Differences between endocarditis caused by Streptococcus bovis and Enterococcus spp. and their association with colorectal cancer.

Streptococcus bovis group and Enterococcus spp. share phenotypic characteristics and intestinal habitat. Both have been associated with endocarditis and colorectal neoplasm (CRN). We studied all cases of endocarditis diagnosed between 1988 and 2014 in our centre and caused by S. bovis (109, 48.8 % of the bacteremia) and by Enterococcus spp. (36, 3.4 % of the bacteremia). Patients were seen until death or during a long-term follow-up, in order to rule out a concomitant CRN. The 109 cases of S. bovis endocarditis (SbIE) compared with the 36 caused by enterococci showed: a higher proportion of males (91 % vs. 72 %, p=0.005), more multivalvular involvement (28 % vs. 6 %, p=0.004), embolic complications (44 vs. 22 %, p=0.02) and colorectal neoplasm (64 % vs. 25 %, p=0.001). SbIE showed fewer co-morbidities (32 vs. 58 %, p=0.005), and less frequently urinary infection source (0 vs. 25 %, p=0.001) and healthcare-related infection (2 vs. 44 %, p=0.001). A total of 123 patients were followed up for an extended period (mean: 65.9 ± 57.5 months). During the follow-up, 6 of 28 (21 %) cases with enterococcal endocarditis and 43 of 95 (45.2 %, p=0.01) cases with SbIE developed a new CRN. These neoplasiae appeared a mean of 60.4 months later (range 12-181 months). Among the 43 cases with SbIE and CRN, 12 had had a previously normal colonoscopy and 31 had had a previous CRN and developed a second neoplasm. Cases of SbIE present important differences with those caused by Enterococcus spp. Colonoscopy must be mandatory both in the initial evaluation of SbIE, as during the follow-up period.

Is colonoscopy necessary in cases of infection by Streptococcus bovis biotype II?

The association of colorectal neoplasia (CRN) with Streptococcus bovis biotype I (SBI) infection is well recognized. However, this is not the case for Streptococcus bovis biotype II (SBII). We conducted this study in order to analyze the relationship between SBII and CRN. We analyzed all cases of bacteremia due to SBI (n = 99) and SBII (n = 36) diagnosed in our hospital (during the period 1988-2011) that were followed up with colonoscopy. In addition, we reviewed the literature (during the period 1982-2011) to select all cases of infection of SB that had undergone colonoscopy or other adequate form of colorectal examination. A multivariate analysis was performed to detect CRN risk factors in patients infected with SB. From the 223 cases of SB infection included in the analysis (135 from our institution and 88 from the literature review), 159 were due to SBI and 64 were caused by SBII. As compared with SBI, the SBII cases had a lower frequency of CRN (27 % vs. 67 %, p <0.001), advanced adenomas (8 % vs. 29 %, p <0.01), and carcinomas (6 % vs. 21 %, p <0.01). In a multivariate analysis, and after adjusting for age, sex, type of infection, and biotype, SBII infection was not associated with CRN: odds ratio (OR) = 0.17; 95 % confidence interval (CI) = 0.09 to 0.33. The only factor independently associated with CRN was SBI infection: OR = 5.7; 95 % CI = 3.0 to 10.9. The prevalence of CRN in patients infected with SBII is significantly lower than patients with SBI and does not appear to be higher than the CRN prevalence among the general population.

Sedation with propofol controlled by endoscopists during percutaneous endoscopic gastrostomy.

BACKGROUND: propofol is a hypnotic used with increasing frequency for sedation during endoscopic procedures. Most of the reports published related with its employment by non-anaesthesiologists, refers to basic endoscopy, with little reference to its use in advanced endoscopy. OBJECTIVE: to evaluate the efficacy and safety of propofol sedation administered by endoscopists, while performing percutaneous endoscopic gastrostomy, an advanced technique that is usually performed in high anesthetic level risk patients. MATERIAL AND METHODS: prospective study of a series of endoscopic gastrostomy performed consecutively in our department; the sedation was carried out exclusively with propofol. The staff in the room consisted of two medical gastroenterologists, a nurse and a nursing assistant. Propofol was administered by bolus doses adjusted to patient weight. Arterial oxygen saturation, heart rate and blood pressure were monitored; respiratory activity was monitored visually by observing respiratory excursions of the patient. RESULTS: we included 47 patients, with an average age of 82 years. 87% were ASA III and the rest, ASA IV. The mean dose of propofol was 51 mgr. Complications were recorded: 8 cases of desaturation and two of hypotension, all of them minor and quickly reversible. All procedures were carried out successfully, at a median time of 8 minutes. CONCLUSION: the propofol sedation carried out by non-anaesthesiologist trained staff, seems to appear as a safe and effective procedure while performing percutaneous endoscopic gastrostomy.

