Low-grade dysplasia in Barrett's esophagus: A problematic diagnosis / Displasia de bajo grado en el esófago de Barrett: un diagnóstico problemático

Although low-grade dysplasia (LGD) in Barrett's esophagus (BE) is a histopathological diagnosis based on different histological abnormalities, it is still problematic for different reasons. Patients without confirmed diagnosis of LGD undergo unnecessary and intensified follow-up where the risk of progression is low in the majority of cases. In contrast, the presence of confirmed LGD indicates a high risk of progression. In this article we try to address these reasons focusing on re-confirmation of LGD diagnosis, interobserver agreement, and persistent confirmed LGD. The progression risk of LGD to high-grade dysplasia and esophageal adenocarcinoma will also be reviewed. (AU)

Aunque la displasia de bajo grado (DBG) en el esófago de Barrett (EB) es un diagnóstico histopatológico basado en diferentes anomalías histológicas, este no deja de ser problemático por diferentes razones. Los pacientes sin diagnóstico confirmado de DBG se someten a un seguimiento innecesario e intensificado donde el riesgo de progresión es bajo en la mayoría de los casos. Por el contrario, la presencia de DBG confirmada indica un alto riesgo de progresión. En este artículo tratamos de abordar estas razones centrándonos en la reconfirmación del diagnóstico de la DBG, la concordancia entre observadores y la DBG confirmada y persistente. También se revisará el riesgo de progresión de la DBG a displasia de alto grado y adenocarcinoma esofágico. (AU)

Low-grade dysplasia in Barrett's esophagus: A problematic diagnosis.

Although low-grade dysplasia (LGD) in Barrett's esophagus (BE) is a histopathological diagnosis based on different histological abnormalities, it is still problematic for different reasons. Patients without confirmed diagnosis of LGD undergo unnecessary and intensified follow-up where the risk of progression is low in the majority of cases. In contrast, the presence of confirmed LGD indicates a high risk of progression. In this article we try to address these reasons focusing on re-confirmation of LGD diagnosis, interobserver agreement, and persistent confirmed LGD. The progression risk of LGD to high-grade dysplasia and esophageal adenocarcinoma will also be reviewed.

Using Interpretable Machine Learning to Identify Baseline Predictive Factors of Remission and Drug Durability in Crohn's Disease Patients on Ustekinumab.

Ustekinumab has shown efficacy in Crohn's Disease (CD) patients. To identify patient profiles of those who benefit the most from this treatment would help to position this drug in the therapeutic paradigm of CD and generate hypotheses for future trials. The objective of this analysis was to determine whether baseline patient characteristics are predictive of remission and the drug durability of ustekinumab, and whether its positioning with respect to prior use of biologics has a significant effect after correcting for disease severity and phenotype at baseline using interpretable machine learning. Patients' data from SUSTAIN, a retrospective multicenter single-arm cohort study, were used. Disease phenotype, baseline laboratory data, and prior treatment characteristics were documented. Clinical remission was defined as the Harvey Bradshaw Index ≤ 4 and was tracked longitudinally. Drug durability was defined as the time until a patient discontinued treatment. A total of 439 participants from 60 centers were included and a total of 20 baseline covariates considered. Less exposure to previous biologics had a positive effect on remission, even after controlling for baseline disease severity using a non-linear, additive, multivariable model. Additionally, age, body mass index, and fecal calprotectin at baseline were found to be statistically significant as independent negative risk factors for both remission and drug survival, with further risk factors identified for remission.

Long-Term Real-World Effectiveness and Safety of Ustekinumab in Crohn's Disease Patients: The SUSTAIN Study.

