Changing perspectives: unveiling the risks of ashwagandha-induced hepatotoxicity.

Ashwagandha, an herb popular in Ayurvedic medicine, is renowned for its health-enhancing properties. However, its association with liver damage in recent years has raised significant concerns, necessitating careful assessment and management. This case underscores the dangers of Ashwagandha, particularly for individuals with preexisting liver conditions, where it can lead to life-threatening acute-on-chronic liver failure. The lack of solid clinical evidence supporting Ashwagandha's health claims emphasizes the need for an evidence-based approach. Public education is essential to raise awareness of the risks associated with herbal supplements and prevent liver diseases.

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.

Two-week, high-dose proton pump inhibitor, moxifloxacin triple Helicobacter pylori therapy after failure of standard triple or non-bismuth quadruple treatments.

BACKGROUND: Aim was to evaluate the efficacy and tolerability of a moxifloxacin-containing second-line triple regimen in patients whose previous Helicobacter pylori eradication treatment failed. METHODS: Prospective multicentre study including patients in whom a triple therapy or a non-bismuth-quadruple-therapy failed. Moxifloxacin (400mg qd), amoxicillin (1g bid), and esomeprazole (40 mg bid) were prescribed for 14 days. Eradication was confirmed by (13)C-urea-breath-test. Compliance was determined through questioning and recovery of empty medication envelopes. RESULTS: 250 patients were consecutively included (mean age 48 ± 15 years, 11% with ulcer). Previous (failed) therapy included: standard triple (n = 179), sequential (n = 27), and concomitant (n = 44); 97% of patients took all medications, 4 were lost to follow-up. Intention-to-treat and per-protocol eradication rates were 82.4% (95% CI, 77-87%) and 85.7% (95% CI, 81-90%). Cure rates were similar independently of diagnosis (ulcer, 77%; dyspepsia, 82%) and previous treatment (standard triple, 83%; sequential, 89%; concomitant, 77%). At multivariate analysis, only age was associated with eradication (OR = 0.957; 95% CI, 0.933-0.981). Adverse events were reported in 25.2% of patients: diarrhoea (9.6%), abdominal pain (9.6%), and nausea (9.2%). CONCLUSION: 14-day moxifloxacin-containing triple therapy is an effective and safe second-line strategy in patients whose previous standard triple therapy or non-bismuth quadruple (sequential or concomitant) therapy has failed, providing a simple alternative to bismuth quadruple regimen.

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)

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.

Talidomida en dosis altas para la hemorragia digestiva oscura grave idiopática en una paciente de alto riesgo trombótico / High-dose thalidomide for severe idiopathic obscure gastrointestinal bleeding in a patient at high-thrombotic risk

Se presenta el caso de una mujer de 81 años con accidentes vasculares cerebrales (ACV) recurrentes con doble antiagregación y hemorragia digestiva de origen oscuro. No se encontró el origen del sangrado con cápsula endoscópica, enteroscopia de doble balón, laparotomía exploradora y enteroscopia intraoperatoria bidireccional desde boca a ano. La paciente requirió la transfusión de 117 concentrados de hematíes durante 2 años pese a suspensión de la medicación antiagregante y tratamiento con análogos de la somatostatina. Por ello, se inició terapia con dosis crecientes de talidomida, hasta 300mg, asociadas a profilaxis tromboembólica durante 3 meses, sin respuesta. Al suspender la heparina, la hemorragia se controló durante 3 meses, pero se retiró la talidomida por efectos secundarios. Dado que la hemorragia recidivó al mes de la suspensión, se realizó un segundo ciclo de 3 meses de tratamiento con talidomida. Durante un año de seguimiento, la paciente no ha precisado transfusión de hemoderivados (AU)

We report the challenging case of an 81-year-old woman on dual antiplatelet therapy with recurrent strokes, who presented with severe obscure gastrointestinal bleeding. A thorough diagnostic work-up, including capsule endoscopy, double balloon enteroscopy, arteriography, exploratory laparotomy and mouth-to-anus intraoperative enteroscopy, failed to reveal the source of the bleeding. During a 2-year period, the patient required 117 packed red blood cell units, despite withdrawal of antiplatelet drugs and empirical therapy with high-dose somatostatin analogues. The patient was administered an increasing dosage of thalidomide, up to 300mg/day, with thromboembolism prophylaxis for 3 months, with no clinical response. The bleeding stopped for 3 months after heparin was discontinued, but thalidomide had to be withdrawn owing to adverse effects. Since bleeding recurred a month later, the patient underwent another 3-month course of thalidomide. The patient has not required further blood transfusion after a 1-year follow-up (AU)

[High-dose thalidomide for severe idiopathic obscure gastrointestinal bleeding in a patient at high-thrombotic risk]. / Talidomida en dosis altas para la hemorragia digestiva oscura grave idiopática en una paciente de alto riesgo trombótico.

