnostic tool to triage IDA patients for early endoscopic referral, resulting in considerable reduction of unnecessary colonoscopies.

Encuesta internacional on-line sobre el manejo de la hemorragia digestiva baja grave. ¿Lo tenemos claro? / International on-line questionnaire about severe lower gastrointestinal bleeding management: Do we have it clear?

Introducción: La estrategia diagnóstico-terapéutica en la hemorragia digestiva baja (HDB) grave varía según la situación clínica del paciente. Las guías de práctica clínica actuales proponen diferentes estrategias de manejo. Objetivo: Conocer la toma de decisiones de los gastroenterólogos de distintos centros hospitalarios en el manejo de esta enfermedad. Métodos: Estudio observacional descriptivo mediante una encuesta on-line, dirigida a facultativos de aparato digestivo de España y Latinoamérica, en diciembre de 2021. Resultados: Se incluyeron 281 encuestas anónimas de facultativos de España y Latinoamérica. El manejo diagnóstico-terapéutico de la HDB grave fue heterogéneo entre los encuestados. Con respecto a los estudios iniciales mostraron variabilidad entre la solicitud de angiografía por tomografía computarizada (angio-TC) (44,5%), gastroscopia (33,1%), colonoscopia (20,6%) y arteriografía (1,1%). La decisión terapéutica tras angio-TC positiva variaba mayoritariamente entre la solicitud de arteriografía (38,1%) y colonoscopia (44,1%). Si la angio-TC era negativa se realizaba gastroscopia en la mayoría de los casos. Si el paciente ingresaba en una unidad de cuidados intensivos y precisaba colonoscopia, la mayor parte de los encuestados la realizaban urgente (<24h) (31% siempre, 43,4% en la mayoría de los casos); mientras que, si no requerían ingreso en intensivos este porcentaje se reducía (10% siempre, 33,8% en la mayoría de los casos). Reconocían tener dudas en el manejo de estos pacientes el 40,9% de los encuestados, y consideraban necesario la creación de un protocolo de actuación el 98,2% de los participantes. Conclusiones: Existe una gran variabilidad interhospitalaria en el manejo de la HDB grave entre los gastroenterólogos. Es necesario unificar la actuación diagnóstico-terapéutica en esta enfermedad.(AU)

Background and aims: The diagnostic and therapeutic strategy in severe lower gastrointestinal bleeding (LGIB) varies depending on the patient's clinical situation. Actual clinical practice guidelines propose different management strategies. We aim to know the attitude of the gastroenterologists from different hospitalary centers in the management of this entity. Methods: Descriptive and observational study using an on-line questionnaire, addressed to gastroenterologists in Spain and Latin America, in December 2021. Results: We included 281 anonymous questionnaires of gastroenterologists from Spain and Latin America. Diagnostic and therapeutic management of severe LGIB was heterogeneous among the participants. Regarding to the first diagnostic modalities they showed variability between performing computed tomography angiography (CTA) (44.5%), gastroscopy (33.1%), colonoscopy (20.6%) and arteriography (1.1%). The therapeutic attitude after a positive CTA mostly varied between performing arteriography (38.1%) and colonoscopy (44.1%). If negative CTA, in the majority of cases a gastroscopy was performed. If the patient needed intensive critical unit (ICU) care and to undergo colonoscopy, most participants performed an urgent colonoscopy (<24h) (31% always, 43.4% in most cases); while if the patient did not require ICU admission this percentage was lower (10% always, 33.8% in most cases). The 40.9% of the participants admitted having doubts about the management of this patients and the 98.2% considered the need for a creation of an action protocol. Conclusions: There is a high interhospitalary variability on the management of severe lower gastrointestinal bleeding among gastroenterologists. It is necessary to unify the diagnostic and therapeutic management of this pathology.(AU)

International on-line questionnaire about severe lower gastrointestinal bleeding management: Do we have it clear? / Encuesta internacional on-line sobre el manejo de la hemorragia digestiva baja grave. ¿Lo tenemos claro?

