Post-operative morbidity and mortality of a cohort of steroid refractory acute severe ulcerative colitis: Nationwide multicenter study of the GETECCU ENEIDA Registry.

BACKGROUND: Despite the increased use of rescue medical therapies for steroid refractory acute severe ulcerative colitis, mortality related to this entity still remains high. We aimed to assess the mortality and morbidity related to colectomy and their predictive factors in steroid refractory acute severe ulcerative colitis, and to evaluate the changes in mortality rates, complications, indications of colectomy, and the use of rescue therapy over time. METHODS: We performed a multicenter observational study of patients with steroid refractory acute severe ulcerative colitis requiring colectomy, admitted to 23 Spanish hospitals included in the ENEIDA registry (GETECCU) from 1989 to 2014. Independent predictive factors of mortality were assessed by binary logistic regression analysis. Mortality along the study was calculated using the age-standardized rate. RESULTS: During the study period, 429 patients underwent colectomy, presenting an overall mortality rate of 6.3% (range, 0-30%). The main causes of death were infections and post-operative complications. Independent predictive factors of mortality were: age ≥50 years (OR 23.34; 95% CI: 6.46-84.311; p < 0.0001), undergoing surgery in a secondary care hospital (OR 3.07; 95% CI: 1.01-9.35; p = 0.047), and in an emergency setting (OR 10.47; 95% CI: 1.26-86.55; p = 0.029). Neither the use of rescue medical treatment nor the type of surgical technique used (laparoscopy vs. open laparotomy) influenced mortality. The proportion of patients undergoing surgery in an emergency setting decreased over time (p < 0.0001), whereas the use of rescue medical therapy prior to colectomy progressively increased (p > 0.001). CONCLUSIONS: The mortality rate related to colectomy in steroid refractory acute severe ulcerative colitis varies greatly among hospitals, reinforcing the need for a continuous audit to achieve quality standards. The increasing use of rescue therapy is not associated with a worse outcome and may contribute to reducing emergency surgical interventions and improve outcomes.

Long-Term Efficacy and Safety of Cyclosporine in a Cohort of Steroid-Refractory Acute Severe Ulcerative Colitis Patients from the ENEIDA Registry (1989-2013): A Nationwide Multicenter Study.

OBJECTIVES: To determine the efficacy and safety of cyclosporine (CyA) in a large national registry-based population of patients with steroid-refractory (SR) acute severe ulcerative colitis (ASUC) and to establish predictors of efficacy and adverse events. METHODS: Multicenter study of SR-ASUC treated with CyA, based on data from the ENEIDA registry. SR-ASUC patients treated with infliximab (IFX) or sequential rescue therapy (CyA-IFX or IFX-CyA) were used as comparators. RESULTS: Of 740 SR-ASUC patients, 377 received CyA, 131 IFX and 63 sequential rescue therapy. The cumulative colectomy rate was higher in the CyA (24.1%) and sequential therapy (32.7%) than in the IFX group (14.5%; P=0.01) at 3 months and 5 years. There were no differences in early and late colectomy between CyA and IFX in patients treated after 2005. 62% of patients receiving CyA remained colectomy-free in the long term (median 71 months). There were no differences in mortality between CyA (2.4%), IFX (1.5%) and sequential therapy (0%; P=0.771). The proportion of patients with serious adverse events (SAEs) was lower in CyA (15.4%) than in IFX treated patients (26.5%) or sequential therapy (33.4%; P<0.001). This difference in favor of CyA was maintained when only patients treated after 2005 were analyzed. CONCLUSIONS: Treatment with CyA showed a lower rate of SAE and a similar efficacy to that of IFX thereby supporting the use of either CyA or IFX in SR-ASUC. In addition, the risk-benefit of sequential CyA-IFX for CyA non-responders is acceptable.

Gammagrafía con 75SeHCAT en la diarrea crónica por malabsorción de ácidos biliares / 75SeHCAT scan in bile acid malabsorption in chronic diarrhoea

La diarrea crónica es una entidad común en la práctica clínica diaria y supone un deterioro en la calidad de vida de los pacientes. Puede ser el síntoma principal de múltiples etiologías, entre las que se encuentra la malabsorción de ácidos biliares (MAB), que en la población general presenta una prevalencia comparable a la enfermedad celíaca. La MAB ocurre por una alteración en la homeostasis de los ácidos biliares en la circulación enterohepática. Puede aparecer como consecuencia de una disfunción o enfermedad ileal (MAB tipo II), por causas idiopáticas (MAB tipo II) o asociada con otras entidades gastrointestinales (MAB tipo III). Entre los diferentes métodos diagnósticos disponibles destacamos la gammagrafía con 75SeHCAT como gold standard debido a sus valores de sensibilidad, especificidad, seguridad y bajo coste. La principal desventaja es que no se encuentra disponible en todos los países, por lo que se han desarrollado otros métodos como la medición sérica de FGF19 y C4 que, sin embargo, presentan una mayor complejidad y coste. El tratamiento de primera línea ante un diagnóstico de MAB es con quelantes de ácidos biliares como la colestiramina, pero presenta baja tolerabilidad y efectos secundarios, que son menores con los nuevos fármacos como el colesevelam. En resumen, la MAB es una entidad común que se encuentra infradiagnosticada e infratratada, por lo que es fundamental establecer un adecuado algoritmo diagnóstico de la diarrea crónica en el que el estudio con 75SeHCAT ocuparía la primera o segunda línea en el diagnóstico diferencial de estos pacientes (AU)

