Prevalence of Malnutrition and Nutritional Characteristics of Patients With Inflammatory Bowel Disease.

BACKGROUND AND AIMS: This study sought to determine the prevalence of malnutrition in patients with inflammatory bowel disease, to analyse the dietary beliefs and behaviours of these patients, to study their body composition, to evaluate their muscular strength and to identify the factors associated with malnutrition in these patients. METHODS: This was a prospective, multicentre study. Crohn's disease and ulcerative colitis patients from 30 Spanish centres, from the outpatient clinics, were included. A questionnaire of 11 items was applied to obtain data from patients' dietary behaviour and beliefs. Patients who accepted were evaluated to assess their nutritional status using Subjective Global Assessment and body mass index. Body composition was evaluated through bioelectrical impedance. RESULTS: A total of 1271 patients were included [51% women, median age 45 years, 60% Crohn's disease]. Of these, 333 patients underwent the nutritional evaluation. A total of 77% of patients declared that they avoided some foods to prevent disease relapse. Eighty-six per cent of patients avoided some foods when they had disease activity because of fear of worsening the flare. Sixty-seven per cent of patients modified their dietary habits after disease diagnosis. The prevalence of malnutrition was 16% [95% confidence interval = 12-20%]. In the multivariate analysis, history of abdominal surgery, active disease and avoidance of some foods during flares were associated with higher risk of malnutrition. CONCLUSIONS: The prevalence of malnutrition in inflammatory bowel disease patients was high. We identified some predictive factors of malnutrition. Most of the patients had self-imposed food restrictions, based on their beliefs.

Espiroquetosis intestinal: una causa infrecuente de diarrea crónica / Intestinal spirochetosis: A rare cause of chronic diarrhea

No disponible

Intermittent boluses versus pump continuous infusion for endoscopist-directed propofol administration in colonoscopy.

BACKGROUND: non-anesthesiologist administration of propofol (NAAP) using continuous infusion systems may achieve a more sustained sedative action. AIM: to compare intermittent boluses (IB) with pump continuous infusion (PCI) for NAAP, targeted to moderate sedation, for colonoscopy. METHODS: 192 consecutive outpatients were randomized to receive IB (20 mg propofol boluses on demand) or PCI (3 mg/kg/h plus 20 mg boluses on demand). Sedation could be stopped at cecal intubation at the discretion of the endoscopist. Satisfaction rates of the patient, nurses and endoscopist, propofol doses, depth of sedation (at the beginning, at cecal intubation and at the end), recovery times, complications and were collected. RESULTS: there were no differences between groups regarding patient, nurse or endoscopist satisfaction rates with procedural sedation. Propofol doses (mg) were significantly higher during the induction phase -86 (30-172) vs. 78 [30-160], p 0.03- and overall -185 (72-400) vs. 157 (60-460), p = 0.003- for PCI group. 81 % of assessments of the depth of sedation were moderate. The level of sedation (O/AAS scale) was borderline significantly deeper at cecal intubation (2.38 vs. 2.72; p = 0.056) and at the end of the procedure (4.13 vs. 4.45; p = 0.05) for PCI group, prolonging thus early recovery time (6.3 vs. 5.1 minutes, p = 0.008), but not discharge time. Complications, all of them in minors, were non-significantly more frequent in the PCI group (9 vs. 7 %, p = 0.07). CONCLUSIONS: NAAP for colonoscopy was safely administered with comparable satisfaction and complication rates with either IB or PCI.

Intermittent boluses versus pump continuous infusion for endoscopist-directed propofol administration in colonoscopy / Administración de propofol mediante bolus intermitente frente a infusión continua con bomba controlada por el endoscopista en la colonoscopia