BACKGROUND AND AIMS: The diagnostic and therapeutic strategy in severe lower gastrointestinal bleeding (LGIB) varies depending on the patient's clinical situation. Actual clinical practice guidelines propose different management strategies. We aim to know the attitude of the gastroenterologists from different hospitalary centers in the management of this entity. METHODS: Descriptive and observational study using an on-line questionnaire, addressed to gastroenterologists in Spain and Latin America, in December 2021. RESULTS: We included 281 anonymous questionnaires of gastroenterologists from Spain and Latin America. Diagnostic and therapeutic management of severe LGIB was heterogeneous among the participants. Regarding to the first diagnostic modalities they showed variability between performing computed tomography angiography (CTA) (44.5%), gastroscopy (33.1%), colonoscopy (20.6%) and arteriography (1.1%). The therapeutic attitude after a positive CTA mostly varied between performing arteriography (38.1%) and colonoscopy (44.1%). If negative CTA, in the majority of cases a gastroscopy was performed. If the patient needed intensive critical unit (ICU) care and to undergo colonoscopy, most participants performed an urgent colonoscopy (<24h) (31% always, 43.4% in most cases); while if the patient did not require ICU admission this percentage was lower (10% always, 33.8% in most cases). The 40.9% of the participants admitted having doubts about the management of this patients and the 98.2% considered the need for a creation of an action protocol. CONCLUSIONS: There is a high interhospitalary variability on the management of severe lower gastrointestinal bleeding among gastroenterologists. It is necessary to unify the diagnostic and therapeutic management of this pathology.

Retrospective cohort study of laparoscopic ICG-Guided Lymphadenectomy in gastric cancer from a Western country center.

BACKGROUND: Indocyanine green (ICG) guided lymphadenectomy has been proposed has a technique to improve the lymphadenectomy of patients with gastric cancer. Nevertheless, experience with this procedure is scarce in Western countries. METHODS: A retrospective analytic study in a tertiary hospital in Spain was performed, comparing patients who underwent laparoscopic gastrectomy with (ICG cohort) and without (historic cohort) ICG guided lymphadenectomy. RESULTS: Thirty four patients were included (17 in each group). Although the number of positive nodes was similar in both groups (0.0 in the ICG cohort vs. 2 in the historic cohort, p = 0.119), the number of lymph nodes removed was higher in the ICG cohort (42.0 vs 28.0, p = 0.040). In the ICG cohort, more lymph nodes were positive for adenocarcinoma in the group of nodes that were positive for IGC (10.6% of the IGC + nodes vs. 1.9% in the ICG - nodes, p < 0.001). CONCLUSIONS: ICG lymphadenectomy is a promising procedure that could improve the lymphadenectomy of patients with gastric cancer. ICG lymphadenectomy could be used to increase the number of lymph nodes removed in patients with a high-risk of nodal invasion or it could be used to reduce the surgical aggressiveness in fragile patients with a low-risk of nodal invasion.

El reto del colon derecho / The right colon challenge

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The right colon challenge.

Colorectal cancer (CRC) is the third most common cancer and the fourth cause of cancer-related mortality worldwide. In an attempt to raise awareness on this situation, and to implement preventive measures, March 31st has been established as international colorectal cancer awareness day. Our country, with the Spanish "Alianza para la Prevención del Cáncer de Colon", pioneered in 2008 an institution that brought together scientific and civil societies to pursue this goal. A stabilization, even a decrease in the incidence and mortality of this condition has been reported in western countries for the last few years, which may be attributed to a number of highly relevant factors.

Déficit de vitamina D en la enfermedad hepática crónica, análisis clínico epidemiológico y tras aporte vitamínico / Vitamin D deficiency in chronic liver disease, clinical-epidemiological analysis and report after vitamin d supplementation

INTRODUCCIÓN: La vitamina D (VD) participa en multitud de funciones extraesqueléticas en el organismo y cada vez es más importante su relación con las enfermedades hepáticas crónicas (EHC). OBJETIVOS: Analizar la prevalencia de déficit o insuficiencia de VD en los pacientes con EHC de nuestra área. Evaluar si el aporte de VD influye en la concentración sérica y se asocia a mejoría de la función hepática. MATERIAL Y MÉTODOS: Realizamos un estudio en 2 fases. En el primer tiempo se analizaron características clínico-epidemiológicas de 94 pacientes con EHC; en un segundo tiempo, se administraron diferentes dosis de calcifediol (25-OH-VD) a aquellos pacientes con déficit (<20ng/mL) e insuficiencia (20-30ng/mL) de VD. Se determinaron concentraciones plasmáticas, variables analíticas y de función hepática (Child-Pugh y MELD) al finalizar el tratamiento y se compararon con los datos basales. RESULTADOS: El 87% de los pacientes tenían concentraciones deficitarias o insuficientes de VD, con una media de 18,8ng/mL, siendo menor en los cirróticos (15,9ng/mL) (p = 0,002) y en la etiología por alcohol. Igualmente la concentración sérica de VD era inversamente proporcionales al grado de función hepática: Child A (16,52ng/mL) vs. C (7,75ng/mL). Tras el aporte con VD, se consiguió normalizar los niveles en el 94% de los pacientes, mejorar significativamente la cifra de plaquetas, de albúmina (p < 0,05) y el grado funcional valorado por la escala de Child-Pugh (p < 0,05). CONCLUSIÓN: Dada la alta prevalencia de déficit o insuficiencia de VD debería plantearse la necesidad de cribado en la población con EHC. El aporte de VD podría ser seguro y eficaz

