[Difficulties and controversies in hospitalized patients with lower gastrointestinal bleeding]. / Dificultades y controversias en el manejo hospitalario de la hemorragia digestiva baja.

OBJECTIVES: Lower intestinal bleeding (LGIB) is a frequent reason for hospitalization; however, the prognostic factors have not been clearly defined. The aim of this paper was to analyze several clinical parameters and the management of this entity in our department from 2005 to 2007. MATERIAL AND METHODS: all hospitalized patients with LGIB were retrospectively (2005-2006) and prospectively (2006-2007) included. Medical records, physical examination (anal digital examination included), blood testing, and colonoscopic examination (in most of patients) were performed. RESULTS: 137 patients were included during 2005-2006: 36% of them required blood transfusion; thirty-one percent of patients showed previous episodes of LGIB, and 62% had a favorable outcome. Time from admission to colonoscopy was 4.1 days, and length of stay was 10.2 days. In the 2006-2007 study 96 patients were included: 42% of them required blood transfusion, thirty-three percent of patients showed previous episodes of LGIB, and 68% had a favorable outcome. Time from admission to colonoscopy was 2.6 days, and length of stay was 7.7 days. The most frequent etiology was diverticulosis in both studies. CONCLUSIONS: Hospital length of stay and time from admission to colonoscopy in patients with LGIB was reduced by 25% and 37%, respectively, in the 2005-2006 period with regard to the 2006-2007 one; however, there were no more bleeding points or a decrease in bleeding recurrence.

[Eosinophilic esophagitis in the adult--clinical, endoscopic, pH-metric, and manometric findings]. / Esofagitis eosinofílica en el adulto: aspectos clínicos, endoscópicos, pH-métricos y manométricos.

OBJECTIVES: Eosinophilic esophagitis (EE) is a condition characterized by dysphagia and frequent food impaction in young adults. The aim of our study was to evaluate the clinical aspects, endoscopic features, pH-metric and motility disorders in EE. PATIENTS AND METHODS: Adult patients with EE were prospectivity included. Endoscopy with biopsy, stationary esophageal manometry, and 24-hour pH-metry were performed. We analyzed the duration of disease, allergies, blood peripheral eosinophilia, prevalence of dysphagia, number of food impaction episodes, and complications during the endoscopic procedure. RESULTS: Eleven male patients with a mean age of 35 years were followed. Endoscopy showed esophageal disorders in all cases: 5 esophageal felinizations, mucosal abnormalities in 4 cases, distal rings in 3 cases, and 2 esophageal stenoses. In two cases mucosal tearing during the endoscopic procedure was described. In 6 patients the manometric study showed motor disorders affecting the esophageal body, 5 of them displaying hypomotility. Two patients showed pathological gastroesophageal reflux during pH-monitoring. Blood peripheral eosinophilia was detected in 3 patients. CONCLUSION: Although endoscopic abnormalities are frequently found, they do not usually explain dysphagia and food impaction episodes in EE. Ineffective esophageal peristalsis is the most prevalent manometric disorder associated with this entity, although it is not clearly related to symptom worsening either.

Dificultades y controversias en el manejo hospitalario de la hemorragia digestiva baja / No disponible

Objetivos: la hemorragia digestiva baja (HDB) es una causa frecuentede ingreso hospitalario; pese a ello, no se conocen con exactitudlos factores que influyen en su evolución. Los objetivos de estetrabajo fueron comparar los cambios en el manejo de la HDB ennuestro Servicio entre los años 2005 y 2007, así como analizar diferentesparámetros que pudieran influir en su pronóstico.Pacientes y métodos: se incluyeron retrospectivamente todoslos ingresos por HDB durante el periodo 2005-2006 y prospectivamentelos del 2006-2007. En todos se realizó historia clínica,exploración –incluyendo tacto rectal– y análisis sanguíneo.Se realizó colonoscopia en la mayoría de los pacientes.Resultados: se incluyeron 137 pacientes en el 2005-2006: requirierontransfusión de hemoderivados el 36%. El 31% había presentadoalgún episodio de HDB previamente. El 62% presentó unaevolución favorable. El tiempo desde el ingreso hasta la colonoscopiay la estancia media fueron de 4,1 y 10,2 días respectivamente. En el2006-2007 se incluyeron 96 pacientes: requirieron transfusión el42%. El 33% había presentado HDB previamente. La evolución fuefavorable en el 67%. El tiempo hasta la colonoscopia y la estanciamedia fueron de 2,6 y 7,7 días respectivamente. Los divertículos fueronel hallazgo más frecuente en ambos periodos.Conclusiones: durante el 2006-2007 la estancia media delos pacientes con HDB ingresados en el Servicio de Aparato Digestivose redujo respecto al 2005-2006 en un 25% y el tiempode realización de la colonoscopia en un 37%; esto no logró máslocalizaciones del punto sangrante ni una disminución en la recurrenciade la hemorragia

