New Trends and Advances in Non-Variceal Gastrointestinal Bleeding-Series II.

The gastrointestinal tract is a long tubular structure wherein any point in the mucosa along its entire length could be the source of a hemorrhage. Upper (esophagel and gastroduodenal) and lower (jejunum, ileum, and colon) gastrointestinal bleeding are common. Gastroduodenal and colonic bleeding are more frequent than bleeding from the small bowel, but nowadays the entire gastrointestinal tract can be explored endoscopically and bleeding lesions can be locally treated successfully to stop or prevent further bleeding. The extensive use of antiplatelet and anticoagulants drugs in cardiovascular patients is, at least in part, the cause of the increasing number of patients suffering from gastrointestinal bleeding. Patients with these conditions are usually older and more fragile because of their comorbidities. The correct management of antithrombotic drugs in cases of gastrointestinal bleeding is essential for a successful outcome for patients. The influence of the microbiome in the pathogenesis of small bowel bleeding is an example of the new data that are emerging as potential therapeutic target for bleeding prevention. This text summarizes the latest research and advances in all forms of acute gastrointestinal bleeding (i.e., upper, small bowel and lower). Diagnosis is approached, and medical, endoscopic or antithrombotic management are discussed in the text in an accessible and comprehensible way.

Esophageal cancer: Risk factors, screening and endoscopic treatment in Western and Eastern countries.

Esophageal cancer is one of the most unknown and deadliest cancers worldwide, mainly because of its extremely aggressive nature and poor survival rate. Esophageal cancer is the 6(th) leading cause of death from cancer and the 8(th) most common cancer in the world. The 5-year survival is around 15%-25%. There are clear differences between the risk factors of both histological types that affect their incidence and distribution worldwide. There are areas of high incidence of squamous cell carcinoma (some areas in China) that meet the requirements for cost-effectiveness of endoscopy for early diagnosis in the general population of those areas. In Europe and United States the predominant histologic subtype is adenocarcinoma. The role of early diagnosis of adenocarcinoma in Barrett's esophagus remains controversial. The differences in the therapeutic management of early esophageal carcinoma (high-grade dysplasia, T1a, T1b, N0) between different parts of the world may be explained by the number of cancers diagnosed at an early stage. In areas where the incidence is high (China and Japan among others) early diagnoses is more frequent and has led to the development of endoscopic techniques for definitive treatment that achieve very effective results with a minimum number of complications and preserving the functionality of the esophagus.

Colonic diverticular disease. Treatment and prevention.

Diverticular disease represents the most common disease affecting the colon in the Western world. Most cases remain asymptomatic, but some others will have symptoms or develop complications. The aims of treatment in symptomatic uncomplicated diverticular disease are to prevent complications and reduce the frequency and intensity of symptoms. Fibre, probiotics, mesalazine, rifaximin and their combinations seem to be usually an effective therapy. In the uncomplicated diverticulitis, outpatient management is considered the optimal approach in the majority of patients, and oral antibiotics remain the mainstay of treatment. Admission to hospital and intravenous antibiotic are recommended only when the patient is unable to intake food orally, affected by severe comorbidity or does not improve. However, inpatient management and intravenous antibiotics are necessary in complicated diverticulitis. The role of surgery is also changing. Most diverticulitis-associated abscesses can be treated with antibiotics and/or percutaneous drainage and emergency surgery is considered only in patients with acute peritonitis. Finally, patient related factors, and not the number of recurrences, play the most important role in selecting recipients of elective surgery to avoid recurrences.

Balancing the risk and benefits of low-dose aspirin in clinical practice.

Antiplatelet agents are widely used in primary and secondary prevention of cardiovascular events. The scientific evidence has provided strong support for the benefits of aspirin in decreasing the risk of cardiovascular events in a wide range of pathologies. The relatively rare occurrence of major bleeding complications should not be underestimated, mainly due to its high morbi-mortality. The assessment of both gastrointestinal risk and cardiovascular benefits of low-dose aspirin for any individual patient may be difficult in clinical practice. In this review, we summarize the evidence supporting the efficacy of aspirin and the risks of side effects due to hemorrhagic complications. This article proposes a unifying framework for application to help the clinician in the decision making process of individuals who have different risk of cardiovascular and bleeding events with different examples. Finally, new developments in the field directed towards individualized risk assessment strategies are described.