INTRODUCTION: Vitamin D (VD) is known to have multiple extra-skeletal health functions. There is emerging interest in exploring the relationship between vitamin D and chronic liver disease (CLD). OBJECTIVES: To determine the prevalence of VD deficiency in patients with CLD in our setting and to assess whether VD supplementation influences plasma levels and is associated with improved liver function. MATERIAL AND METHODS: We conducted a study in 2 phases. First, we analysed clinical and epidemiological characteristics in 94 patients with CLD; second, different doses of calcifediol (25-OH-VD) were administered to patients with VD deficiency (<20ng/mL) and insufficiency (20-30ng/mL). Plasma concentrations and liver function (Child-Pugh and MELD) at the end of treatment were compared with baseline data. RESULTS: Deficient or insufficient VD levels were found in 87% of the patients, with an average concentration of 18.8ng/mL. Levels were lower in patients with cirrhosis (15.9ng/mL) (P=.002) and in alcoholic liver disease. VD levels were inversely proportional to the degree of liver function: Child A (16.52ng/mL) vs C (7.75ng/mL). After VD supplementation, optimal serum levels were achieved in 94% of patients and significant improvements were observed in platelet count, albumin levels (P<.05) and functional status assessed by the Child-Pugh scale (P<.05). CONCLUSION: Given the high prevalence of VD deficiency or insufficiency, the need for screening should be considered in the population with CLD. VD supplementation could be safe and effective

Estudio comparativo del tratamiento médico frente al quirúrgico en el control ácido del esófago de Barrett / A comparison of medical versus surgical treatment in Barrett's esophagus acid control

INTRODUCCIÓN: El esófago de Barrett (EB) es una lesión esofágica ocasionada mayoritariamente por reflujo gastroesofágico ácido. El control del reflujo ácido es uno de los principales objetivos del tratamiento de esta patología. OBJETIVO: Evaluar en nuestra área de salud el grado de control del reflujo ácido en los pacientes con EB en función del tratamiento de mantenimiento recibido, médico o quirúrgico. MÉTODOS: Estudio retrospectivo de pacientes con diagnóstico endoscópico e histológico de EB. Un grupo de pacientes recibió tratamiento médico con inhibidores de la bomba de protones (IBP) y otro grupo fue sometido a intervención quirúrgica (funduplicatura de Nissen). Se compararon datos epidemiológicos y resultados de pHmetría (tiempo de pH < 4, reflujos prolongados > 5 min, puntuación de DeMeester) de cada grupo. La pH-metría se realizó con IBP en el grupo de tratamiento médico y en el grupo de cirugía sin consumo de antisecretores ácidos. Se definió fracaso del tratamiento como un pH < 4 total superior al 5%. RESULTADOS: Fueron incluidos 128 pacientes con EB (tratamiento médico 75, tratamiento quirúrgico 53). Ambas cohortes eran homogéneas respecto a sus características demográficas. Las puntuaciones de DeMeester, fracción de tiempo de pH < 4 y cantidad de reflujos prolongados fueron significativamente inferiores en los pacientes con funduplicatura frente a los que recibían IBP (p < 0,001). De forma global se apreció un fracaso de tratamiento en el 29% de los pacientes, que fue significativamente mayor en el grupo de tratamiento médico (40% vs 13%; p < 0,001). CONCLUSIONES: El grado de control del reflujo ácido gastroesofágico es subóptimo en un elevado porcentaje de pacientes con EB. El tratamiento médico ofrece resultados inferiores a la cirugía antirreflujo y se debería intentar optimizar sus resultados

INTRODUCTION: Barrett's oesophagus (BE) is an oesophageal injury caused by gastroesophageal acid reflux. One of the main aims of treatment in BE is to achieve adequate acid reflux control. OBJECTIVE: To assess acid reflux control in patients with BE based on the therapy employed: medical or surgical. METHODS: A retrospective study was performed in patients with an endoscopic and histological diagnosis of BE. Medical therapy with proton pump inhibitors (PPI) was compared with surgical treatment (Nissen fundoplication). Epidemiological data and the results of pH monitoring (pH time < 4, prolonged reflux > 5min, DeMeester score) were evaluated in each group. Treatment failure was defined as a pH lower than 4 for more than 5% of the recording time. RESULTS: A total of 128 patients with BE were included (75 PPI-treated and 53 surgically-treated patients). Patients included in the two comparison groups were homogeneous in terms of demographic characteristics. DeMeester scores, fraction of time pH < 4 and the number of prolonged refluxes were significantly lower in patients with fundoplication versus those receiving PPIs (P < .001). Treatment failure occurred in 29% of patients and was significantly higher in those receiving medical therapy (40% vs 13%; P < .001). CONCLUSIONS: Treatment results were significantly worse with medical treatment than with anti-reflux surgery and should be optimized to improve acid reflux control in BE. Additional evidence is needed to fully elucidate the utility of PPI in this disease

Reactivación de tuberculosis pulmonar durante el tratamiento con triple terapia de la hepatitis C / Reactivation of pulmonary tuberculosis during treatment with triple therapy for hepatitis C

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[Vitamin D deficiency in chronic liver disease, clinical-epidemiological analysis and report after vitamin d supplementation]. / Déficit de vitamina D en la enfermedad hepática crónica, análisis clínico epidemiológico y tras aporte vitamínico.