Background: non-anesthesiologist administration of propofol (NAAP) using continuous infusion systems may achieve a more sustained sedative action. Aim: to compare intermittent boluses (IB) with pump continuous infusion (PCI) for NAAP, targeted to moderate sedation, for colonoscopy. Methods: 192 consecutive outpatients were randomized to receive IB (20 mg propofol boluses on demand) or PCI (3 mg/ kg/h plus 20 mg boluses on demand). Sedation could be stopped at cecal intubation at the discretion of the endoscopist. Satisfaction rates of the patient, nurses and endoscopist, propofol doses, depth of sedation (at the beginning, at cecal intubation and at the end), recovery times, complications and were collected. Results: there were no differences between groups regarding patient, nurse or endoscopist satisfaction rates with procedural sedation. Propofol doses (mg) were significantly higher during the induction phase (86 [30-172] vs. 78 [30-160], p 0.03) and overall (185 [72-400] vs. 157 [60-460], p = 0.003) for PCI group. 81 % of assessments of the depth of sedation were moderate. The level of sedation (O/AAS scale) was borderline significantly deeper at cecal intubation (2.38 vs. 2.72; p = 0.056) and at the end of the procedure (4.13 vs. 4.45; p = 0.05) for PCI group, prolonging thus early recovery time (6.3 vs. 5.1 minutes, p = 0.008), but not discharge time. Complications, all of them in minors, were non-significantly more frequent in the PCI group (9 vs. 7 %, p = 0.07). Conclusions: NAAP for colonoscopy was safely administered with comparable satisfaction and complication rates with either IB or PCI (AU)

Optimized nonbismuth quadruple therapies cure most patients with Helicobacter pylori infection in populations with high rates of antibiotic resistance.

BACKGROUND & AIMS: Strategies to eradicate Helicobacter pylori infection could be improved by suppressing acid and extending the duration of therapy (optimization). We compared the efficacy of 2 different optimized nonbismuth quadruple regimens in areas of high resistance to antimicrobial agents. METHODS: We performed a prospective noninferiority multicenter trial in which 343 consecutive individuals with H pylori infection were assigned randomly to groups given hybrid therapy (40 mg omeprazole and 1 g amoxicillin, twice daily for 14 days; 500 mg clarithromycin and 500 mg nitroimidazole were added, twice daily for the final 7 days) or concomitant therapy (same 4 drugs taken concurrently, twice daily for 14 days). We assessed bacterial resistance to these drugs in a subset of patients using the E-test. Efficacy, side effects, and compliance were determined. RESULTS: In per-protocol analysis, rates of eradication for hybrid and concomitant therapies were 92% (95% confidence interval [CI], 87%-95%) and 96.1% (95% CI, 93%-99%), respectively (P = .07). In intention-to-treat analysis, rates were 90% (95% CI, 86%-93%) and 91.7% (95% CI, 87%-95%), respectively (P = .35). Almost all patients (95.5%) were fully compliant; 23.5% of patients had H pylori strains that were resistant to clarithromycin (Italy, 26%; Spain, 19.5%), 33% were resistant to metronidazole (Italy, 33%; Spain, 34%), and 8.8% were resistant to both drugs (Italy, 7.1%; Spain, 11.5%). Side effects (only mild) were reported in 51.5% of patients (47% hybrid vs 56% concomitant; P = .06). Compliance greater than 80% was the only significant predictor of eradication (odds ratio, 12.5; 95% CI, 3.1-52; P = .001). Significantly more patients were compliant with hybrid therapy (98.8%) than concomitant therapy (95.2%; P = .05). CONCLUSIONS: Optimized nonbismuth quadruple hybrid and concomitant therapies cured more than 90% of patients with H pylori infections in areas of high clarithromycin and metronidazole resistance. ClinicalTrials.gov number NCT01464060.

Preparación con picosulfato sódico/citrato de magnesio en dosis fraccionadas para colonoscopias en turno de mañana realizadas entre las 2 y 6 horas posteriores a la ingesta de líquidos / Split-dose sodium picosulphate/magnesium citrate for morning colonoscopies performed 2 to 6hours after fluid intake