[Antiplatelet agents and proton pump inhibitors. How can the risk-benefit balance be optimized in patients at risk for cardiovascular disease and gastrointestinal bleeding?]. / Antiagregantes plaquetarios e inhibidores de la bomba de protones. Cómo optimizar el riesgo-beneficio en los pacientes con riesgo cardiovascular y riesgo de hemorragia gastrointestinal?

Antiplatelet agents are routinely used in both primary and secondary prevention of cardiovascular events. The development of new antiplatelet agents and the strong growth of interventional cardiology have led to this therapy being more widely prescribed and for longer periods. The most important secondary effect is the rise in the incidence of hemorrhagic complications, the most prevalent being gastrointestinal bleeding. In this context, the balance between the cardiovascular benefits and bleeding risk of these agents must be optimized. This review provides specific management recommendations and highlights important practical aspects related to antiplatelet therapy, including the interaction between clopidogrel and proton pump inhibitors. The benefits and hazards in distinct clinical settings are outlined within the context of optimizing the balance between the cardiovascular benefits and bleeding risk of antiplatelet therapy.

[Appropriate use of non-steroidal anti-inflammatory drugs in rheumatology: guidelines from the Spanish Society of Rheumatology and the Mexican College of Rheumatology]. / Uso apropiado de los antiinflamatorios no esteroideos en reumatología: documento de consenso de la Sociedad Española de Reumatología y el Colegio Mexicano de Reumatología.

OBJECTIVE: To develop guidelines for the appropriate use of NSAIDs in rheumatology. METHODS: We used a methodology modified from the one developed by RAND/UCLA. Two groups of panellists were selected, one by the CMR and another by the SER. Recommendations were proposed from nominal groups and the agreement to them was tested among rheumatologists from both societies by a tworound Delphi survey. The analysis of the second Delphi round supported the generation of the final set of recommendations and the assignment of a level of agreement to each of them. Systematic reviews of five recommendations in which the agreement was low or was divided were also carried out. RESULTS: Here we present recommendations for the safe use of NSAIDs in rheumatic diseases, based on the best available evidence, expert opinion, the agreement among rheumatologists, and literature review. The trend is to reduce the frequency, duration and dose of NSAIDs in favour of non-pharmacological measures, analgesic drugs or disease modifying drugs. In addition, the recommendations help to identify profiles for increased toxicity, with an emphasis on gastrointestinal and cardiovascular risks. The recommendations deal with the course of action and monitoring in different risk groups and in patients using antiplatelet or anticoagulant drugs. The overall level of agreement is high. CONCLUSIONS: The NSAIDs are safe and effective drugs for the treatment of rheumatic diseases. However, it is necessary to individualize its use according to their risk profile.

Aspirina en dosis bajas y complicaciones gastrointestinales / Low dose aspirin and gastrointestinal complications

The use of aspirin is associated with a significant increase of gastrointestinal bleeding. This risk appears to be dose-dependent and although it is lower than the one observed with classical NSAIDS there is no risk-free dose. Risk factors are poorly described, although a previous history of peptic ulcer or complications as well as Helicobacter pylori infection seem to be the most relevant ones. Patients with one or more risk factors or those with poor health conditions requiring aspirin, should receive prophylaxis, although data concerning such issues is still scarce. The ideal prophylactic strategy has yet to be defined but proton pump inhibitors are the best option available and they are very beneficial in high-risk patients. H. pylori eradication could be a reasonable prophylactic alternative but more studies are needed to clarify the exact role H. pylori has and the population that would benefit from eradication.

La utilización de aspirina se asocia con incremento significativo de hemorragia gastrointestinal. Dicho riesgo parece ser dependiente de la dosis y, aunque es menor que el observado para antiinflamatorios no esteroides clásicos, no parece existir una dosis libre de riesgo. Los factores de riesgo no están totalmente definidos aunque la historia previa de úlcera o complicaciones y la infección por Helicobacter pylori parecen ser los más importantes. Si bien la información al respecto continúa siendo escasa debería ofrecerse profilaxis a aquellos pacientes con uno o más factores de riesgo o a aquellos pacientes que presentando mala salud requieran aspirina. Aunque la terapia profiláctica ideal está todavía por definirse, la mejor opción para la profilaxis parecen ser los inhibidores de la bomba de protones, especialmente beneficiosa en los pacientes de alto riesgo. La erradicación de la infección por H. pylori podría ser otra alternativa en la profilaxis aunque hacen falta más estudios que aclaren su papel exacto y en qué población debe aplicarse.