Objectives: lower intestinal bleeding (LGIB) is a frequent reasonfor hospitalization; however, the prognostic factors have notbeen clearly defined. The aim of this paper was to analyze severalclinical parameters and the management of this entity in our departmentfrom 2005 to 2007.Material and methods: all hospitalized patients with LGIBwere retrospectively (2005-2006) and prospectively (2006-2007)included. Medical records, physical examination (anal digital examinationincluded), blood testing, and colonoscopic examination(in most of patients) were performed.Results: 137 patients were included during 2005-2006: 36%of them required blood transfusion; thirty-one percent of patientsshowed previous episodes of LGIB, and 62% had a favorable outcome.Time from admission to colonoscopy was 4.1 days, andlength of stay was 10.2 days. In the 2006-2007 study 96 patientswere included: 42% of them required blood transfusion, thirtythreepercent of patients showed previous episodes of LGIB, and68% had a favorable outcome. Time from admission tocolonoscopy was 2.6 days, and length of stay was 7.7 days. Themost frequent etiology was diverticulosis in both studies.Conclusions: hospital length of stay and time from admissionto colonoscopy in patients with LGIB was reduced by 25% and37%, respectively, in the 2005-2006 period with regard to the2006-2007 one; however, there were no more bleeding points ora decrease in bleeding recurrence

Esofagitis eosinofílica en el adulto: aspectos clínicos, endoscópicos, pH-métricos y manométricos / No disponible

Objetivos: la esofagitis eosinofílica (EE) es una entidad de interéscreciente caracterizada en el adulto por disfagia y episodiosde impactación alimentaria recurrentes. Nuestro objetivo fue estudiarlas características clínicas, endoscópicas, manométricas y pHmétricasen los pacientes con EE, así como la relación que pudieraexistir entre ellas.Pacientes y métodos: se estudiaron de forma prospectivadurante un año los pacientes adultos diagnosticados de EE. En todosse realizó endoscopia digestiva alta con toma de biopsias, manometríaesofágica estacionaria y pH-metría ambulatoria. Se documentóademás el tiempo de evolución clínica, los antecedentesde atopia, la presencia de eosinofilia periférica, la frecuencia de ladisfagia y el número de desimpactaciones y complicaciones endoscópicas.Resultados: se estudiaron 11 pacientes (edad media 35años). Todas las endoscopias presentaron hallazgos patológicos:traquealización en 5, alteraciones mucosas en 4, en 3 anillos esofágicosdistales y en 2 estenosis esofágicas. Precisaron desimpactacionesendoscópicas 7 pacientes. Se produjeron desgarros de lamucosa esofágica durante la endoscopia en 2 pacientes. La manometríaesofágica fue patológica en 6 pacientes, de estos, 5 fuerontrastornos de hipomotilidad. La pH-metría fue patológica en2 casos. Presentaron eosinofilia periférica 3 pacientes.Conclusión: aunque los hallazgos patológicos en la endoscopiason frecuentes, no siempre justifican los episodios de impactaciónalimentaria característicos de la EE. Los trastornos de motilidad enforma de peristalsis esofágica ineficaz son el hallazgo manométricomás frecuente, aunque tampoco se han podido relacionar con unmayor número de episodios de disfagia o de impactaciones

