[Recommendations of the Chilean Association for Digestive Endoscopy for the management of gastric pre-malignant lesions]. / Diagnóstico precoz de cáncer gástrico: Propuesta de detección y seguimiento de lesiones premalignas gástricas: protocolo ACHED.

An expert panel analyzed the available evidence and reached a consensus to release 24 recommendations for primary and secondary prevention of gastric cancer (CG) in symptomatic patients, with indication for upper GI endoscopy. The main recommendations include (1) Search for and eradicate H. pylori infection in all cases. (2) Systematic gastric biopsies (Sydney protocol) in all patients over 40 years of age or first grade relatives of patient with CG, to detect gastric atrophy, intestinal metaplasia or dysplasia. (3) Incorporate the OLGA system (Operative Link on Gastritis Assessment) to the pathological report, to categorize the individual risk of CG. (4) Schedule endoscopic follow-up according to the estimated risk of CG, namely annual for OLGA III- IV, every 3 years for OLGA I- II or persistent H. pylori infection, every 5 years for CG relatives without other risk factors and no follow-up for OLGA 0, H. pylori (-). (4) Establish basic human and material resources for endoscopic follow-up programs, including some essential administrative processes, and (5) Suggest the early CG/total CG diagnosis ratio of each institution and the proportion of systematic recording of endoscopic images, as quality indicators. These measures are applicable using currently available resources, they can complement any future screening programs for asymptomatic population and may contribute to improve the prognosis of CG in high-risk populations.

Treatment of common bile duct injuries after surgery.

The treatment of common biliary duct injuries after surgery is a permanent challenge for physicians, and management by a multidisciplinary team is often required. The endoscopic approach is a valuable tool because it is able to assess the problem and also provide a therapeutic option for both fistulas and stenosis of the biliary tree. This article discusses the endoscopic management of postsurgical injuries of the common bile duct and discusses the application of practical tools.

Escurrimiento oleoso anaranjado o «keriorrea», («orange oily anal leakage»): una nueva enfermedad ligada a cambios de hábito alimentario / Orange oily anal leakage: a new entity linked to dietary changes

Introducción Se acumula información relativa a casos clínicos de excepción, relacionados con la ingesta de determinados alimentos y con su forma de consumo, los que presentan un cuadro caracterizado por descarga anal, las más de las veces inadvertida, de líquido anaranjado oleoso que alarma a los pacientes. Método Se registran los antecedentes de una serie de casos recogidos de forma consecutiva, que presentan un cuadro clínico caracterizado por descarga masiva e involuntaria, sin sensación esfinteriana, de deposiciones de aspecto oleoso anaranjado después de ingerir pescado en la gran mayoría de los casos, de cocina japonesa. Resultados Se evaluaron 11 pacientes con el cuadro clínico mencionado. Cuatro mujeres y siete de ellos varones. Edad promedio de 47,3 años. Cuatro pacientes tenían estudio colonoscópico previo sin lesiones. La keriorrea se produciría por acumulación de «ésteres cerosos» no digeribles, presentes en algunos peces escolares, algunos de ellos incorporados recientemente a la ingesta cruda en forma de sashimi o mal llamados mero cocido. Estos aceites, al ser no absorbibles ni digeribles, se filtran insensiblemente desde el recto. También se postularía una disfunción esfinteriana secundaria a toxinas. En ocasiones se produce la misma sintomatología por consumo de estas especies en su forma cocida. El antecedente epidemiológico de ingesta previa de pescado de las características mencionadas, los datos clínicos y lo autolimitado del cuadro, permiten el diagnóstico sin necesidad de realizar mayores estudios. Conclusión Se describe y comunica una serie de casos, de enfermedad recientemente descrita, asociada a cambios de hábito alimentario, de curso benigno y autolimitado. Nos parece importante que este cuadro sea reconocido por los clínicos, para informar a los pacientes y manejar correctamente estos casos(AU)