BACKGROUND: Large real-world-evidence studies are required to confirm the durability of response, effectiveness, and safety of ustekinumab in Crohn's disease (CD) patients in real-world clinical practice. METHODS: A retrospective, multicentre study was conducted in Spain in patients with active CD who had received ≥1 intravenous dose of ustekinumab for ≥6 months. Primary outcome was ustekinumab retention rate; secondary outcomes were to identify predictive factors for drug retention, short-term remission (week 16), loss of response and predictive factors for short-term efficacy and loss of response, and ustekinumab safety. RESULTS: A total of 463 patients were included. Mean baseline Harvey-Bradshaw Index was 8.4. A total of 447 (96.5%) patients had received prior biologic therapy, 141 (30.5%) of whom had received ≥3 agents. In addition, 35.2% received concomitant immunosuppressants, and 47.1% had ≥1 abdominal surgery. At week 16, 56% had remission, 70% had response, and 26.1% required dose escalation or intensification; of these, 24.8% did not subsequently reduce dose. After a median follow-up of 15 months, 356 (77%) patients continued treatment. The incidence rate of ustekinumab discontinuation was 18% per patient-year of follow-up. Previous intestinal surgery and concomitant steroid treatment were associated with higher risk of ustekinumab discontinuation, while a maintenance schedule every 12 weeks had a lower risk; neither concomitant immunosuppressants nor the number of previous biologics were associated with ustekinumab discontinuation risk. Fifty adverse events were reported in 39 (8.4%) patients; 4 of them were severe (2 infections, 1 malignancy, and 1 fever). CONCLUSIONS: Ustekinumab is effective and safe as short- and long-term treatment in a refractory cohort of CD patients in real-world clinical practice.

This large retrospective study demonstrated the short- and long-term effectiveness and safety of ustekinumab in patients with Crohn's disease in real-world clinical practice, including those with refractory disease.

A retrospective and prospective 12-month observational study of the socioeconomic burden of moderate to severe irritable bowel syndrome with constipation in Spain / Estudio observacional, retrospectivo y prospectivo a 12 meses del coste socioeconómico del síndrome del intestino irritable moderado a grave con estreñimiento en España

Introduction: The socioeconomic burden of irritable bowel syndrome with constipation (IBS-C) has never been formally assessed in Spain. Patients and methods: This 12-month (6-month retrospective and prospective periods) observational, multicentre study assessed the burden of moderate-to-severe IBS-C in Spain. Patients were included if they had been diagnosed with IBS-C (Rome III criteria) within the last 5 years and had moderate-to-severe IBS-C (IBS Symptom Severity Scale score [IBS-SSS] ≥175) at inclusion. The primary objective was to assess the direct cost to the Spanish healthcare system (HS). Results: A total of 112 patients were included, 64 (57%) of which had severe IBS-C at inclusion. At baseline, 89 (80%) patients reported abdominal pain and distention. Patient quality of life (QoL), measured by the IBS-C QoL and EQ-5D instruments, was found to be impaired with a mean score of 59 and 57 (0-100, worst-best), respectively. Over the 6-month prospective period the mean IBS-C severity, measured using the IBS-SSS showed some improvement (315-234 [0-500, best-worst]). During the year, 89 (80%) patients used prescription drugs for IBS-C, with laxatives being the most frequently prescribed (n=70; 63%). The direct cost to the HS was €1067, and to the patient was €568 per year. The total direct cost for moderate-to-severe IBS-C was €1635. Discussion: The majority of patients reported continuous IBS-C symptoms despite that 80% were taking medication to treat their IBS-C. Overall healthcare resource use and direct costs were asymmetric, with a small group of patients consuming the majority of resources

