[Endoscopic dilatation of caustic esophageal strictures]. / Tratamiento mediante dilatación endoscópica de las estenosis esofágicas cáusticas.

OBJECTIVE: To evaluate the results of endoscopic dilatation in caustic esophageal strictures and to analyze the factors associated with a favorable response. PATIENTS AND METHOD: We performed a retrospective study of 33 patients who underwent dilatation with Savary bougie between 1989 and 2001. Response to initial dilatation and outcome during follow-up were analyzed. RESULTS: The mean age was 50 years (8-83) and 58% were women. Intake was accidental in 29 (88%). In all patients, the caustic substance ingested was alkali. Dilatation was started in the acute phase in 12 patients (36%) and 13 presented inflammatory phenomena adjacent to the stenosis. During initial dilatation, 2 1.6 sessions (2-18) were performed and a favorable response was obtained in 18 patients (54%). At the end of follow-up, 68% of the patients presented satisfactory health status. The comparative study revealed that statistically significant variables for a favorable response to treatment were: accidental alkali intake, instauration of treatment in the chronic phase, absence of inflammatory phenomena, and a small number of initial dilatation sessions. CONCLUSIONS: In our series, more than half the patients with esophageal stenosis due to intake of corrosive alkalis showed a favorable initial response. In these patients with acute-phase stenosis who required a greater number of initial dilatation sessions, endoscopic therapy was less effective.

[Early-onset acute toxic hepatitis induced by intravenous amiodarone administration]. / Hepatitis tóxica aguda de instauración precoz por amiodarona intravenosa.

Amiodarone is a widely used and effective long-term antiarrhythmic drug but with known adverse effects. Prolonged oral administration of this drug has been implicated in numerous hepatic lesions, ranging from isolated, asymptomatic transaminase elevation to fulminant, fatal liver failure. Few cases of acute hepatotoxicity due to intravenous administration have been reported. We present a 69-year-old woman with atrial fibrillation who developed acute hepatitis within 24 hours of amiodarone infusion at the recommended dosage. The drug was withdrawn and laboratory findings progressively returned to normal over the following days. We analyze a possible mechanism of action for hepatotoxicity and highlight the importance of monitoring liver function in patients receiving this drug.

[Doxycycline-induced esophageal ulcer]. / Ulcera esofágica por doxiciclina.

We present the case of a 25-year-old woman who presented an esophageal ulcer due to doxycycline. We show the endoscopic image of the lesion and analyse the incidence, pathogenic mechanisms, symptomatology, diagnosis, treatment, and prevention of doxycycline-induced esophageal lesions.

Criterios diagnósticos y manejo terapéutico de la colitis colágena / Diagnosic criteria and therapeutical management of collagen colitis

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[Role of early colonoscopy in severe acute lower gastrointestinal bleeding]. / Rendimiento de la colonoscopia precoz en la hemorragia digestiva baja aguda grave.

BACKGROUND: Severe acute lower gastrointestinal bleeding (SALGIB) accounts for 15% of cases of acute lower gastrointestinal bleeding (ALGIB). The incidence increases with age and comorbidity. Identification of the origin of bleeding may be difficult. Colonoscopy has been proposed as the primary investigative tool. AIM: To assess the role of early colonoscopy as the primary method of evaluation in patients with SALGIB. PATIENTS AND METHOD: Retrospective study based on a guideline for clinical practice approved in our institution. The study included 50 patients with SALGIB admitted to our gastrointestinal bleeding unit between January 1998 and April 2000. SALGIB was suspected when patients fulfilled two or more of the following criteria: 1) significant hemodynamic compromise, 2) decrease in hemoglobin 2 g/dl, and 3) transfusion requirement >= 2 blood units. Early colonoscopy was performed within 24 hours of onset of bleeding. An accurate endoscopic diagnosis was established if a lesion with active bleeding, visible non-hemorrhagic vessel or adherent red clot was identified. A presumptive diagnosis was made when hematochezia or fresh blood localized in a colonic segment, associated with a single, potentially hemorrhagic lesion, was observed and when the results of esophagogastroduodenoscopy were negative. Colonoscopy, esophagogastroduodenoscopy, barium studies, nuclear scan and angiography were performed. RESULTS: Two hundred twenty-two patients were admitted for ALGIB. Fifty patients(22%) fulfilled the SALGIB criteria. The male/female ratio was 1:1. Definitive diagnosis was accurate in 20 patients. The most frequent cause was angiodysplasia (6 patients) and rectal ulcer (6 patients). Eighteen patients had a presumptive diagnosis; of these 14 had diverticulosis. In 12 patients, no cause was identified. Colonoscopy was performed in 45 patients, of which 32 were performed early and 13 electively. Accurate endoscopic diagnosis was more frequently established with early colonoscopy than with elective colonoscopy (15 [47%] vs 2 [15%], p < 0.05). The results of urgent nuclear scans contributed to accurate diagnosis in 5 out of the 10 patients in whom this technique was performed. Angiography was performed in 2 patients. Endoscopic therapy was attempted in 4 patients, all during early colonoscopy. Ten patients (20%) underwent surgery and 3 patients (6%) died. CONCLUSIONS: In 22% of patients with ALGIB admitted to our hospital bleeding was severe. Colonoscopy is the diagnostic tool of choice. When performed within 24 hours of hospital admission, this technique provides more accurate diagnosis than when performed electively.