Introduction Information is accumulating on exceptional cases of oily orange anal leakage, probably caused by certain foods and their form of consumption. The leakage is usually inadvertent and is worrisome for patients. Method Clinical data was gathered on a case series presenting with massive and inadvertent orange oily anal leakage, without sphincter sensation, causing the patients to feel alarmed. This condition usually occurs after eating fish, especially Japanese cuisine. Results Eleven patients were included (four women and seven men). The mean age was 47.3 years. Colonoscopy had previously been performed in four patients, with normal results. The symptoms, described as keriorrhea, were probably produced by accumulation of indigestible "wax esters", es Mero present in some oily fish, recently incorporated in raw fish dishes (sashimi) or as Japanese Mero sea bass. These oils, which cannot be absorbed or digested, accumulate in the rectum and may also filter spontaneously and induce toxin-related sphincter dysfunction. The same symptoms are sometimes produced after consumption of cooked versions of these species. The diagnosis is given by clinical data, prior ingestion of these types of fish and the self-limiting nature of the symptoms, without the need for further investigations. Conclusion We describe a case series of a recently described entity associated with dietary changes. This entity is benign and self-limiting. Clinicians should be familiar with the symptoms to inform patients correctly and avoid unnecessary laboratory studies(AU)

[Orange oily anal leakage: a new entity linked to dietary changes]. / Escurrimiento oleoso anaranjado o "keriorrea", ("orange oily anal leakage"): una nueva enfermedad ligada a cambios de hábito alimentario.

INTRODUCTION: Information is accumulating on exceptional cases of oily orange anal leakage, probably caused by certain foods and their form of consumption. The leakage is usually inadvertent and is worrisome for patients. METHOD: Clinical data was gathered on a case series presenting with massive and inadvertent orange oily anal leakage, without sphincter sensation, causing the patients to feel alarmed. This condition usually occurs after eating fish, especially Japanese cuisine. RESULTS: Eleven patients were included (four women and seven men). The mean age was 47.3 years. Colonoscopy had previously been performed in four patients, with normal results. The symptoms, described as keriorrhea, were probably produced by accumulation of indigestible "wax esters", es Mero present in some oily fish, recently incorporated in raw fish dishes (sashimi) or as Japanese Mero sea bass. These oils, which cannot be absorbed or digested, accumulate in the rectum and may also filter spontaneously and induce toxin-related sphincter dysfunction. The same symptoms are sometimes produced after consumption of cooked versions of these species. The diagnosis is given by clinical data, prior ingestion of these types of fish and the self-limiting nature of the symptoms, without the need for further investigations. CONCLUSION: We describe a case series of a recently described entity associated with dietary changes. This entity is benign and self-limiting. Clinicians should be familiar with the symptoms to inform patients correctly and avoid unnecessary laboratory studies.

[Colorectal cancer screening at Clínica Alemana, Santiago de Chile]. / Plan de tamizaje de cáncer colorrectal ("Mes del Colon") en la Clínica Alemana de Santiago de Chile.

INTRODUCTION: Colorectal cancer (CRC) incidence is rapidly increasing. It has been demonstrated that it can be prevented and cured when the diagnosis is made in early stages. OBJECTIVE: For this reason it is necessary to apply a screening program in asymptomatic patients. METHOD: Since 2003, we conducted a CRC screening plan called "Mes del Colon" at Clínica Alemana Santiago. A press and local diffusion campaign was designed. Open to the community CRC talks were scheduled. An ad hoc database was designed. An informed consent was available. Patients older than 50 years and high risk patients were included. Total colonoscopy and a medical interview after the procedure were included in the plan with favorable economic conditions. RESULTS: Since 2003, 1158 patients were included The 1.8% of them were excluded because of incomplete data or because they did not meet the inclusion criteria. The 54% of patients were women. Mean age was 58.4 years old and mean body mass index 25.5 kg/m2. Polipoid lesions were seen in 45% of the patients. Six (1%) of them were adenocarcinomas, 291 (57%) adenomas (98% tubular adenomas), 189 (37%) hyperplastic polyps and 25 (5%) miscellaneous lesions. In this series, the necessary number to investigate for 1 adenoma was 3.9. CONCLUSIONS: CRC prevention campaigns are needed due to the continuous increase of the incidence in our country. The detection of precursor or early lesions that are longstanding before becoming advanced cancer allows its treatment avoiding progression.