Objectives: eosinophilic esophagitis (EE) is a condition characterizedby dysphagia and frequent food impaction in youngadults. The aim of our study was to evaluate the clinical aspects,endoscopic features, pH-metric and motility disorders in EE.Patients and methods: adult patients with EE were prospectivityincluded. Endoscopy with biopsy, stationary esophagealmanometry, and 24-hour pH-metry were performed. We analyzedthe duration of disease, allergies, blood peripheraleosinophilia, prevalence of dysphagia, number of food impactionepisodes, and complications during the endoscopic procedure.Results: eleven male patients with a mean age of 35 yearswere followed. Endoscopy showed esophageal disorders in allcases: 5 esophageal felinizations, mucosal abnormalities in 4cases, distal rings in 3 cases, and 2 esophageal stenoses. In twocases mucosal tearing during the endoscopic procedure was described.In 6 patients the manometric study showed motor disordersaffecting the esophageal body, 5 of them displayinghypomotility. Two patients showed pathological gastroesophagealreflux during pH-monitoring. Blood peripheraleosinophilia was detected in 3 patients.Conclusion: although endoscopic abnormalities are frequentlyfound, they do not usually explain dysphagia and food impactionepisodes in EE. Ineffective esophageal peristalsis is themost prevalent manometric disorder associated with this entity, althoughit is not clearly related to symptom worsening either

[Complexity index and analysis of digestive endoscopies at a university hospital]. / Indice de complejidad y análisis de los costes de las endoscopias digestivas en un hospital universitario.

BACKGROUND: In Spain neither the cost of digestive endoscopies nor the complexity index (CI) have been objectively estimated. Consequently, the profitability of an endoscopy unit cannot be evaluated. OBJECTIVES: 1: To classify endoscopies according to the time taken to accomplish them in order to estimate the CI and determine the relative value unit (RVU). 2: To evaluate the cost of each examination in order to determine the profitability of endoscopy as a diagnostic and therapeutic tool. 3: To measure unnecessary delays in examinations and to determine whether there are differences in the time an examination takes according to the endoscopist's experience and the patient's age or sex. MATERIAL AND METHODS: The cost per hour of an endoscopy room was estimated by dividing the cost per year of employees, equipment, maintenance and the hospital's general costs between the hours of work per year of the endoscopy team. The time taken to perform endoscopies was estimated and the result was used to calculate the RVI, the CI and the cost of 500 consecutive endoscopies. RESULTS: The annual cost amounted to 349,617.69 E. Staffing costs represented 65.5%, of which 56.3% were direct costs. Gastroscopy was taken as the RVU (cost = 27.52 E). Anoscopy was the simplest procedure (RVU = 0.61, cost = 15.08 E) and colonoscopy plus polypectomy was the most complex procedure (RVU = 4.41, cost = 74.28 E). The greater the experience of the member of staff performing the procedure, the less time it took (p < 0.01). CONCLUSION: CI was lowest for anoscopy (URV = 0.61) and highest for total colonoscopy plus polypectomy (URV = 4.41). Cost and exploration time depended on the endoscopist's experience. Staff represented the highest percentage of cost.

Prevalence of appendectomy among ulcerative colitis patients and their relatives.

BACKGROUND: It has been suggested that appendectomy may protect against ulcerative colitis (UC). However, the incidences of appendectomy and UC in developed countries have diverged over the last 50 years, possibly as a consequence of environmental factors. AIM: To determine whether the incidence of appendectomy is lower in patients with UC than in the general population. METHODS: Patients with UC (153), their relatives (116) and members of the general population (306) that had been matched for age, sex and educational status were studied. RESULTS: Six per cent of UC patients had undergone appendectomy. The corresponding figure for non-family controls was 20% (P < 0.0001; OR = 0.27; 95% CI = 0.15-0.45). The rate of appendectomy within families (cases plus siblings) was 17/269 (6.3%) and was similar to that for UC patients alone(P < 0.001). CONCLUSIONS: A negative association between appendectomy and UC exists in our patients with UC. In addition, the appendectomy rate in families of UC patients was lower than that in the general population, possibly implying that common environmental and genetic factors could play an important role in the divergent incidences of appendicitis and UC over the last 50 years.

Association of MALTectomy (appendectomy and tonsillectomy) and inflammatory bowel disease: a familial case-control study.