Introducción La preparación de la colonoscopia en dosis fraccionadas (DF) mejora la calidad de la limpieza. Objetivo Comparar la preparación para colonoscopias de mañana con picosulfato sódico/citrato de magnesio (Citrafleet®) en DF con su administración el día previo. Material y métodos Pacientes consecutivos fueron aleatorizados a Citrafleet® el día anterior o en DF administrándose la segunda mitad individualizadamente con un intervalo de 2 a 6 h antes del procedimiento, sin bisacodilo. La sedación fue realizada con propofol, definiéndose una limpieza adecuada si ≥ 6 (escala de Boston), sin ninguna puntuación 0/1.ResultadosSe incluyeron 193 pacientes. La calidad de la limpieza fue significativamente mejor en el grupo DF de manera global (7 vs. 5,2, p<0,001), en ciego (2,4 vs. 1,4, p<0,001), colon ascendente (2,5 vs.1,6, p = 0,001) y colon transverso (2,4 vs. 2, p = 0,004). La limpieza adecuada del colon se detectó en un porcentaje significativamente superior de pacientes con DF (71 vs. 30%, p<0,001). Los pacientes del grupo DF bebieron un volumen de líquido superior (4,9 vs. 4 l, p = 0,006) y percibieron con mayor frecuencia el proceso como fácil o muy fácil de completar (89 vs. 68%, p = 0,04), aunque durmieron menor número de horas (6,5 vs.7,9, p<0,001). No se registró ninguna bronconeumonía aspirativa. Conclusiones La preparación en DF con Citrafleet® incrementó en un 40% las exploraciones con una limpieza adecuada, especialmente en colon proximal, aumentó el volumen de ingesta líquida y mejoró la percepción de facilidad para su cumplimiento, sin complicaciones derivadas de la sedación (AU)

Background Split dosage of bowel preparations has been shown to substantially improve bowel cleansing. Aim To compare the split dose (SD) sodium picosulphate/magnesium oxide/anhydrous citric acid (Citrafleet®) regimen for morning colonoscopies with standard cleansing the day before. Methods Consecutive outpatients were randomized to receive Citrafleet® the day before colonoscopy or SD, in whom the second half was administered on an individual basis from 2 to 6hours before the procedure. No bisacodyl was administered. All procedures were performed with non-anesthesiologist administered propofol sedation. The Boston scale was used to assess the quality of bowel preparation (adequate cleansing if score ≥ 6, with no score of 0/1 in any segment).Results A total of 193 patients were included. Overall bowel cleansing was significantly better in the SD group (7 vs. 5.2, p<0.001), as well as in the cecum (2.4 vs. 1.4, p < 0.001), ascending colon (2.5vs. 1.6, p<0.001) and transverse colon (2.4 vs. 2, p = 0.004). A significant proportion of SD patients had adequate bowel cleansing (71% vs. 30%, p<0.001). Patients in the SD group drank a greater amount of liquid (4.9 vs. 4 liters, p = 0.006) and more frequently perceived the cleansing process to be easy or very easy to complete (89 vs. 68%, p = 0.04), although they slept significantly fewer hours (6.5 vs. 7.9, p<0.001). No bronchoaspiration pneumonia was reported. Conclusions SD Citrafleet® 2 to 6hours before colonoscopy increased the rate of procedures with adequate bowel cleansing by 40%, especially in the proximal colon, allowed more liquids to be drunk and increased the perception of ease in completing the preparation, with no sedation-related complications (AU)

[Split-dose sodium picosulphate/magnesium citrate for morning colonoscopies performed 2 to 6 hours after fluid intake]. / Preparación con picosulfato sódico/citrato de magnesio en dosis fraccionadas para colonoscopias en turno de mañana realizadas entre las 2 y 6 horas posteriores a la ingesta de líquidos.