Chronic diarrhoea is a common entity in daily clinical practice and it leads to a loss in these patients quality of life. It may be the main symptom of multiple ethiologies including bile acid malabsorption (BAM) which has a comparable prevalence to celiac disease. The BAM results from imbalances in the homeostasis of bile acids in the enterohepatic circulation. It can be a consequence of ileal disease or ileal dysfunction (BAM type I), it can be considered idiopathic or primary (BAM type II) or associated with other gastrointestinal entities (BAM type III). Among the different diagnostic methods available, 75SeHCAT study is the primary current method due to its sensitivity, specificity, safety and low cost. The main disadvantage is that it's not available in all countries, so other diagnostic methods have appeared, such as serum measurement of FGF19 and C4, however they are significantly more complex and costly. The first-line treatment of bile acid diarrhoea is bile acid sequestrant, such as cholestyramine, which can be difficult to administer due to its poor tolerability and gastrointestinal side effects. These are less prominent with newer agents such as colesevelam. In summary, the BAM is a common entity underdiagnosed and undertreated, so it is essential to establish a diagnosis algorithm of chronic diarrhoea in which the 75SeHCAT study would be first or second line in the differential diagnosis of these patients (AU)

75SeHCAT scan in bile acid malabsorption in chronic diarrhoea. / Gammagrafía con 75SeHCAT en la diarrea crónica por malabsorción de ácidos biliares.

Chronic diarrhoea is a common entity in daily clinical practice and it leads to a loss in these patients quality of life. It may be the main symptom of multiple ethiologies including bile acid malabsorption (BAM) which has a comparable prevalence to celiac disease. The BAM results from imbalances in the homeostasis of bile acids in the enterohepatic circulation. It can be a consequence of ileal disease or ileal dysfunction (BAM type i), it can be considered idiopathic or primary (BAM type ii) or associated with other gastrointestinal entities (BAM type iii). Among the different diagnostic methods available, 75SeHCAT study is the primary current method due to its sensitivity, specificity, safety and low cost. The main disadvantage is that it's not available in all countries, so other diagnostic methods have appeared, such as serum measurement of FGF19 and C4, however they are significantly more complex and costly. The first-line treatment of bile acid diarrhoea is bile acid sequestrant, such as cholestyramine, which can be difficult to administer due to its poor tolerability and gastrointestinal side effects. These are less prominent with newer agents such as colesevelam. In summary, the BAM is a common entity underdiagnosed and undertreated, so it is essential to establish a diagnosis algorithm of chronic diarrhoea in which the 75SeHCAT study would be first or second line in the differential diagnosis of these patients.

[Musculoskeletal hydatidosis: an unusual location]. / Hidatidosis musculoesquelética: una localización atípica.

Hydatidosis is a zoonosis with a continuing high prevalence in our environment. The most commonly affected organs are the lungs and the liver, with the musculoskeletal location being considered an unusual one. We comment the case of a patient who presented a series of lesions in his left iliac crest and middle left buttock with spontaneous fistulization to the skin surface. In this case a combined treatment was given; prior to the surgical operation we administered a cycle of albendazol. Following removal of the lesion, the patient was given two further cycles of albendazol in order to minimize the risk of a recurrence of the illness. This patient is currently free of any symptoms relating to this illness.

[Spontaneous intramural dissection of the esophagus]. / Perforación intramural espontánea del esófago.

Spontaneous intramural dissection of the esophagus (SIDE) is an unusual clinical entity. It is a benign disease that, despite its alarming endoscopic appearance, usually responds well to conservative management and has an excellent prognosis. Nevertheless, some situations require emergency surgical treatment. These situations include esophageal perforation with mediastinitis, massive bleeding, and abscess, among others. Upper gastrointestinal endoscopy is a useful diagnostic test when radiological examinations (hydrosoluble contrast esophagogram, computed tomography, or magnetic resonance imaging) have excluded perforation. We present the case of a 42-year-old woman who was admitted to our hospital complaining of acute chest pain, dysphagia, and odynophagia. Because of the persistence of symptoms and diagnostic uncertainty (SIDE versus complicated esophageal duplication cyst) surgery was performed. The definitive diagnosis was SIDE.

Hidatidosis musculoesquelética: una localización atípica / Musculoskeletal hydatidosis: an unusual location

La hidatidosis es una zoonosis con una elevada prevalencia aún en nuestro medio. Generalmente afecta a hígado y pulmón, debiendo considerarse la afectación músculo-esquelética una localización atípica de la enfermedad. Presentamos el caso de un paciente con lesiones en cresta iliaca y glúteo medio izquierdos, con fistulización espontánea a través de la piel. Se realizó tratamiento combinado con un ciclo de albendazol previo a la intervención y exéresis quirúrgica de la lesión. En el postoperatorio se completaron dos ciclos más de tratamiento con albendazol en un intento de disminuir el riesgo de recurrencia de la enfermedad. El paciente se encuentra asintomático y no ha presentado ninguna complicación hasta la fecha

Hydatidosis is a zoonosis with a continuing high prevalence in our environment. The most commonly affected organs are the lungs and the liver, with the musculoskeletal location being considered an unusual one. We comment the case of a patient who presented a series of lesions in his left iliac crest and middle left buttock with spontaneous fistulization to the skin surface. In this case a combined treatment was given; prior to the surgical operation we administered a cycle of albendazol. Following removal of the lesion, the patient was given two further cycles of albendazol in order to minimize the risk of a recurrence of the illness. This patient is currently free of any symptoms relating to this illness