UNLABELLED: There is some controversy regarding the prevalence of tonsillectomy and appendectomy among patients with Crohn's disease (CD) and a lower rate of appendectomy among patients with ulcerative colitis (UC). However, some environmental and familial factors that could alter those figures have not been studied. OBJECTIVE: To explore the prevalence of MALTectomy (appendectomy and tonsillectomy) among patients with IBD, stressing those factors that may be significantly associated to it. METHOD: Age-and-sex matched case-control study in patients with IBD, their relatives and the general population. Two hundred and eighty seven cases were IBD patients (153 UC, and 134 CD), the "family control" group included 203 siblings and the population-based control group included 570 individuals. Potential confounding factors, such as smoking, educational level, oral contraceptive use, place of birth and residence up to the age of 15 years, were ruled out. RESULTS: Appendectomy and UC: 7% of UC patients had undergone appendectomy versus 20% (OR: 0.23; 95% CI: 0.11-0.5; p < 0.0001) of controls. Appendectomy rates in families with at least one case of UC were 17/153 (6.3%) and 61/306 (20%) in the control group (p < 0.001). Appendectomy and CD: Twelve per cent of CD patients had undergone appendectomy six months before the onset of the disease versus 17% among the control population (OR: 0.43; 95% CI: 0.29-0.95; p < 0.01). The frequency of appendectomy in families with at least one case of CD was 22/221 (10%), which was significantly lower (p < 0.05) than among the control group 45/264 (17%). No differences were found between IBD patients and familial controls. Tonsillectomy and CD: Forty six per cent of CD patients had undergone tonsillectomy versus 39% of control patients (OR: 1.77; 95% CI: 0.92-2.05; p = ns). Tonsillectomy and UC: Twenty eight per cent of UC patients had undergone tonsillectomy versus 39% of the population control group (OR: 1.07; 95 CI: 0.57-1.25: p = ns). In fact, no differences were found regarding the prevalence of tonsillectomies within families with IBD cases as compared to population controls. CONCLUSIONS: Appendectomy is not only less frequent among CD and UC patients, but also among their relatives, thus suggesting the existence of environmental and genetic factors with opposed etiological roles in IBD and appendicitis.

6-mercaptopurine or methotrexate added to prednisone induces and maintains remission in steroid-dependent inflammatory bowel disease.

BACKGROUND: As treatment of steroid-dependent patients with inflammatory bowel disease (IBD) is controversial, we analysed the efficacy and tolerance of 6-mercaptopurine (6-MP) and methotrexate (MTX) added to prednisone in increasing and maintaining the disease remission rate. METHODS: Seventy-two steroid-dependent IBD patients, 34 with ulcerative colitis (UC) and 38 with Crohn's disease (CD), receiving treatment with prednisone were randomly assigned in a 2:2:1 ratio to additionally receive, orally, over a period of 30 weeks 1.5 mg/kg/day of 6-MP (group A) or 15 mg/week of MTX (group B), or 3 g/day of 5-aminosalicylic acid (5-ASA) (group C). All patients who achieved remission were included in a maintaining remission study for 76 weeks. Remission was defined after stopping prednisone as a CD activity index of <150 and normal serum orosomucoid concentration for CD patients and a Mayo Clinic score <7 for UC patients. RESULTS: With regard to achieved remission, a significantly higher (P< 0.05) rate existed for UC patients in group A (78.6%) than in group C (25%), with no statistical differences in group B (58.3%) versus C. For CD patients, the rates were significantly higher (P< 0.001 and 0.01, respectively) in groups A (93.7%) and B (80%) versus C (14%). With regard to maintaining remission, UC patients in group A (63.6%) presented significantly higher rates (P < 0.0015 and P < 0.001, respectively) versus 14.3% in group B and none in group C. For CD patients, statistical differences (P < 0.001) existed when comparing rates in groups A (53.3%) and B (66.6%) versus none in group C. Noticeable side effects appeared in 13.3% of patients from group A and 11.5% from group B. CONCLUSIONS: These results suggest that 6-MP or MTX added to prednisone could be effective in steroid sparing, as well as in achieving and maintaining remission in steroid-dependent IBD patients. MTX was less effective in maintaining remission in UC patients.