Introducción: El coste socioeconómico del síndrome del intestino irritable con estreñimiento (SII-E) no ha sido evaluado formalmente en España. Pacientes y métodos: Este estudio observacional, multicéntrico a 12 meses (periodos retrospectivo y prospectivo de 6 meses) evaluó el coste del SII-E moderado-grave en España. Se incluyeron pacientes diagnosticados con SII-E (criterios Roma III) en los últimos 5 años y SII-E moderado-grave (puntuación IBS-Symptom Severity Scale [IBS-SSS]≥175) en la inclusión. El objetivo principal fue evaluar el coste directo para el sistema sanitario (SS) español. Resultados: Se incluyeron un total de 112 pacientes, 64 (57%) de los cuales presentaban SII-E grave en la inclusión. En el momento basal, 89 (80%) pacientes presentaron dolor y distensión abdominal. La calidad de vida del paciente, medida mediante los instrumentos IBS-C QoL y EQ-5D, estaba deteriorada, con una puntuación de 59 y 57 (0-100, peor-mejor), respectivamente. En el periodo prospectivo la gravedad media del SII-E, medida mediante IBS-SSS, mostró alguna mejoría (315 a 234 [0-500, mejor-peor]). Durante el periodo a studio, 89 (80%) pacientes usaron fármacos prescritos para el SII-E, principalmente laxantes (n=70; 63%). El coste directo anual fue de 1.067€ y 568€ para el SS y el paciente, respectivamente. El coste total directo del SII-E moderado-grave fue de 1.635€. Discusión: La mayoría de pacientes presentaron síntomas continuos del SII-E pese a que el 80% tomaban medicación específica. El uso de recursos sanitarios y los costes directos globales fueron asimétricos, con un pequeño grupo de pacientes consumiendo la mayoría de los recursos

A retrospective and prospective 12-month observational study of the socioeconomic burden of moderate to severe irritable bowel syndrome with constipation in Spain.

INTRODUCTION: The socioeconomic burden of irritable bowel syndrome with constipation (IBS-C) has never been formally assessed in Spain. PATIENTS AND METHODS: This 12-month (6-month retrospective and prospective periods) observational, multicentre study assessed the burden of moderate-to-severe IBS-C in Spain. Patients were included if they had been diagnosed with IBS-C (Rome III criteria) within the last 5 years and had moderate-to-severe IBS-C (IBS Symptom Severity Scale score [IBS-SSS] ≥175) at inclusion. The primary objective was to assess the direct cost to the Spanish healthcare system (HS). RESULTS: A total of 112 patients were included, 64 (57%) of which had severe IBS-C at inclusion. At baseline, 89 (80%) patients reported abdominal pain and distention. Patient quality of life (QoL), measured by the IBS-C QoL and EQ-5D instruments, was found to be impaired with a mean score of 59 and 57 (0-100, worst-best), respectively. Over the 6-month prospective period the mean IBS-C severity, measured using the IBS-SSS showed some improvement (315-234 [0-500, best-worst]). During the year, 89 (80%) patients used prescription drugs for IBS-C, with laxatives being the most frequently prescribed (n=70; 63%). The direct cost to the HS was €1067, and to the patient was €568 per year. The total direct cost for moderate-to-severe IBS-C was €1635. DISCUSSION: The majority of patients reported continuous IBS-C symptoms despite that 80% were taking medication to treat their IBS-C. Overall healthcare resource use and direct costs were asymmetric, with a small group of patients consuming the majority of resources.

Factores pronósticos de mortalidad en la cirrosis hepática tras un primer episodio de peritonitis bacteriana espontánea. Estudio multicéntrico / Prognostic factors of liver cirrhosis mortality after a first episode of spontaneous bacterial peritonitis. A multicenter study

Introducción: la peritonitis bacteriana espontánea es una complicación infecciosa con impacto negativo sobre la supervivencia de los pacientes con cirrosis. Objetivo: analizar la supervivencia a corto y largo plazo después de un primer episodio de peritonitis bacteriana espontánea y los factores pronósticos asociados. Material y métodos: estudio multicéntrico retrospectivo que incluyó a los pacientes ingresados por peritonitis bacteriana espontánea entre 2008 y 2013. Las variables independientes relacionadas con la mortalidad se analizaron mediante regresión logística. Se analizó el poder pronóstico de los índices Child Pugh, MELD y Charlson mediante curva de ROC. Resultados: fueron incluidos 159 pacientes. El 72% fueron hombres con una edad media de 63,5 años y con una puntuación MELD de 19 (DE ± 9,5). La mortalidad a los 30 días, 90 días, al año y a los dos años fue del 21%, 31%, 55% y 69%, respectivamente. La encefalopatía hepática (p = 0,008; OR 3,5; IC 95% 1,4-8,8) y la función renal (p = 0,026; OR 2,7; IC 95% 1,13-16,7) fueron factores independientes de mortalidad a corto y largo plazo. El MELD fue un buen indicador de supervivencia a corto y largo plazo (área bajo la curva [AUC] 0,7: IC 95% 1,02-1,4). El índice de Charlson se relacionó con la mortalidad a largo plazo (AUC 0,68: IC 95% 0,6-0,77). Conclusiones: en la peritonitis bacteriana espontánea la mortalidad a corto y largo plazo sigue siendo elevada. Los principales factores pronósticos de mortalidad son el deterioro de la función hepática y renal. El MELD y el índice de Charlson son unos buenos indicadores de supervivencia (AU)