Diagnóstico etiopatogénico de la pancreatitis crónica y de la recurrente / Etiopathogenic diagnosis of chronic and relapsing pancreatitis

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[Efficacy of fecal detection of Helicobacter pylori with the HpSA technique in patients with upper digestive hemorrhage]. / Eficacia de la determinación fecal de Helicobacter pylori mediante la técnica HpSA en enfermos con hemorragia digestiva alta.

BACKGROUND: The rapid urease test is the most commonly used test in the diagnosis of Helicobacter pylori infection in patients with upper gastrointestinal hemorrhage. However, some studies have suggested that results of this test are frequently false negative when blood is present. An effective new enzyme immunoassay for determining H. pylori antigens in stools has recently begun to be used. AIM: To determine the efficacy of the H. pylori stool antigen test (HpSAT) in patients with upper gastrointestinal hemorrhage. PATIENTS AND METHODS: Thirty-two patients with upper gastrointestinal hemorrhage were prospectively studied from November 1998 to April 1999. In all patients the following tests were performed in the first 72 hours after onset of bleeding and 24 hours after hospital admission: upper gastrointestinal endoscopy, biopsy samples for the rapid urease test and histological study, blood samples for serology, stool samples for HpSAT, and the 13C urea breath test. Criteria for infection was a positive result in at least two of the four diagnostic techniques, except in the case of HpSAT. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: Of the 32 patients, 23 (71.8%) were infected. The results of four HpSAT (12.5%) were negative and 28 were positive (87.5%). HpSAT showed high sensitivity (95.6%) but low specificity (33.3%). The PPV and NPV were 78.5% and 75% respectively. Of the 32 HpSAT, 25 (78.1) were performed in melenic stools: 22 were positive and 3 were negative. Seventy-five percent of negative HpSAT and 78.5% of positive HpSAT corresponded to melenic stools. CONCLUSIONS: HpSAT is a rapid, non-invasive technique that does not appear to be influenced by the presence of blood. Consequently, it can be applied in patients with upper gastrointestinal hemorrhage. The rapid urease test showed high sensitivity, specificity and PPV and should remain the first-line test in patients with upper gastrointestinal hemorrhage. HpSAT is appropriate as a second-line technique and is useful when the rapid urease test is negative and infection is strongly suspected, when no samples for the rapid urease test have been taken and when endoscopy cannot be performed. The result obtained in the present study should be confirmed in future studies with larger samples.

[Clinical approach to portal hypertension]. / Aspectos clínicos del síndrome de hipertensión portal.

Portal Hypertension is one of the most common and severe complication arising from hepatic cirrhosis natural history. Its development conditions the patient prognosis, and its diagnosis and correct evaluation contribute to the correct management of the patient. New techniques for the measurement of portal pressure gradient allow the study and follow-up of patients with esophageal and gastric varices and with risk of hemorrhage, analyzing the efficacy of the treatment applied in a reliable and secure way. It has been probed its utility in the study of the patient with hepatocellular carcinoma, complications after liver transplantation, portal hypertension with no hepatopathy, etc. This review analyzes, from a clinical point of view, the repercussion of the development of portal hypertension in the patient with hepatic cirrhosis, its diagnosis and interpretation, and the importance that its adequate valuation has for the clinical practice.

[Evaluation of the efficacy of the endoscopic treatment in volvulus of the colon]. / Evaluación de la eficacia del tratamiento endoscópico en el vólvulo de colon.

Volvulus of the colon mainly affects the elderly and early surgery, with high morbidity and mortality, is often required. The efficacy of endoscopic devolvulization as an alternative is evaluated herein. From January 1993 to April 1999, 25 patients diagnosed with volvulus of the colon were retrospectively reviewed. Endoscopic devolvulization was not performed in one patient who showed signs of necrosis but was carried out in the remaining 24. The mean follow-up was 35.3 months. In all patients the procedure was initially effective. After the first attempt, 9 of the 24 patients (37%) relapsed, 4 out of 7 (57%) after a second attempt and 2 out of 2 (100%) after a third attempt. No morbidity or mortality was associated with the endoscopy. Six patients underwent surgery. Of these, none relapsed but two presented complications associated with the surgery. Mean hospital stay of the patients undergoing surgery was 30.8 days and that of those undergoing endoscopic devolvulization was 9.1 days. We conclude that endoscopic devolvulizatio is an effective therapeutic option when the mucosa is viable, with a high percentage of initial success, few complications inherent to the technique and with the possibility of carrying out a maximum of two attempts in cases of relapse. In the majority of patients, this technique is a valid alternative to urgent surgery, which has higher morbidity and mortality and longer mean hospital stay.

