Hemorragia digestiva en paciente con hiperplasia de glándulas de Brunner / Digestive tract hemorrhaging in a patient with Brunner's gland hyperplasia

Resumen Objetivo: analizar las características epidemiológicas, bases etiopatogénicas y presentación clínica, así como el diagnóstico y el tratamiento de la hiperplasia de glándulas de Brunner (HGB). Métodos: describir un caso de HGB diagnosticado de forma incidental durante una endoscopia electiva y realizar una revisión de la literatura disponible hasta el momento. Resultados: esta neoformación consiste en una proliferación glandular localizada preferentemente en el duodeno proximal. Su diagnóstico, normalmente realizado mediante biopsia endoscópica, puede asociarse con complicaciones que, aunque infrecuentes, no deben ser subestimadas. Conclusiones: las neoplasias duodenales representan un porcentaje pequeño dentro del total de las que afectan al tracto gastrointestinal. Debido a que el diagnóstico de estas lesiones suele realizarse de forma casual durante una endoscopia programada, el tratamiento deberá basarse en la sintomatología, así como el tamaño de las mismas, de acuerdo con los estándares de tratamiento de cada centro.

Abstract Objective: This study analyzes the epidemiological characteristics, etiological and pathogenic bases, clinical presentation, diagnosis and treatment of Brunner's gland hyperplasia. Methods: We describe a case of Brunner's gland hyperplasia that was diagnosed incidentally during elective endoscopy and review the available literature. Results: This neoplasm consists of glandular proliferation preferentially located in the proximal duodenum. Its diagnosis, normally made by endoscopic biopsy, can be associated with complications that, although infrequent, should not be underestimated. Conclusions: Duodenal neoplasms are a small percentage of those that affect the gastrointestinal tract. Because diagnosis is usually made by chance during a scheduled endoscopy, treatment should be based on the symptoms and size of the lesion according to the treatment standards of each medical center.

Hemorragia digestiva recurrente por lesión de Dieulafoy tratada con éxito mediante esclerosis guiada por ecoendoscopia / Recurrent gastrointestinal bleeding secondary to Dieulafoy's lesion successfully treated with endoscopic ultrasound-guided sclerosis

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What Is the Value of the Learning Curve in Endoscopic Balloon Dilatation of the Major Papilla?

INTRODUCTION: Endoscopic papillary large balloon dilatation (EPLBD) is an alternative for the treatment of common bile duct (CBD) stones. Existing evidence of factors associated with its outcomes is contradictory. OBJECTIVE: To identify predictors (including the experience of an endoscopist) of success and adverse events in EPLBD. METHODS: We reviewed the first 200 EPLBD with endoscopic sphincterotomy (EST) performed at our center. Demographic, clinical, and anatomic variables were studied, as well as the performance characteristics, correlating them with individual and group experience. RESULTS: Global success was obtained in 87% of cases, and adverse events occurred in 16% of cases. Success was associated with stone size, CBD diameter, and the need to perform mechanical lithotripsy (ML). Despite that adverse events were not univariately associated with any factor, severe adverse events were more likely to occur in stones > 13.5 mm. Multivariate analysis which disclosed success was higher when ML was not required and stones were < 13.5 mm. It also showed that no factor was associated with adverse events or their severity. No differences were found on success or adverse events that could be directly related to experience. CONCLUSIONS: Success of EPLBD-EST is higher in stones < 13.5 mm and when ML is not required. Experience does not appear to play a major role.

Eficacia y efectividad de la terapia biológica en la Enfermedad Inflamatoria Intestinal. Estudio EFIFECT / Efficacy and effectiveness of biologic therapy in inflammatory bowel disease. EFIFECT study