Introduction: Spontaneous bacterial peritonitis is an infectious complication with a negative impact on survival of patients with cirrhosis. Objective: To analyze the short- and long-term survival after a first episode of bacterial peritonitis and the associated prognostic factors. Patients and methods: This was a retrospective, multicenter study of patients admitted to hospital for spontaneous bacterial peritonitis between 2008 and 2013. Independent variables related to mortality were analyzed by logistic regression. The prognostic power of the Child Pugh Score, the Model for End-Stage Liver Disease (MELD) and the Charlson index was analyzed by ROC curve. Results: A total of 159 patients were enrolled, 72% were males with a mean age of 63.5 years and a mean MELD score of 19 (SD ± 9.5). Mortality at 30 and 90 days and one and two years was 21%, 31%, 55% and 69%, respectively. Hepatic encephalopathy (p = 0.008, OR 3.5, 95% CI 1.4-8.8) and kidney function (p = 0.026, OR 2.7, 95% CI 1.13-16.7) were independent factors for short- and long-term mortality. MELD was a good marker of short- and long-term survival (area under the curve [AUC] 0.7: 95% CI 1.02-1.4). The Charlson index was related to long-term mortality (AUC 0.68: 95% CI 0.6-0.77). Conclusions: Short- and long-term mortality of spontaneous bacterial peritonitis is still high. The main prognostic factors for mortality are impairment of liver and kidney function. MELD and the Charlson index are good markers of survival (AU)

Prognostic factors of liver cirrhosis mortality after a first episode of spontaneous bacterial peritonitis. A multicenter study.

INTRODUCTION: Spontaneous bacterial peritonitis is an infectious complication with a negative impact on survival of patients with cirrhosis. OBJECTIVE: To analyze the short- and long-term survival after a first episode of bacterial peritonitis and the associated prognostic factors. PATIENTS AND METHODS: This was a retrospective, multicenter study of patients admitted to hospital for spontaneous bacterial peritonitis between 2008 and 2013. Independent variables related to mortality were analyzed by logistic regression. The prognostic power of the Child Pugh Score, the Model for End-Stage Liver Disease (MELD) and the Charlson index was analyzed by ROC curve. RESULTS: A total of 159 patients were enrolled, 72% were males with a mean age of 63.5 years and a mean MELD score of 19 (SD ± 9.5). Mortality at 30 and 90 days and one and two years was 21%, 31%, 55% and 69%, respectively. Hepatic encephalopathy (p = 0.008, OR 3.5, 95% CI 1.4-8.8) and kidney function (p = 0.026, OR 2.7, 95% CI 1.13-16.7) were independent factors for short- and long-term mortality. MELD was a good marker of short- and long-term survival (area under the curve [AUC] 0.7: 95% CI 1.02-1.4). The Charlson index was related to long-term mortality (AUC 0.68: 95% CI 0.6-0.77). CONCLUSIONS: Short- and long-term mortality of spontaneous bacterial peritonitis is still high. The main prognostic factors for mortality are impairment of liver and kidney function. MELD and the Charlson index are good markers of survival.

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.