BACKGROUND: Split dosage of bowel preparations has been shown to substantially improve bowel cleansing. AIM: To compare the split dose (SD) sodium picosulphate/magnesium oxide/anhydrous citric acid (Citrafleet(®)) regimen for morning colonoscopies with standard cleansing the day before. METHODS: Consecutive outpatients were randomized to receive Citrafleet(®) the day before colonoscopy or SD, in whom the second half was administered on an individual basis from 2 to 6 hours before the procedure. No bisacodyl was administered. All procedures were performed with non-anesthesiologist administered propofol sedation. The Boston scale was used to assess the quality of bowel preparation (adequate cleansing if score ≥ 6, with no score of 0/1 in any segment). RESULTS: A total of 193 patients were included. Overall bowel cleansing was significantly better in the SD group (7 vs. 5.2, p<0.001), as well as in the cecum (2.4 vs. 1.4, p < 0.001), ascending colon (2.5 vs. 1.6, p<0.001) and transverse colon (2.4 vs. 2, p=0.004). A significant proportion of SD patients had adequate bowel cleansing (71% vs. 30%, p<0.001). Patients in the SD group drank a greater amount of liquid (4.9 vs. 4 liters, p=0.006) and more frequently perceived the cleansing process to be easy or very easy to complete (89 vs. 68%, p=0.04), although they slept significantly fewer hours (6.5 vs. 7.9, p<0.001). No bronchoaspiration pneumonia was reported. CONCLUSIONS: SD Citrafleet(®) 2 to 6 hours before colonoscopy increased the rate of procedures with adequate bowel cleansing by 40%, especially in the proximal colon, allowed more liquids to be drunk and increased the perception of ease in completing the preparation, with no sedation-related complications.

Nonbismuth quadruple (concomitant) therapy: empirical and tailored efficacy versus standard triple therapy for clarithromycin-susceptible Helicobacter pylori and versus sequential therapy for clarithromycin-resistant strains.

BACKGROUND: Using quadruple clarithromycin-containing regimens for Helicobacter pylori eradication is controversial with high rates of macrolide resistance. AIM: To evaluate antibiotic resistance rates and the efficacy of empirical and tailored nonbismuth quadruple (concomitant) therapy in a setting with cure rates <80% for triple and sequential therapies. METHODS: 209 consecutive naive H. pylori-positive patients without susceptibility testing were empirically treated with 10-day concomitant therapy (proton pump inhibitors (PPI), amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg; all drugs b.i.d.). Simultaneously, 89 patients with positive H. pylori culture were randomized to receive triple versus concomitant therapy for clarithromycin-susceptible H. pylori, and sequential versus concomitant therapy for clarithromycin-resistant strains. Eradication was confirmed with ¹³C-urea breath test or histology 8 weeks after completion of treatment. RESULTS: Per-protocol (PP) and intention-to-treat eradication rates after empirical concomitant therapy without susceptibility testing were 89% (95%CI:84-93%) and 87% (83-92%). Antibiotic resistance rates were: clarithromycin, 20%; metronidazole, 34%; and both clarithromycin and metronidazole, 10%. Regarding clarithromycin-susceptible H. pylori, concomitant therapy was significantly better than triple therapy by per protocol [92% (82-100%) vs 74% (58-91%), p = 0.05] and by intention to treat [92% (82-100%) vs 70% (57-90%), p = 0.02]. As for antibiotic-resistant strains, eradication rates for concomitant and sequential therapies were 100% (5/5) vs 75% (3/4), for clarithromycin-resistant/metronidazole-susceptible strains and 75% (3/4) vs 60% (3/5) for dual-resistant strains. CONCLUSIONS: Empirical 10-day concomitant therapy achieves good eradication rates, close to 90%, in settings with multiresistant H. pylori strains. Tailored concomitant therapy is significantly superior to triple therapy for clarithromycin-susceptible H. pylori and at least as effective as sequential therapy for resistant strains.

Nonanesthesiologist-administered propofol versus midazolam and propofol, titrated to moderate sedation, for colonoscopy: a randomized controlled trial.