INTRODUCCIÓN: Los ensayos clínicos aleatorizados proporcionan la mejor evidencia científica de la eficacia de los fármacos biológicos en la enfermedad inflamatoria intestinal (EII). Sin embargo, los resultados pueden no ser reproducibles en la práctica clínica. Los objetivos de este estudio son analizar el porcentaje de pacientes con EII tratados con fármacos biológicos que habrían podido ser elegidos para un ensayo clínico aleatorizado y comparar la eficacia teórica de los fármacos biológicos con su efectividad en la práctica clínica. MÉTODOS: Realizamos un estudio retrospectivo multicéntrico en 375 pacientes con EII tratados con anti-TNF con un seguimiento de un año. Los criterios de elegibilidad para la condición de ensayo clínico fueron extraídos de los estudios pivotales ACCENT, SONIC, ACT, CLASSIC y CHARM. Los pacientes elegibles fueron incluidos en un segundo análisis para comparar los resultados en la práctica clínica con los obtenidos tras realizar una estimación teórica si el paciente hubiese sido incluido en un estudio pivotal. RESULTADOS: Solo el 45,6% de los 375 pacientes cumplían los criterios de selección para un estudio pivotal. El beneficio clínico al año fue similar entre los pacientes elegibles y no elegibles (68,4% vs 68,6%). El beneficio clínico en los pacientes elegibles fue mayor en la práctica clínica que en la condición hipotética de un ensayo clínico (68,4% vs 44,4%, p < 0,001). CONCLUSIÓN: Más de la mitad de los pacientes con EII tratados con fármacos biológicos no estarían representados en los ensayos pivotales. La efectividad de los fármacos anti-TNF en la práctica clínica es superior a su eficacia teórica

INTRODUCTION: Randomized controlled trials provide the best scientific evidence for the efficacy of biological drugs in inflammatory bowel disease (IBD). However, findings obtained from these trials might not be reproducible in clinical practice. This study aimed to estimate the percentage of patients with IBD treated with biologics who would have been eligible for randomized controlled trials, and to compare the theoretical efficacy of biological drugs with their effectiveness in clinical practice. METHODS: We performed a retrospective multicenter study in 375 patients with IBD treated with anti-TNF agents and followed-up for 1 year. The eligibility criteria for the trial were taken from the ACCENT, SONIC, ACT, CLASSIC and CHARM trials. Eligible patients were included in a second analysis to compare results in clinical practice versus those hypothetically obtained if the patient had been included in a trial. RESULTS: Only 45.6% of 375 patients would have been eligible for pivotal trials. One-year clinical benefit (remission or response) was similar for eligible and non-eligible cohorts (68.4% vs. 68.6%, P=.608). The clinical benefit was greater for current clinical practice than for a hypothetical trial situation (68.4% vs. 44.4%, P<.001) in eligible patients. CONCLUSION: More than half of patients with IBD treated with biologic drugs would not be represented in pivotal trials. The effectiveness of anti-TNF drugs in clinical practice exceeds their theoretical efficacy

Metástasis pancreática de carcinoma de células de Merkel diagnosticada mediante biopsia guiada por ecoendoscopia / Pancreatic metastasis from a Merkel cell carcinoma diagnosed by ultrasound-guided biopsy

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[Efficacy and effectiveness of biologic therapy in inflammatory bowel disease. EFIFECT study]. / Eficacia y efectividad de la terapia biológica en la Enfermedad Inflamatoria Intestinal. Estudio EFIFECT.

INTRODUCTION: Randomized controlled trials provide the best scientific evidence for the efficacy of biological drugs in inflammatory bowel disease (IBD). However, findings obtained from these trials might not be reproducible in clinical practice. This study aimed to estimate the percentage of patients with IBD treated with biologics who would have been eligible for randomized controlled trials, and to compare the theoretical efficacy of biological drugs with their effectiveness in clinical practice. METHODS: We performed a retrospective multicenter study in 375 patients with IBD treated with anti-TNF agents and followed-up for 1 year. The eligibility criteria for the trial were taken from the ACCENT, SONIC, ACT, CLASSIC and CHARM trials. Eligible patients were included in a second analysis to compare results in clinical practice versus those hypothetically obtained if the patient had been included in a trial. RESULTS: Only 45.6% of 375 patients would have been eligible for pivotal trials. One-year clinical benefit (remission or response) was similar for eligible and non-eligible cohorts (68.4% vs. 68.6%, P=.608). The clinical benefit was greater for current clinical practice than for a hypothetical trial situation (68.4% vs. 44.4%, P<.001) in eligible patients. CONCLUSION: More than half of patients with IBD treated with biologic drugs would not be represented in pivotal trials. The effectiveness of anti-TNF drugs in clinical practice exceeds their theoretical efficacy.