Alteraciones psicológicas en pacientes con enfermedad celiaca del adulto / Psychological alterations in patients with adult celiac disease

Pacientes con enfermedad celiaca del adulto de reciente diagnóstico fueron evaluados con los test GSRS y PGWBI con el objetivo de valorar las alteraciones psicológicas que presentan, su relación con la sintomatología gastrointestinal y su evolución después de la instauración de dieta sin gluten. Previo asesoramiento nutricional los pacientes iniciaron dieta sin gluten y 6 meses después fueron reevaluados. Las variables cuantitativas se expresan como medianas y percentil Resultados Se incluyeron 21 pacientes, 17 mujeres y 4 hombres, edad 43 años (31-47). La histología fue compatible con lesión Marsh I en 6 casos, Marsh IIIa en 6 y Marsh IIIb en 9.Basalmente 8 pacientes presentaban distrés psicológico severo, 4 distrés moderado y 9 no presentaban distrés. La puntuación GSRS fue 34 (17-43) y el PGWBI 64 (48-87), objetivando la correlación significativa entre los 2 índices (rho = -0,58, p = 0,006).A los 6 meses 3 pacientes tenían distrés psicológico severo, 5 distrés moderado, 9 no presentaban distrés y 4 presentaban bienestar psicológico, la puntuación GSRS del 6.° mes fue 13 (8-17) y el PGWBI 83 (68-95) (p < 0,05 respecto de los datos basales para los 3 indicadores), constatándose mejoría significativa de los 6 ejes del PGWBI y sin que entonces se objetive correlación entre el GSRS y PGWBI. Conclusiones Los pacientes con enfermedad celiaca presentan alteraciones psicológicas cuya intensidad está relacionada con la sintomatología gastrointestinal, que mejoran después de la instauración de DSG

Patients with recently-diagnosed adult celiac disease were evaluated with the Gastrointestinal Symptom rating Scale (GSRS) and Psychological General Well-Being Index (PGWBI) to evaluate their psychological alterations, the association between any alterations and gastrointestinal symptoms, and their outcome after starting a gluten-free diet. The patients underwent nutritional assessment and then started a gluten-free diet; they were reassessed 6 months later. Quantitative variables are expressed as the median and 25th-75th percentiles. Results: We included 21 patients, 17 women and 4 mena, with a mean age of 43 years (31-47). The results of histological analysis were compatible with Marsh I lesions in 6 patients, Marsh IIIa in 6 and Marsh IIIb in 9. At baseline, 8 patients showed severe psychological distress, 4 showed moderate distress and 9 showed no distress. The GSRS score was 34 (17-43) and the PGWBI was 64 (48-87), with a significant correlation between the 2 indexes (rho = -.58, P = .006). At 6 months, 3 patients had severe psychological distress, 5 had moderate distress, 9 showed no distress and 4 showed psychological well-being. The GSRS score at 6 months was 13 (8-17) and the PGWBI was 83 (68-95) (P < .05 compared with baseline data for the 3 indicators). The 6 axes of the PGWBI showed significant improvement. At 6 months, no correlation was found between the GSRS and PGWBI. Conclusions: Patients with celiac disease have psychological alterations whose intensity is relted to gastrointestinal symptoms. These symptoms improve after the start of a gluten-free diet

[Psychological alterations in patients with adult celiac disease]. / Alteraciones psicológicas en pacientes con enfermedad celiaca del adulto.

UNLABELLED: Patients with recently-diagnosed adult celiac disease were evaluated with the Gastrointestinal Symptom rating Scale (GSRS) and Psychological General Well-Being Index (PGWBI) to evaluate their psychological alterations, the association between any alterations and gastrointestinal symptoms, and their outcome after starting a gluten-free diet. The patients underwent nutritional assessment and then started a gluten-free diet; they were reassessed 6 months later. Quantitative variables are expressed as the median and 25th-75th percentiles. RESULTS: We included 21 patients, 17 women and 4 mena, with a mean age of 43 years (31-47). The results of histological analysis were compatible with Marsh I lesions in 6 patients, Marsh IIIa in 6 and Marsh IIIb in 9. At baseline, 8 patients showed severe psychological distress, 4 showed moderate distress and 9 showed no distress. The GSRS score was 34 (17-43) and the PGWBI was 64 (48-87), with a significant correlation between the 2 indexes (rho=-.58, P=.006). At 6 months, 3 patients had severe psychological distress, 5 had moderate distress, 9 showed no distress and 4 showed psychological well-being. The GSRS score at 6 months was 13 (8-17) and the PGWBI was 83 (68-95) (P<.05 compared with baseline data for the 3 indicators). The 6 axes of the PGWBI showed significant improvement. At 6 months, no correlation was found between the GSRS and PGWBI. CONCLUSIONS: Patients with celiac disease have psychological alterations whose intensity is related to gastrointestinal symptoms. These symptoms improve after the start of a gluten-free diet.