Sedación con propofol controlada por endoscopista durante la realización de gastrostomía percutánea endoscópica / Sedation with propofol controlled by endoscopists during percutaneous endoscopic gastrostomy

Introducción: el propofol es un hipnótico usado cada vez conmás frecuencia para la sedación durante procedimientos endoscópicos.La mayor parte de los trabajos publicados en relación consu empleo por personal no anestesista se refiere a exploracionesde endoscopia básica, siendo escasas las referencias a su empleoen endoscopia avanzada.Objetivo: valorar la eficacia y la seguridad de la sedación mediantepropofol administrado por endoscopistas, durante la realizaciónde gastrostomía endoscópica percutánea, técnica avanzaday generalmente aplicada sobre pacientes de riesgo anestésico alto.Material y métodos: estudio prospectivo de una serie degastrostomías endoscópicas realizadas consecutivamente en nuestroservicio; las sedaciones se llevaron a cabo exclusivamente conpropofol. El personal presente en la sala consistió en dos médicosgastroenterólogos, una enfermera y una auxiliar de enfermería. Elpropofol se administró en bolos, ajustando las dosis al peso de lospacientes. Se monitorizaron la saturación arterial de oxígeno, lafrecuencia cardiaca y la tensión arterial. La actividad respiratoriase controló de forma visual mediante la observación de las excursionesrespiratorias de los enfermos.Resultados: se incluyeron 47 pacientes, con una edad mediade 82 años. El 87% fueron ASA III y el resto ASA IV. La dosismedia de propofol fue de 51 mg. Como complicaciones se registraron8 casos de desaturación y dos de hipotensión, todas leves yrápidamente reversibles. Todos los procedimientos se llevaron acabo satisfactoriamente, en un tiempo medio de 8 minutos.Conclusión: la sedación mediante propofol llevada a cabopor personal entrenado no anestesista parece mostrarse como unmétodo seguro y eficaz durante la realización de gastrostomía percutáneaendoscópica(AU)

Background: propofol is a hypnotic used with increasing frequencyfor sedation during endoscopic procedures. Most of thereports published related with its employment by non-anaesthesiologists,refers to basic endoscopy, with little reference to its usein advanced endoscopy.Objective: to evaluate the efficacy and safety of propofol sedationadministered by endoscopists, while performing percutaneousendoscopic gastrostomy, an advanced technique that is usuallyperformed in high anesthetic level risk patients.Material and methods: prospective study of a series of endoscopicgastrostomy performed consecutively in our department;the sedation was carried out exclusively with propofol.The staff in the room consisted of two medical gastroenterologists,a nurse and a nursing assistant. Propofol was administeredby bolus doses adjusted to patient weight. Arterial oxygen saturation,heart rate and blood pressure were monitored; respiratoryactivity was monitored visually by observing respiratory excursionsof the patient.Results: we included 47 patients, with an average age of 82years. 87% were ASA III and the rest, ASA IV. The mean dose ofpropofol was 51 mgr. Complications were recorded: 8 cases ofdesaturation and two of hypotension, all of them minor and quicklyreversible. All procedures were carried out successfully, at a mediantime of 8 minutes.Conclusion: the propofol sedation carried out by non-anaesthesiologisttrained staff, seems to appear as a safe and effectiveprocedure while performing percutaneous endoscopic gastrostomy(AU)

Colonoscopia / No disponible

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[Eosinophilic esophagitis due to allergy to sheep and goat milk proteins]. / Esofagitis eosinofílica por sensibilización a proteínas de leche de cabra y oveja.

Eosinophilic esophagitis is an inflammatory disease of the esophagus characterized by the presence of high numbers of eosinophils in the esophageal mucosal layer (> 20 high-power field). It is uncommon in adults but in such cases intermittent dysphagia and food impaction are the most common presenting symptoms. We report the case of a male with long-standing intermittent dysphagia after eating selected goat and sheep cheese types, who required medical help following the impaction of an ibuprofen pill in the esophagus. A biopsy demonstrated the presence of eosinophilic inflammation, and allergy testing showed specific IgE against proteins in the milk of goats and sheep. Topical steroid therapy with oral fluticasone, and the elimination of these dairy products from the diet induced complete symptom resolution, and biopsy specimens taken 4 months later showed no eosinophils.