Ataxia y síndrome frontal en una paciente joven resuelto con dieta sin gluten / Ataxia and frontal syndrome in a young woman resolved with a gluten-free diet

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¿Es posible suspender el tratamiento con antivirales orales en los pacientes con hepatitis crónica B antígeno e negativa? Experiencia y nuevas expectativas / Is it possible to stop treatment with nucleos(t)ide analogs in patients with e-antigen negative chronic hepatitis B? Experience and new expectations

INTRODUCCIÓN: El tratamiento de la hepatitis crónica B antígeno e negativa (HCB HBeAg negativa) con antivíricos orales (AO) suele prolongarse de forma indefinida debido a que la pérdida del antígeno de superficie como objetivo para su suspensión es un hecho infrecuente. Recientemente han aparecido las primeras evidencias que sugieren finalizar la terapia con AO en casos seleccionados. OBJETIVOS: Analizar la tasa de rebote virológico en pacientes con HCB Age negativa que suspendieron el tratamiento con AO. MATERIAL Y MÉTODOS: Estudio retrospectivo observacional que incluyó 140 casos de HCB HBeAg negativa. Veintidós pacientes, que recibieron exclusivamente AO, los suspendieron por diversos motivos realizándose un seguimiento posterior. Todos presentaban transaminasas normales, ADN indetectable y ausencia de cirrosis o comorbilidades importantes al finalizar el tratamiento. RESULTADOS: Doce pacientes presentaron rebote virológico (54,54%), transcurriendo una media de 6,38 meses (± 1,9) desde la suspensión hasta el rebote (el 75% dentro de los 12 primeros meses tras la suspensión). Cinco recibieron adefovir, uno lamivudina más adefovir, uno tenofovir y 5 lamivudina. La duración media del tratamiento, desde el inicio hasta la suspensión, fue de 38,5 meses (± 4,5). El grupo con respuesta sostenida presentaba una edad media y duración del tratamiento superior a los sujetos con rebote, si bien estas diferencias no resultaron estadísticamente significativas. CONCLUSIONES: Los resultados sugieren que es posible suspender la terapia con AO en casos seleccionados de HCB Age negativa, siempre que no exista cirrosis, se cumpla un tiempo mínimo de tratamiento, las transaminasas sean normales y el ADN indetectable de forma mantenida. En estos casos, se debe realizar un seguimiento estrecho durante el primer año y posteriormente de forma indefinida

BACKGROUND: Treatment of HBeAg-negative chronic hepatitis B (CHB) with nucleos(t)ide analogues (NA) is usually indefinite, since the loss of HBsAg, as a criterion for its discontinuation, is a rare event. Recent evidence suggests that discontinuing NA therapy may be feasible in selected patients. OBJECTIVES: To analyze the rate of virological relapse in patients with HBeAg-negative CHB who discontinued treatment with NAs. METHODS: We performed a single-center observational study that included 140 patients with HBsAg-negative CHB. Twenty-two patients, who received only NAs, discontinued treatment for different reasons and were subsequently monitored. All had normal ALT and AST, undetectable DNA and absence of cirrhosis or significant comorbidities before stopping treatment. RESULTS: Twelve patients showed virologic relapse (54.54%). The mean interval between discontinuation and relapse was 6.38 months (± 1.9) (75% relapsed during the first 12 months after discontinuation). Five received adefovir, 1 lamivudine and adefovir, 1 tenofovir and 5 lamivudine alone. The mean treatment duration in this group was 38.5 months (± 4.5). The sustained response group had a higher mean age and longer treatment duration than patients with virologic relapse but these differences were not statistically significant. CONCLUSIONS: The results suggest that NA treatment can be stopped in selected patients with CHB as long as they are not cirrhotic, have completed a minimum period of treatment, have normal ALT and sustained undetectable DNA. These patients should be closely monitored during the first year and then indefinitely

[Is it possible to stop treatment with nucleos(t)ide analogs in patients with e-antigen negative chronic hepatitis B? Experience and new expectations]. / ¿Es posible suspender el tratamiento con antivirales orales en los pacientes con hepatitis crónica B antígeno e negativa? Experiencia y nuevas expectativas.