Amebiasis y enfermedad inflamatoria intestinal / Amoebiasis and inflammatory bowel disease

No disponible

High-dose intravenous cyclosporine in steroid refractory attacks of inflammatory bowel disease.

BACKGROUND/AIMS: To determin whether cyclosporine is effective in inducing remission in patients with severe active inflammatory bowel disease, refractory to steroids. METHODOLOGY: Twenty-three patients with severe and steroid-refractory inflammatory bowel disease (15 ulcerative colitis and 8 Crohn's disease) were included. The Mayo Clinic Score and the CDAI were used to evaluate activity. Cyclosporine (4 mg/kg/day) was administered for a maximum of ten and a minimum of 7 days. RESULTS: Ten of the 15 ulcerative colitis patients achieved remission with a mean response lag time to onset improvement of 8 days. Seven of these patients remained stable with mesalazine 4 months after cyclosporine treatment. Two patients relapsed and underwent colectomy on the 50th and 200th day after treatment. Five patients presented no response and required urgent colectomy. Six of the 8 Crohn's disease patients achieved remission with a mean response lag time to onset improvement of 7 days. The 6 patients remained stable with mesalazine four months after cyclosporine treatment. The other 2 developed reversible renal failure and had to be released from the study. CONCLUSIONS: Intravenous high dose cyclosporine is effective and can be used as a rapid onset treatment for acute steroid refractory IBD.

[Mallory-Weiss syndrome. Considerations on 27 cases]. / Síndrome de Mallory-Weiss. Considerações sobre 27 casos.

Twenty seven patients, inspected by endoscope, and diagnosed as having the Mallory-Weiss syndrome, have been studied taking into account their age, sex, background, clinic presentation, manifestations, number of lacerations, associated lesions and evolution. Twenty three of them were males and 4 females. The age average was 46.7 years. Only 8 patients had intra-abdominal increased pressure, suffering retching and vomiting 7 of them, while one had a cough access. Out of the 21 patients that we controlled, 9 were chronic alcoholism while 3 had ethanol intoxication previously. Immediate prior ingestion of salicylates had taken place in 6 patients. The clinical presentation of 22 of them was gastrointestinal bleeding, that is, 4.9% of all the upper endoscopies carried out within the bleeding patients. Single laceration was present in 22 cases, double one in 4, and triple in 1. We have frequently found endoscopy lesions associated, the most common one (37%), was hiatal hernia. They all were medically treated except one, who was operated because of gastric perforation was associated. Just one of the Mallory-Weiss syndrome patient died, due to an associated diffused bleeding gastritis.

Sindrome de Mallory-Weiss. Consideracoes sobre 27 casos. / Mallory-Weiss syndrome.Considerations on 27 cases

Foram estudados 27 pacientes com diagnostico endoscopico de sindrome de Mallory-Weiss, valorizando os seguintes parametros: idade e sexo, antecedentes, forma de apresentacao, manifestacoes clinicas, numero de dilaceracoes, lesoes associadas e evolucao. Vinte e tres pacientes eram do sexo masculino e 4 do feminino. A idade media foi de 46,5% anos.Somente em 8 foram encontrados antecedentes de aumento de pressao intra-abdominal: 7 com nauseas e vomitos e um com acesso de tosse.Dos 21 doentes controlados nesta serie, 9 eram etilistas cronicos e 3 apresentaram uma intoxicacao alcoolica aguda. Seis contavam uma ingestao recente de salicilatos. Em 22 pacientes a forma de apresentacao foi uma hemorragia digestiva, correspondendo a 4,9% do total de sangrantes nos quais foi realizado endoscopia digestiva alta. Em 22 casos a dilaceracao era unica, em 4 haviam duas dilaceracoes e em um, tres lesoes lineais. Com frequencia foram encontradas lesoes endoscopicas associada, sendo mais comum a hernia hiatal (37%). O tratamento foi medico em todos os casos, salvo em um, no qual foi necessario a cirurgia por uma perfuracao gastrica associada. Um paciente com sindrome de Mallory-Weiss e gastrite erosiva faleceu, sendo a gastrite erosiva a causa principal da hemorragia e do obito