Anisakiasis, un atentado culinario prevenible contra el tracto gastrointestinal / Anisakiasis, a preventable culinary attempt for the gastrointestinal tract

Nuevos hábitos culinarios se han esparcido, desde las culturas originales, para convertirse en costumbres universales. El riesgo que esta globalización puede aparejar probablemente sea subestimado, a no ser que los gastroenterólogos estén conscientes de nuevas enfermedades relacionadas, por ejemplo, con la presencia de agentes infecciosos. Anisakiasis es una de tales enfermedades, relacionadas con la ingestión de pescado crudo o poco cocido, que se presenta en la cultura japonesa, (“el sushi”, “sashimi”), áreas en Sudamérica (“ceviche”), España (“anchoas de vinagre”) y Países Bajos (el pescado crudo). La prevención, está relacionada con la manipulación apropiada, la cocción adecuada y el almacenamiento en frío del pescado. Anisakiasis podría convertirse en un problema clínico serio, debido al compromiso gástrico con ulceraciones, dolor y raras veces pseudotumores en la pared digestiva. El compromiso del intestino delgado es también considerable, secundario a una reacción inflamatoria local severa con edema y estenosis intestinal que simula una obstrucción intestinal. El tratamiento esteroidal generalmente resuelve la crisis, de lo contrario la cirugía es requerida. La reacción alérgica a la presencia del parásito puede llegar a ser un grave problema. La presente revisión trata de aspectos clínicos patológicos, así como del ciclo del parásito, instrumentos diagnósticos y manejo terapéutico.

New culinary habits have been spread, from their original cultures, to become universally known today. They are probably not or insufficiently considered as risky, unless the gastroenterologists become aware of new diseases related for instance with the presence of infective agents. Anisakiasis is one of such diseases, related with the ingestion of raw or undercooked fish, with occurrence in the Japanese culture, (“Sushi”, “sashimi”), areas in South America (“Ceviche”), Spain (“vinegar anchovies”) and The Netherlands (Raw fish). Prevention is related with proper manipulation, cooking and fish frozen storage. Anisakiasis could become a severe clinical problem, because of gastric involvement with ulcerations, pain and rarely intramural pseudotumors. Small intestine involvement is also considerable due to severe inflammatory local reaction, with edema and intense narrowing of the intestinal lumen that mimics intestinal obstruction. Steroidal treatment often solves the crisis. Allergic and general reaction to the occurrence of the parasite is also sometimes a big problem. The present review deals with clinical pathological aspects, as well as parasite cycle, diagnostic tools and treatment.

[Inverted colonic diverticula: an uncommon endoscopic finding]. / Divertículo colónico invertido: un hallazgo endoscópico infrecuente.

BACKGROUND: The appearance of inverted colonic diverticula (ICD) is similar to that of elevated polypoid lesions. The aim of this study was to describe the endoscopic characteristics of ICD with a view to avoiding misdiagnosis, and to report the frequency of these lesions. MATERIAL AND METHOD: Using an endoscopic database, we retrospectively analyzed all patients who underwent colonoscopy at our institution between July 2001 and July 2004. Patients diagnosed with ICD were identified and both patient and ICD characteristics were recorded, including location, endoscopic characteristics, and the presence of synchronous colon polyps. RESULTS: Among the 4508 colonoscopies performed in the selected period, 33 patients (0.7%) were diagnosed with ICD. The mean age was 62.3 years, with a male-to-female ratio of 1:1.2. Most ICD (89%) were in an area of multiple colonic diverticula and 75% were located in the sigmoid colon. One patient had active bleeding directly from the inverted diverticulum and was treated with injection therapy. The endoscopic characteristics of ICDs were described. There were no complications in this series. CONCLUSIONS: ICD is a rare endoscopic finding that can be complicated by local bleeding. Misdiagnosis can be dangerous and biopsy or endoscopic resection could lead to serious complications. The endoscopic criteria described should be considered to avoid the complications associated with biopsy or resection.