BACKGROUND: Nonanesthesiologist-administered propofol (NAAP) is controversial due to deep sedation concerns. AIM: The purpose of this study was to evaluate the feasibility of moderate sedation with two different NAAP regimens for colonoscopy. METHODS: This was a double-blinded, randomised, placebo-controlled trial allocating 135 consecutive outpatients to placebo (group P) or midazolam 2 mg (group M+P) before NAAP targeted to moderate sedation. Depth of sedation every 2 min throughout the procedure, propofol doses, recovery times, complications and patient and endoscopist satisfaction were measured. RESULTS: A total of 84 % of assessments of the depth of sedation were moderate. Mean induction (76 [40-150] vs. 53 [30-90]) and total propofol doses (mg) (136 [60-270] vs. 104 [50-190]) were significantly higher for group P (p < 0.001). However, deep sedation was significantly more prevalent in group M+P in minutes 4 (16 vs. 1 %, p = 0.05), 6 (20 vs. 3.5 %, p = 0.046) and 8 (17 vs. 1.8 %, p = 0.06) of the procedure, coinciding with midazolam peak action. From minute 8 on, moderate sedation was significantly deeper for M+P (p = 0.002). Early recovery time (6.8 min vs. 5.2, p = 0.007), but not discharge time (10.4 min vs. 9.8, p = 0.5), was longer for M+P. Pain perception (P 1.03 vs. M+P 0.3, p = 0.009) and patient satisfaction scores (P 9.4 vs. M+P 9.8, p = 0.047) were better for M+P. No major complications occurred. CONCLUSIONS: Moderate sedation was feasible with both NAAP regimens. Drug synergy in the midazolam plus propofol sedation regimen promotes a deeper and longer moderate sedation, improving patient satisfaction rates but prolonging early recovery time (Clinical Trials gov NCT01428882).

Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults.

BACKGROUND & AIMS: Despite consensus recommendations, eosinophilic esophagitis (EoE) is commonly diagnosed upon esophageal eosinophilic infiltration (EEI; based on ≥ 15 eosinophils per high power field; eo/HPF). We evaluated the prevalence of EEI before and after proton pump inhibitor (PPI) therapy and assessed the accuracy of EEI and pH monitoring analyses. METHODS: Biopsies were taken from the upper-middle esophagus of 712 adults with upper gastrointestinal symptoms who were referred for endoscopy due to upper gastrointestinal symptoms. Patients with EEI were treated with rabeprazole (20 mg, twice daily) for 2 months. EoE was defined by persistent symptoms and >15 eo/HPF following PPI therapy. RESULTS: Thirty-five patients (4.9%) had EEI, of whom 55% had a history of allergies, and 70% had food impaction or dysphagia as their primary complaint. Twenty-six EEI patients (75%) achieved clinicopathological remission with PPI therapy; of these, 17 had GERD-like profile (EEI <35 eo/HPF and objective evidence of reflux, based on endoscopy or pH monitoring), and 9 had EoE-like profile (EEI 35-165 eo/HPF, typical EoE symptoms and endoscopic findings). The PPI response was 50% in the EoE-like profile patients. The PPI-response was 50% in EoE-like profile patients. Likewise, PPI-responsive EEI occurred with normal (33%) and pathologic (80%) pH monitoring. Higher histologic cut-off values improved specificity and positive predictive for EoE (35%-35% for >20 eo/HPF; 46%-39% for >24 eo/HPF; 65%-50% for 35 eo/HPF). CONCLUSIONS: In adults with EEI, 75% of unselected patients and 50% with an EoE phenotype respond to PPI therapy; pH monitoring is poorly predictive of response. Patients with PPI-responsive EEI >35 eo/HPF are phenotypically undistinguishable from EoE patients. EoE might be overestimated without clinical and pathologic follow-up of patient response to PPI.

Endoscopic trimming of an embedded distally migrated metallic rectal stent with argon plasma coagulation.

There is little experience regarding the use of argon plasma coagulation (APC) to trim malpositioned or migrated, endoscopic, metallic, self-expanding, colorectal stents. We report a case of a distally migrated, uncovered rectal stent complicated with several ulcerations because of impaction against the rectal wall and embedment within the healthy mucosa distal to the neoplasm. Endoscopic en bloc removal was not possible because of diffuse tumoral ingrowth. By using a second generation APC device (60 W, 0.6 L/min), the stent was trimmed allowing access to the back wall, which was tailored after digging up the embedded wires with gentle traction of the stent. Complete extraction of the protruding end of the stent by a 2.5 cm, fully covered pseudoepithelization tissue, was carried out through a flexible overtube. This is the first report of APC endoscopic transection of a long embedded segment from a distally migrated colorectal stent.