BACKGROUND: Treatment of HBeAg-negative chronic hepatitis B (CHB) with nucleos(t)ide analogues (NA) is usually indefinite, since the loss of HBsAg, as a criterion for its discontinuation, is a rare event. Recent evidence suggests that discontinuing NA therapy may be feasible in selected patients. OBJECTIVES: To analyze the rate of virological relapse in patients with HBeAg-negative CHB who discontinued treatment with NAs. METHODS: We performed a single-center observational study that included 140 patients with HBsAg-negative CHB. Twenty-two patients, who received only NAs, discontinued treatment for different reasons and were subsequently monitored. All had normal ALT and AST, undetectable DNA and absence of cirrhosis or significant comorbidities before stopping treatment. RESULTS: Twelve patients showed virologic relapse (54.54%). The mean interval between discontinuation and relapse was 6.38 months (± 1.9) (75% relapsed during the first 12 months after discontinuation). Five received adefovir, 1 lamivudine and adefovir, 1 tenofovir and 5 lamivudine alone. The mean treatment duration in this group was 38.5 months (± 4.5). The sustained response group had a higher mean age and longer treatment duration than patients with virologic relapse but these differences were not statistically significant. CONCLUSIONS: The results suggest that NA treatment can be stopped in selected patients with CHB as long as they are not cirrhotic, have completed a minimum period of treatment, have normal ALT and sustained undetectable DNA. These patients should be closely monitored during the first year and then indefinitely.

Sensibilidad al gluten no celíaca: ¿una verdadera entidad o solo una quimera? / Non-celiac gluten sensitivity: A true entity or just a chimera?

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Adenocarcinoma de bulbo duodenal, un diagnóstico poco sospechado / Bulbar duodenal adenocarcinoma. An unsuspected diagnosis

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Pancreatitis aguda por hipertrigliceridemia / Acute hypertrygliceridemic pancreatitis

La pancreatitis aguda por hipertrigliceridemia es la tercera causa de pancreatitis aguda en la población occidental. Normalmente hay una alteración subyacente del metabolismo lipidémico, sobre la que actúa un factor secundario. La presentación clínica es similar a la de las pancreatitis agudas de otras etiologías, aunque su curso parece ser más tórpido y recurrente. Para su diagnóstico hay que saber que algunos parámetros de la analítica pueden estar artefactados, lo que puede conducir a un fallo en el diagnóstico. Tal es el caso de la amilasa, que puede estar falsamente descendida. El tratamiento se basa en sueroterapia intensa y analgesia. Cuando no responde al tratamiento conservador, deben utilizarse otros métodos para disminuir el nivel de triglicéridos. Para ello disponemos de la plasmaféresis, la insulina y la heparina. Este artículo pretende mostrar una revisión de la literatura actual sobre esta patología (AU)

Acute hypertriglyceridemic pancreatitis is the third cause of acute pancreatitis in the Western population. There is usually an underlying alteration in lipid metabolism and a secondary factor. Clinical presentation is similar to that of pancreatitis of other etiologies, but the course of acute hypertriglyceridemic pancreatitis seems to be worse and more recurrent. Some laboratory data can be artefacts, leading to diagnostic errors. This is the case of amylase, which can show false low levels. Treatment is based on intense fluidotherapy and analgesia. When there is no response to conservative management, other methods to lower triglyceride levels should be used. Several options are available, such as plasmapheresis, insulin, and heparin. The present article provides a review of the current literature on this entity (AU)

[Acute hypertrygliceridemic pancreatitis]. / Pancreatitis aguda por hipertrigliceridemia.

Acute hypertriglyceridemic pancreatitis is the third cause of acute pancreatitis in the Western population. There is usually an underlying alteration in lipid metabolism and a secondary factor. Clinical presentation is similar to that of pancreatitis of other etiologies, but the course of acute hypertriglyceridemic pancreatitis seems to be worse and more recurrent. Some laboratory data can be artefacts, leading to diagnostic errors. This is the case of amylase, which can show false low levels. Treatment is based on intense fluidotherapy and analgesia. When there is no response to conservative management, other methods to lower triglyceride levels should be used. Several options are available, such as plasmapheresis, insulin, and heparin. The present article provides a review of the current literature on this entity.