Divertículo colónico invertido: un hallazgo endoscópico infrecuente / Inverted colonic diverticula: An uncommon endoscopic finding

INTRODUCCIÓN: El divertículo colónico invertido (DCI) tieneuna apariencia similar a las lesiones polipoideas elevadas. Elobjetivo del presente estudio es describir las característicasendoscópicas del DCI a fin de evitar errores en el diagnósticoy reportar la frecuencia de estas lesiones.MATERIAL Y MÉTODO: Se realizó un análisis retrospectivo detodos los pacientes que se sometieron a una colonoscopia entrejulio de 2001 y julio de 2004, usando una base de datosendoscópicos. Se incluyeron los pacientes con diagnóstico deDCI y se analizaron sus características. Con respecto alDCI, se registró la localización, las características endoscópicasy la presencia de pólipos colónicos sincrónicos.RESULTADOS: Entre las 4.508 colonoscopias realizadas, 33pacientes (0,7%) tuvieron el diagnóstico de DCI. La edadpromedio de los pacientes fue de 62,3 años, y hubo un levepredominio del sexo femenino con una relación 1:1,2. El89% de los DCI se localizó en un área de diverticulosis, y el75% se localizó en el colon sigmoides. Un paciente presentóuna hemorragia digestiva activa con su origen en el divertículoinvertido y se trató con inyectoterapia. Se describieronlas características endoscópicas del DCI. No se reportaroncomplicaciones en esta serie.CONCLUSIONES: El DCI es un hallazgo endoscópico raro quepuede complicarse por el sangrado local. El error diagnósticopuede ser peligroso y su biopsia o resección conllevarían gravescomplicaciones. Los criterios diagnósticos descritos deberíanconsiderarse para evitar la aparición de complicaciones (AU)

BACKGROUND: The appearance of inverted colonic diverticula(ICD) is similar to that of elevated polypoid lesions. Theaim of this study was to describe the endoscopic characteristicsof ICD with a view to avoiding misdiagnosis, and to reportthe frequency of these lesions.MATERIAL AND METHOD: Using an endoscopic database, weretrospectively analyzed all patients who underwent colonoscopyat our institution between July 2001 and July 2004.Patients diagnosed with ICD were identified and both patientand ICD characteristics were recorded, including location,endoscopic characteristics, and the presence of synchronouscolon polyps.RESULTS: Among the 4508 colonoscopies performed in theselected period, 33 patients (0.7%) were diagnosed withICD. The mean age was 62.3 years, with a male-to-femaleratio of 1:1.2. Most ICD (89%) were in an area of multiplecolonic diverticula and 75% were located in the sigmoid colon.One patient had active bleeding directly from the inverteddiverticulum and was treated with injection therapy.The endoscopic characteristics of ICDs were described.There were no complications in this series.CONCLUSIONS: ICD is a rare endoscopic finding that can becomplicated by local bleeding. Misdiagnosis can be dangerousand biopsy or endoscopic resection could lead to seriouscomplications. The endoscopic criteria describedshould be considered to avoid the complications associatedwith biopsy or resection (AU)

[Endoscopic pancreatic sphincterotomy: when and how]. / Esfinterotomía pancreática: cuándo y cómo?