Octreótido long acting release para la hemorragia digestiva en pacientes de edad avanzada con comorbilidad / Octreotide long acting release for severe obscure gastrointestinal haemorrhage in elderly patients with serious comorbidities

Fundamento y objetivo: El octreótido long acting release (OCT-LAR) ha demostrado resultados preliminares prometedores en el tratamiento de la hemorragia recurrente digestiva de origen oscuro. Pacientes y método: Once pacientes con comorbilidades graves se trataron con 20mg intramusculares mensuales de OCT-LAR. No se cambió la medicación concomitante y se monitorizaron trimestralmente los requerimientos transfusionales, los días de ingreso hospitalario y los efectos secundarios. Resultados: La mediana (extremos) de edad y de seguimiento fue de 74 años (65–86) y 15 meses (5–48), respectivamente. Cinco pacientes estaban anticoagulados y otros 5 antiagregados; 8 pacientes tenían (72%) angiodisplasias difusas de intestino delgado. Cuatro pacientes (36%) fallecieron durante el estudio. Únicamente 2 pacientes (18%) permanecieron libres de transfusiones, aunque durante el primer año se redujeron significativamente los requerimientos transfusionales (mediana de concentrados de hematíes de 14 [extremos 9–49] frente a 4 [0–9]; p=0,002) y los días de ingreso hospitalario (mediana de 27 [10–99] frente a 7 [0–23] días; p=0,001). No se registraron efectos secundarios (AU)

Background and objective: Octreotide LAR has shown preliminary promising results in the treatment of recurrent obscure gastrointestinal haemorrhage. Patients and methods: Eleven patients with severe comorbidities were treated with continuous octreotide LAR 20mg once a month. No changes were performed in concomitant drugs. Haemoglobin levels, blood transfusions, hospital admissions and adverse effects were recorded every three months. Results: Median age and follow-up were 74 yr (65–86) and 15 months (5–48). Five patients were on acenocoumarol therapy and other five on antiplatelet drugs. Eight patients (72%) had diffuse small bowel angiodysplasia and 4 patients died during follow-up. Only two patients (18%) remained free of transfusions but it resulted for the first year in an outstanding decrease in the need of red cell packets (14 (9–49) vs 4 (0–9), p=0,002) and in admission days related to gastrointestinal bleeding (27 (10–99) vs 7(0–23), p=0,001). No side effects were reported. Conclusion: Octreotide LAR is an effective, safe and comfortable palliative therapy for severe obscure gastrointestinal bleeding. Medical resources saving and improved quality of life may warrant its use irrespective of comorbidities or life expectancy (AU)

[Octreotide long acting release for severe obscure gastrointestinal haemorrhage in elderly patients with serious comorbidities]. / Octreótido long acting release para la hemorragia digestiva en pacientes de edad avanzada con comorbilidad.

BACKGROUND AND OBJECTIVE: Octreotide LAR has shown preliminary promising results in the treatment of recurrent obscure gastrointestinal haemorrhage. PATIENTS AND METHODS: Eleven patients with severe comorbidities were treated with continuous octreotide LAR 20mg once a month. No changes were performed in concomitant drugs. Haemoglobin levels, blood transfusions, hospital admissions and adverse effects were recorded every three months. RESULTS: Median age and follow-up were 74 yr (65-86) and 15 months (5-48). Five patients were on acenocoumarol therapy and other five on antiplatelet drugs. Eight patients (72%) had diffuse small bowel angiodysplasia and 4 patients died during follow-up. Only two patients (18%) remained free of transfusions but it resulted for the first year in an outstanding decrease in the need of red cell packets (14 (9-49) vs 4 (0-9), p=0,002) and in admission days related to gastrointestinal bleeding (27 (10-99) vs 7(0-23), p=0,001). No side effects were reported. CONCLUSION: Octreotide LAR is an effective, safe and comfortable palliative therapy for severe obscure gastrointestinal bleeding. Medical resources saving and improved quality of life may warrant its use irrespective of comorbidities or life expectancy.