Hipertransaminasemia reversible tras tratamiento dietético / Reversible hypertransaminasemia after dietary treatment

El aumento de transaminasas puede ocurrir por múltiples causas. Presentarnos un enfermo con hipertransaminasemia reversible tras tratamiento dietético específico. Se revisan las diferentes posibilidades etiopatogénicas para explicar la elevación de transaminasas y la mejoría analítica tras la instauración de dicho tratamiento dietético (AU)

An increase in transaminases may be due to multiple causes. We present a case of reversible hypertransaminasemia following specific dietary therapy. The various potential aetiopathogenies are reviewed to explain the raising of transaminase levels and the improvement in analytical results after the institution of this dietary treatment (AU)

Aspectos clínicos del síndrome de hipertensión portal / Clinical approach to portal hypertension

La hipertensión portal es una de las complicaciones más frecuente y grave que aparece en la historia natural de la cirrosis hepática. Su desarrollo condiciona el pronóstico del paciente, y su diagnóstico y valoración correctos facilita el adecuado manejo de estos enfermos. Las nuevas técnicas de medición del gradiente de presión portal permiten el estudio y seguimiento de los pacientes con varices esofago-gástricas y con riesgo de hemorragia, evaluando la eficacia del tratamiento instaurado de forma fiable y segura. Se ha demostrado su utilidad en el estudio del paciente con hepatocarcinoma, complicaciones en el postrasplante hepático, presencia de hipertensión portal sin hepatopatía, etc. El objetivo de esta revisión es analizar, desde un punto de vista clínico, la trascendencia del desarrollo de la hipertensión portal en el paciente con cirrosis hepática, su diagnóstico e interpretación y la importancia que en la práctica diaria tiene su adecuada valoración (AU)

Gestión clínica por los clinicos / Clinical management by the clinicians

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[Study of 13 cases of anisakiasis in the province of Cordoba]. / Estudio de 13 casos de anisakiasis en la provincia de Córdoba.

Anisakiasis, or anisakidosis, is a parasitic zoonosis due to the infestation by nematodes of the Anisakidae family, mainly by Anisakis simplex. Notwithstanding its world wide distribution, in our country its appearance is quite recent (1991) with only 19 cases previously reported. We refer 13 cases diagnosed in different hospitals in the province of Córdoba, Spain, from September 1994 to July 1998 which represents the biggest series described in Spain so far. All the patients had a clinical onset as acute abdomen, so that they required early surgery in which a narrowing and inflammatory intestinal segment was observed and subsequently resected. Pathology revealed in such segments an intense eosinophilic infiltrate in the mucosa. Only in one of the cases parasitic fragments were detected in the intestinal mucosa and in the 12 remaining cases the diagnosis was immunological by IgE specific for Anisakis simplex determination and antigens detection of the nematode with monoclonal antibodies. As interesting epidemiologic antecedent we shall mention the fact that all patients referred a usual raw fish consumption (mainly anchovy with vinegar) which is host of third-stage larval of the parasite.

[Reversible hypertransaminasemia after diet therapy]. / Hipertransaminasemia reversible tras tratamiento dietético.

An increase in transaminases may be due to multiple causes. We present a case of reversible hypertransaminasemia following specific dietary therapy. The various potential aetiopathogenies are reviewed to explain the raising of transaminase levels and the improvement in analytical results after the institution of this dietary treatment.

[Resident physician training in the digestive system. The point of view of the residents]. / Formación MIR en aparato digestivo. El punto de vista de los residentes.

AIM: To evaluate various aspects of current training of Spanish residents in gastroenterology. METHOD: An anonymous postal questionnaire was sent to fourth-year resident physicians in Spanish hospitals with accredited gastroenterology residency programs. RESULTS: Forty residents in the fourth year (53% offered positions), four from the second year and one from the first year (20 men, 25 women) answered the survey. Mean age was 29.7 years (26-42 years). Fifty-one percent of the departments did not have ultrasonography facilities apart from those in the radiology department. Endoscopic retrograde cholangiopancreatography (ERCP) was available in all the departments but in 55% of these, residents did not receive training in this technique. Forty-one percent of residents did not know the objectives of the various training periods. Eighty-four percent evaluated the pressure of clinical work as "intense" or "very intense" with 67% reporting that it disturbed their training "seriously" or "very seriously" and 71% that it disturbed their personal lives. Supervision in ultrasonography, endoscopy and clinical work were mainly evaluated as "good" or "very good". Supervision was rated lower in outpatient departments and while on duty. Forty-two percent of residents rated the supervision of the personal tutor as "average". Seventy-six percent were "fairly" or "very interested" in the introduction of "areas of specific training". CONCLUSIONS: The quality of residents' training in general and of gastroenterology training in particular is high. There are, however, several aspects which could be improved.