Respuesta a «Espectro de la enteropatía sensible al gluten en pacientes con dispepsia de tipo dismotilidad» / Response to «Spectrum of gluten-sensitive entheropathy in patients with dismotility-like dyspepsia»

No disponible

Asistencia urgente a los pacientes con hemorragia digestiva alta en los hospitales comarcales catalanes / Emergency care of patients with upper gastrointestinal bleeding in regional hospitals in Catalonia

Objetivo Valorar los recursos disponibles en los hospitales comarcales catalanes para la asistencia urgente de la hemorragia digestiva alta. Método Se analiza una encuesta enviada a 32 hospitales, sobre la existencia, composición y recursos del turno de guardia (TDG) de endoscopia, referida al año 2009.ResultadosRespondieron 24 centros, que cubrían la asistencia de 3.954.000 habitantes. Tenían TDG 12 hospitales. No disponían de TDG en su centro de referencia 1.483.000 habitantes. Los centros con TDG tenían más camas y cubrían más población. Los TDG estaban formados por 4,5 endoscopistas (rango 2-11), que cubrían 82,1 (33,2-182,5) guardias/año. Diecisiete centros reportaban 1.571 episodios (51 por centro, rango 3-280, 39,68/100.000 hab.). Los centros con TDG reportaban más casos (76 vs. 43, p=0,047). Los que no disponen de TDG derivaron más pacientes (147 vs. 17, p= 0,001). Los pacientes en urgencias estaban a cargo de medicina interna en 4 centros, de cirugía en 14 y repartidos entre ambos servicios en 6. Si ingresaban, quedaron a cargo de Digestivo solo en 6 hospitales. Los recursos más utilizados eran la ligadura en la hemorragia varicosa y las terapias de inyección en la no varicosa. Un 21% de centros no realizaban tratamiento combinado. Conclusiones Una proporción significativa de la población no dispone de endoscopista de guardia en su centro de referencia. La constitución de TDG en hospitales comarcales supone importantes cargas asistenciales. La coordinación entre profesionales y centros permitiría la aplicación eficiente de los recursos terapéuticos y el establecimiento de TDG en centros que no tienen (AU)

Objective To evaluate the resources available in Catalan regional hospitals for the emergency care of upper gastrointestinal hemorrhage. Methods We analyzed a survey sent to 32 hospitals on the availability, composition and resources of a duty endoscopy service for the year 2009.ResultsResponses were obtained from 24 centers, covering 3,954,000 inhabitants. Duty endoscopists were available in 12 hospitals. A total of 1,483,000 inhabitants were unable to access a duty endoscopist in the referral center. Centers with duty endoscopists had more beds and had a larger catchment area. Duty services were composed of 4.5 endoscopists (range 2-11), covering 82.1 (33.2-182.5) duty shifts/year. Seventeen centers reported 1,571 episodes (51%, range: 3-280, 39.68/100,000 inhabitants). Centers with a duty service reported a greater number of cases (76 vs. 43, p=0.047). Centers without this service referred a greater number of patients (147 vs. 17, p=0.001). Patients in the emergency department were under the care of the internal medicine department in four centers, the surgery department in 14 centers and under the care of both departments in six. Admitted patients were under the care of the gastroenterology department in only six hospitals. The most widely used procedures were ligation of varicose bleeding and injection therapies in non-varicose bleeding. Twenty-one percent of centers did not perform combined treatment. Conclusions A significant proportion of the population does not have access to a duty endoscopist in referral centers. Duty shifts represent significant workload in regional hospitals. Coordination among health professionals and centers would allow the efficient application of therapeutic resources and a duty endoscopy service to be established in centers lacking this resource (AU)