Esofagitis eosinofílica por sensibilización a proteínas de leche de cabra y oveja / No disponible

La esofagitis eosinofílica, entidad caracterizada por la infiltraciónde la mucosa esofágica por más de 20 eosinófilos por campo degran aumento, se suele presentar en forma de disfagia intermitentede larga evolución, pudiendo estar asociada a sensibilización alérgicaa aeroalérgenos y/o alimentos. Presentamos el caso de un varóncon clínica de disfagia intermitente coincidiendo con la toma dequesos curados de oveja y cabra que precisó asistencia urgente trasla impactación de un comprimido de ibuprofeno a 30 cm de la arcadadentaria. El estudio practicado demostró la existencia de estenosisen el esófago a ese nivel con infiltración eosinofílica difusa ysensibilización a proteínas de la leche de cabra, oveja y vaca, conespecial relevancia para la IgG bovina, lactoferrina y albúmina sérica.Tras tratamiento con fluticasona deglutida y medidas de evitaciónse consiguió la resolución del cuadro clínico y la desapariciónde los eosinófilos en la mucosa

Eosinophilic esophagitis is an inflammatory disease of theesophagus characterized by the presence of high numbers ofeosinophils in the esophageal mucosal layer (> 20 high-powerfield). It is uncommon in adults but in such cases intermittent dysphagiaand food impaction are the most common presentingsymptoms. We report the case of a male with long-standing intermittentdysphagia after eating selected goat and sheep cheesetypes, who required medical help following the impaction of anibuprofen pill in the esophagus. A biopsy demonstrated the presenceof eosinophilic inflammation, and allergy testing showedspecific IgE against proteins in the milk of goats and sheep. Topicalsteroid therapy with oral fluticasone, and the elimination ofthese dairy products from the diet induced complete symptomresolution, and biopsy specimens taken 4 months later showed noeosinophils

Disfagia en paciente joven con historia de atopia / Dysphagia in young patient with an atopic background

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Directrices "guidelines" de sedación/analgesia en endoscopia / Sedation/analgesia guidelines for endoscopy

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Endoscopic treatment of acute colorectal obstruction with self-expandable metallic stents: experience in a community hospital.

BACKGROUND: The purpose of this study was to evaluate the efficacy and security of treatment with self-expandable metallic stents for acute colonic obstruction. METHODS: Retrospectively, we analyzed our experience in placing colonic stents in patients with acute colonic obstruction. Sixty-two patients with malignant colon obstruction were sent to our hospital endoscopic unit from February 1999 through September 2003. The mean age was 75.21 years. A total of 63 self-expandable metallic stents were implanted. All procedures were done under endoscopic and fluoroscopic guidance. RESULTS: Technical success was obtained in 58 patients (93.54%). Clinical improvement and resolution of the obstruction were confirmed in 56 of these 58 patients (96.55%) within 48-72 h. Sixteen complications were observed in 11 patients (19%). Twelve cases were minor complications: five patients had pain and rectal tenesmus, and there were seven cases of distal migration of the stent. Four patients (6.9%) had severe complications. Three patients underwent surgery to resolve colonic perforations and one patient developed a colovesical fistula 7 months after stent placement. The stent was used as a bridge to the elective surgery in 22 patients (37.93%). The mean time between stent placement and surgery was 7.66 days (range, 2-20). The stent was used as a definitive palliative treatment in 36 patients (62.07%). CONCLUSION: Stenting was a useful treatment of acute malignant colonic obstruction. The use of stents as a "bridge to the elective surgery" allowed the intestinal preparation, general status restoration, and a one-stage operation with resection and primary reanastomosis. We have also used the stents as a definitive palliative treatment, avoiding surgery in those patients with a very widely metastatic disease or who cannot undergo operation because of comorbid underlying conditions.

¿Quién debe responsabilizarse de la realización de las técnicas de sedación en endoscopia digestiva? Nuestro punto de vista / Who should be responsible for sedation techniques in digestive endoscopy? Our point of view

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Endoscopic sphincterotomy for prevention of the recurrence of acute biliary pancreatitis in patients with gallbladder in situ: long-term follow-up of 88 patients.

BACKGROUND: Endoscopic sphincterotomy without cholecystectomy is a therapeutic option in selected patients after acute biliary pancreatitis. We conducted a prospective evaluation of the long-term effects of sphincterotomy in terms of the need for of subsequent cholecystectomy and the recurrence of gallstone pancreatitis. METHODS: We studied 88 patients with acute biliary pancreatitis and an intact gallbladder who, underwent endoscopic sphincterotomy either because they were high-risk candidates for surgery or because they had refused of cholecystectomy. The median follow-up was 51 months (range, 5-86). RESULTS: Only two patients (2.2%) experienced recurrent pancreatitis. Subsequent cholecystectomy was performed in 10 patients because of acute cholecystitis in eight cases and biliary colic in two cases. Sixty-six patients (75%) remained asymptomatic. CONCLUSIONS: Endoscopic sphincterotomy is a safe and acceptable alternative to cholecystectomy for the prevention of recurring attacks of gallstone pancreatitis. As a result of this procedure, 75% of patients remained free of symptoms in the long term.