INTRODUCTION: Vitamin D (VD) is known to have multiple extra-skeletal health functions. There is emerging interest in exploring the relationship between vitamin D and chronic liver disease (CLD). OBJECTIVES: To determine the prevalence of VD deficiency in patients with CLD in our setting and to assess whether VD supplementation influences plasma levels and is associated with improved liver function. MATERIAL AND METHODS: We conducted a study in 2 phases. First, we analysed clinical and epidemiological characteristics in 94 patients with CLD; second, different doses of calcifediol (25-OH-VD) were administered to patients with VD deficiency (<20ng/mL) and insufficiency (20-30ng/mL). Plasma concentrations and liver function (Child-Pugh and MELD) at the end of treatment were compared with baseline data. RESULTS: Deficient or insufficient VD levels were found in 87% of the patients, with an average concentration of 18.8ng/mL. Levels were lower in patients with cirrhosis (15.9ng/mL) (P=.002) and in alcoholic liver disease. VD levels were inversely proportional to the degree of liver function: Child A (16.52ng/mL) vs C (7.75ng/mL). After VD supplementation, optimal serum levels were achieved in 94% of patients and significant improvements were observed in platelet count, albumin levels (P<.05) and functional status assessed by the Child-Pugh scale (P<.05). CONCLUSION: Given the high prevalence of VD deficiency or insufficiency, the need for screening should be considered in the population with CLD. VD supplementation could be safe and effective.

[A comparison of medical versus surgical treatment in Barrett's esophagus acid control]. / Estudio comparativo del tratamiento médico frente al quirúrgico en el control ácido del esófago de Barrett.

INTRODUCTION: Barrett's oesophagus (BE) is an oesophageal injury caused by gastroesophageal acid reflux. One of the main aims of treatment in BE is to achieve adequate acid reflux control. OBJECTIVE: To assess acid reflux control in patients with BE based on the therapy employed: medical or surgical. METHODS: A retrospective study was performed in patients with an endoscopic and histological diagnosis of BE. Medical therapy with proton pump inhibitors (PPI) was compared with surgical treatment (Nissen fundoplication). Epidemiological data and the results of pH monitoring (pH time <4, prolonged reflux >5min, DeMeester score) were evaluated in each group. Treatment failure was defined as a pH lower than 4 for more than 5% of the recording time. RESULTS: A total of 128 patients with BE were included (75 PPI-treated and 53 surgically-treated patients). Patients included in the two comparison groups were homogeneous in terms of demographic characteristics. DeMeester scores, fraction of time pH<4 and the number of prolonged refluxes were significantly lower in patients with fundoplication versus those receiving PPIs (P<.001). Treatment failure occurred in 29% of patients and was significantly higher in those receiving medical therapy (40% vs 13%; P<.001). CONCLUSIONS: Treatment results were significantly worse with medical treatment than with anti-reflux surgery and should be optimized to improve acid reflux control in BE. Additional evidence is needed to fully elucidate the utility of PPI in this disease.

Factors Determining Colorectal Cancer: The Role of the Intestinal Microbiota.

The gastrointestinal tract, in particular the colon, holds a complex community of microorganisms, which are essential for maintaining homeostasis. However, in recent years, many studies have implicated microbiota in the development of colorectal cancer (CRC), with this disease considered a major cause of death in the western world. The mechanisms underlying bacterial contribution in its development are complex and are not yet fully understood. However, there is increasing evidence showing a connection between intestinal microbiota and CRC. Intestinal microorganisms cause the onset and progression of CRC using different mechanisms, such as the induction of a chronic inflammation state, the biosynthesis of genotoxins that interfere with cell cycle regulation, the production of toxic metabolites, or heterocyclic amine activation of pro-diet carcinogenic compounds. Despite these advances, additional studies in humans and animal models will further decipher the relationship between microbiota and CRC, and aid in developing alternate therapies based on microbiota manipulation.

Hepatitis asociada a acetato de glatirámero / Hepatitis induced by glatiramer acetate

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Hemosuccus pancreático, una causa rara de hemorragia digestiva alta / Pancreatic hemosuccus, a rare cause of upper gastrointestinal bleeding

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