Endoscopic pancreatic sphincterotomy (EPS) has fallen into disuse for some time because of the risk of severe complications. More recently, EPS has been advocated as an effective treatment modality for several pancreatic disorders, including severe chronic pancreatitis, pancreatic pseudocyst, ampulloma, pancreas divisum, and pancreatic sphincter dysfunction. Favorable outcomes in patients undergoing EPS to facilitate further interventions, in whom long-term follow-up was available, was 70%; complications occurred in 14% and reintervention was required in 23%. The results were as good as those of surgery after long-term follow-up. Patients who underwent some form of pancreatic drainage after sphincterotomy had fewer complications (p = 0.03). Approximately 75% of patients with pancreas divisum who presented with idiopathic acute recurrent pancreatitis improved after endoscopic therapy, but only 25% of patients experienced pain reduction of at least 50%. The National Institutes of Health Consensus recommends EPS in patients with type I sphincter of Oddi dysfunction (SOD). In patients with type II SOD, prior manometry should be performed. In our series of 17 patients, we obtained results similar to those of other studies, although the number of patients was small. EPS appears to be a safe and effective technique, but further, well-designed, multicenter, prospective and long-term studies are required to evaluate these results and settle current controversies.

Esfinterotomía pancreática: cuándo y cómo / Endoscopic pancreatic sphincterotomy: when and how?

La esfinterotomía pancreática (EP) se ha evitado durante mucho tiempo debido a las complicaciones asociadas. En la última década fue postulada como un tratamiento efectivo para varios trastornos pancreáticos, como la pancreatitis crónica, el seudoquiste pancreático, el ampuloma, el páncreas divisum o la disfunción del esfínter de Oddi (DEO). La tasa de éxito a largo plazo de la EP previa a la endoterapia es del 70%, el 14% puede tener alguna complicación y la tasa de reintervención alcanza el 23%. Si se compara con los resultados obtenidos en cirugía, no se observaron diferencias significativas a largo plazo. Los pacientes con algún drenaje post-EP, ya sea endoprótesis o drenaje nasopancreático, tuvieron menos complicaciones que los no drenados (p = 0,03). Aproximadamente, el 75% de los pacientes con páncreas divisum, que se presentan con pancreatitis aguda recurrente, se benefician de la EP, pero sólo el 25% de los pacientes tienen una mejoría en más del 50% de la puntuación global de dolor. Acerca de la DEO, la NIH estableció en su consenso de 2002 la EP para el tipo 1. En el tipo 2 se aconseja realizar previamente una manometría del esfínter. En nuestra serie de 17 pacientes obtuvimos resultados comparables a los restantes estudios, aunque se trata de una muestra limitada. Si bien parece una técnica segura y con una eficacia comprobada en algunos casos, creemos que son necesarios estudios multicéntricos, bien diseñados, prospectivos, a largo plazo, capaces de evaluar estos resultados y aclarar escenarios aún controvertidos

Endoscopic pancreatic sphincterotomy (EPS) has fallen into disuse for some time because of the risk of severe complications. More recently, EPS has been advocated as an effective treatment modality for several pancreatic disorders, including severe chronic pancreatitis, pancreatic pseudocyst, ampulloma, pancreas divisum, and pancreatic sphincter dysfunction. Favorable outcomes in patients undergoing EPS to facilitate further interventions, in whom long-term follow-up was available, was 70%; complications occurred in 14% and reintervention was required in 23%. The results were as good as those of surgery after long-term follow-up. Patients who underwent some form of pancreatic drai-nage after sphincterotomy had fewer complications (p = 0.03). Approximately 75% of patients with pancreas divisum who presented with idiopathic acute recurrent pancreatitis improved after endoscopic therapy, but only 25% of patients experienced pain reduction of at least 50%. The National Institutes of Health Consensus recommends EPS in patients with type I sphincter of Oddi dysfunction (SOD). In patients with type II SOD, prior manometry should be performed. In our series of 17 patients, we obtained results similar to those of other studies, although the number of patients was small. EPS appears to be a safe and effective technique, but further, well-designed, multicenter, prospective and long-term studies are required to evaluate these results and settle current controversies