Helicobacter pylori infection is associated with decreased odds for eosinophilic esophagitis in Mexican patients. / La infección por Helicobacter pylori se asocia con disminución del riesgo de esofagitis eosinofílica en pacientes mexicanos.

BACKGROUND: The incidence of eosinophilic esophagitis (EoE) is increasing in some regions of the world. Retrospective studies have found an inverse association with Helicobacter pylori infection (H. pylori). A recent prospective study has questioned this relationship. We aimed to evaluate this relationship in Mexican patients. PATIENTS AND METHODS: We evaluated adult patients without prior eradication of H. pylori. Cases were defined by the presence of esophageal symptoms and >15 eosinophils/high power field (HPF) in the esophageal biopsy. Controls were defined by the presence of <15 eosinophils/HPF in esophageal biopsy. H. pylori infection was defined by histology. Patients were matched by age and gender assigning four controls per case. RESULTS: We included 190 patients: 38 cases and 152 controls. Cases had higher frequency of atopy, dysphagia, food impaction, peripheral eosinophilia, and endoscopic EoE abnormalities. The overall prevalence of H. pylori was 63.6%. Cases had significantly lower prevalence of H. pylori than controls (36.8% vs. 70.4%, OR 0.21 95% CI 0.08-0.69, p = 0.001). Atopic patients had lower prevalence of H. pylori than non-atopic: 13.1% vs. 50.5% (OR 0.20, 95% CI 0.06-0.69, p < 0.001), particularly allergic rhinitis and food allergy. CONCLUSIONS: We observed an inverse relationship between H. pylori and EoE as well as atopy. Studies in experimental models of EoE that clarify the role of H. pylori in this interaction are required, as well as robust studies that include other factors (socioeconomic, cultural, microbiota, etc.) in order to clarify this relationship.

Pyogenic granuloma of the terminal ileum diagnosed by colonoscopy: the relevance of ileocecal valve intubation.

Pyogenic granuloma is a benign vascular lesion that is most frequently found in the epidermis or mucosa of the oral cavity. Its finding in the ileum is rare, there are only a few case reports. In most reported cases, diagnosis is made with capsule endoscopy or double-balloon enteroscopy. We present a case of a lesion in the ileum, approximately 15 cm from the ileocecal valve, documented by colonoscopy.

Acute respiratory failure secondary to megaesophagus: think beyond COVID-19.

A 61-year-old man with a history of progressive dysphagia in the last three years and current COVID-19 diagnosis, presented to our emergency department with sudden dyspnea and loss of consciousness. Initial examination revealed a respiratory rate of 30 bpm with an oxygen saturation of 94% with room air. A venous blood gas exam showed acute hypercapnic respiratory failure; therefore, he was intubated and admitted to the medical intensive care unit.

Glanzmann thrombasthenia: an uncommon cause of acute upper gastrointestinal bleeding.

The major function of platelets is to contribute to hemostasis. If an impairment in their production and/or function occurs, abnormal bleeding can develop. An 18-year-old male presented to our hospital after four episodes of hematemesis. His medical history was relevant for Glanzmann thrombasthenia diagnosed during early childhood. On initial examination, he appeared pale and with normal blood pressure. His complete blood count included a hemoglobin concentration of 11.0 g/dL, additional laboratory tests were within the normal ranges. The initial approach consisted of a high dose of proton pump inhibitors. Hours later, esophagogastroduodenoscopy revealed diffuse oozing bleeding from gastric mucosa with no other visible lesions such as peptic ulcers or varices.

Primary pancreatic lymphoma: thinking beyond pancreatic adenocarcinoma.

Primary pancreatic lymphoma is one of the rare primary pancreatic tumors with a low incidence compared to adenocarcinoma, which is the most frequent. Currently there are diagnostic tools such as percutaneous biopsy and endoscopic ultrasound to reach its diagnosis. Primary lymphoma of the pancreas has defined therapeutic targets as well as a better prognosis compared to other tumors.

Clinical, endoscopic and histological characteristics of Mexican adult patients with eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) has high prevalence/incidence in Western Europe, Canada, United States of America and Australia where it has significantly increased over the past three decades to the extent that some consider it an epidemic.

Evaluation and Validation of a New Score to Measure the Severity of Small Bowel Angiodysplasia on Video Capsule Endoscopy.