We report the challenging case of an 81-year-old woman on dual antiplatelet therapy with recurrent strokes, who presented with severe obscure gastrointestinal bleeding. A thorough diagnostic work-up, including capsule endoscopy, double balloon enteroscopy, arteriography, exploratory laparotomy and mouth-to-anus intraoperative enteroscopy, failed to reveal the source of the bleeding. During a 2-year period, the patient required 117 packed red blood cell units, despite withdrawal of antiplatelet drugs and empirical therapy with high-dose somatostatin analogues. The patient was administered an increasing dosage of thalidomide, up to 300 mg/day, with thromboembolism prophylaxis for 3 months, with no clinical response. The bleeding stopped for 3 months after heparin was discontinued, but thalidomide had to be withdrawn owing to adverse effects. Since bleeding recurred a month later, the patient underwent another 3-month course of thalidomide. The patient has not required further blood transfusion after a 1-year follow-up.

Endoscopic-assisted colopexy and push percutaneous colostomy in the transverse colon for refractory chronic intestinal pseudo-obstruction.

Percutaneous endoscopic colostomy (PEC), using the classic pull-through technique in the ascending or the descending colon, has been proven useful to treat chronic intestinal pseudo-obstruction. We report the case of a high-surgical risk 70-year-old male with refractory chronic intestinal pseudo-obstruction, in whom the ascending colon could not be reached due to tortuous left dolichocolon. Endoscopic-assisted colopexy and push colostomy in the proximal transverse colon was decided accordingly. Colopexy was performed under direct endoscopic vision in the proximal transverse colon using 3 preloaded T-fasteners surrounding the intended stoma site. The stoma tract was created with an introducer needle, allowing the advance of the 24 Fr 4-sleeve dilator over a guidewire. Afterwards, the dilator was removed and the peel-away sheath was left in place. Over the guidewire, a 20-Fr gastrostomy tube was advanced into the colon lumen through the covering, which was finally removed. The patient recovered uneventfully, despite postprocedure pneumoperitoneum, which was related to the technique. He died a month later due to unrelated comorbidities, without further abdominal complaints after discharge. This is the first report of PEC both using a push technique, and the first report in a different location than the ascending or the descending colon. We believe this novel push technique may be feasible for PEC, avoiding the need of reinsertion in patients with difficult colonoscopy.

Tuberculosis pancreática primaria en un paciente inmunocompetente: primer caso comunicado en España / Primary pancreatic tuberculosis in an immunocompetent patient: first case report in Spain

La tuberculosis pancreática primaria (TBPP) es una entidad excepcional definida por una lesión aislada del páncreas con confirmación microbiológica, en ausencia de TB conocida y sin afectación a ningún otro nivel. Se presenta el caso de un varón de 47 años con dolor abdominal y síndrome constitucional, diagnosticado mediante técnicas de imagen de masa sólida localmente avanzada en la cabeza del páncreas. La PAAF detectó granulomas necróticos. La prueba de la tuberculina intradérmica fue positiva. La tinción para bacilos ácido-alcohol resistentes del material de la 2.a PAAF fue negativa. No se encuentra TB tras un exhaustivo estudio diagnóstico. Se plantea laparotomía exploradora, pero a los 50 días crece Mycobacterium tuberculosis en el cultivo. La lesión pancreática desapareció tras 4 meses de tratamiento antituberculostático. Este es el primer caso descrito en España de TBPP en inmunocompetentes. Su diagnóstico exige una elevada sospecha y muestras óptimas microbiológicas para evitar cirugías innecesarias (AU)

Primary pancreatic tuberculosis (PPTB) is an extremely rare entity defined by an isolated pancreatic lesion with microbiological confirmation, in the absence of previously identified tuberculosis (TB) and involvement of any other organ. We report the case of a 47-year-old man referred for abdominal pain and weight loss, in whom several imaging techniques revealed a solid mass in the head of the pancreas. CT-guided fine-needle aspiration cytology was consistent with necrotic granuloma. Intradermic tuberculin reaction was positive, but acid fast bacilli staining was negative in repeat cytology. No additional evidence of TB was found after exhaustive diagnostic work-up. Exploratory laparotomy was proposed for a definitive diagnosis, but cultures grew Mycobacterium tuberculosis at 50 days. The pancreatic lesion disappeared after 4 months of antitubercular therapy. This is the first case report of PPTB in an immunocompetent person in Spain. A high index of suspicion and accurate samples for microbiology are mandatory to avoid unnecessary surgical procedures (AU)