INTRODUCTION: Angiodysplasias are responsible of 50% of small bowel bleeding. An endoscopic method that allows measuring its severity is not available. AIMS: The aim of the study was to validate a new endoscopic score with VCE to measure the severity of small bowel angiodysplasias (SBAD). METHODS: Four endoscopists independently reviewed VCE videos of 22 patients with SBAD. The score graded 3 variables: A - extent of lesions: E1, located in one half of the intestine and E2, in both halves; B - number of lesions: N1, <5; N2, 5-10; and N3, >10 lesions; C - probability of bleeding: P1, pale red spots; P2, bright red spots; P3, bleeding stigmata; and P4, active bleeding. Capsule Endoscopy Small Bowel Angiodysplasia Activity Index (CESBAI) was calculated as follows: E × 1 + N × 2 + P × 3. Interobserver variability was analyzed by Spearman's correlation and agreement Kappa statistic tests. RESULTS: The mean CESBAI scores by observers were O1= 11.6 ± 4.1; O2 = 11.3 ± 4.8; O3 = 11.1 ± 4.9; and O4 = 11.8 ± 4.2 (p > 0.05). Spearman's correlation values of CESBAI between every 2 observers were from 0.61 to 0.94 (p < 0.001) with a global correlation of 0.73 among all observers. Kappa values of CESBAI between every 2 observers ranged from 0.42 to 0.87 (p < 0.001) with a global agreement of 0.57 among all observers. All evaluators stated that the method was easy to use. CONCLUSIONS: CESBAI is a reliable and reproducible score. Nevertheless, these results must be validated in other studies with larger population before assessing its power for predicting bleeding recurrence.

Nonaggressive Versus Aggressive Intravenous Fluid Therapy in Acute Pancreatitis With More Than 24 Hours From Disease Onset: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to compare a "nonaggressive" hydration versus an "aggressive" hydration using Hartmann's solution in patients with acute pancreatitis (AP) with more than 24 hours from disease onset. METHODS: We included 88 patients with AP with more than 24 hours from disease onset, and were randomized into 2 groups. Group I (n = 45) received a nonaggressive hydration (Hartmann's solution at 1.5 mL kg h for the first 24 hours and 30 mL kg during the next 24 hours), and group II (n = 43) received an aggressive hydration (bolus of Hartmann's solution 20 mL kg, followed by an infusion of 3 mL kg h for the first 24 hours and then 30 mL kg for the next 24 hours). RESULTS: The mean volume of fluid administered was greater in group II (P < 0.001). We did not find differences when comparing both groups in reference to persistent systemic inflammatory response syndrome (P = 0.528), pancreatic necrosis (P = 0.710), respiratory complications (P = 0.999), acute kidney injury (P = 0.714), or length of hospital stay (P = 0.892). CONCLUSIONS: Our study suggests that the clinical evolution of patients with AP with more than 24 hours from disease onset is similar using an aggressive or nonaggressive hydration.

Prevalence of liver fibrosis in an unselected general population with high prevalence of obesity and diabetes mellitus. Time for screening?

INTRODUCTION: Cirrhosis and liver cancer are currently common causes of death worldwide. The global epidemic of obesity has increased the incidence of nonalcoholic fatty liver disease (NAFLD) and cirrhosis in recent years. Advanced fibrosis increases the morbimortality rate in NAFLD. The Mexican population has one of the highest prevalence of obesity and diabetes mellitus (DM) worldwide. AIM: To determine the prevalence of advanced liver fibrosis in Mexican general population. METHODS: Adult individuals, without a history of liver disease nor heavy alcohol consumption were randomly sampled from 20,919 participants of a health and nutrition survey applied to the general population. Clinical and laboratory evaluations were performed to calculate the NAFLD fibrosis score (NFS) (an extensively validated non-invasive method). Two cut-off points were used. Advanced fibrosis was defined as a result >0.676. RESULTS: In total 695 individuals were included. The mean age was 47.8±16.4. The majority were between 20 and 50 years (59%), 70.2% were female, 35.5% showed obesity and 15.8% DM. The 93% had normal serum ALT. Based on the NFS results, 56 individuals (8.1%) had a high probability of fibrosis. Most patients from this subgroup showed normal serum ALT (92.9%), 89.3% were >45yr. old, 52% were obese and 27% suffered from DM. CONCLUSIONS: Based on these results, 8.1% of Mexican general population without a history of liver disease is at high risk of having advanced liver fibrosis and complications and death derived from cardiovascular disease and cirrhosis. Most of them showed normal ALT serum levels.

Diagnosis of Eosinophilic Enteritis With Video Capsule Endoscopy and Double Balloon Enteroscopy With Favorable Response to Corticosteroids.

Eosinophilic enteritis is a rare disease with nonspecific symptoms, often representing a diagnostic challenge. Video capsule endoscopy (VCE) has enabled examination of the full small bowel. However, capsule retention is an unfortunate complication. We present the case of a female patient admitted for abdominal pain. Appendectomy without resolution of symptoms was performed. A normal computed tomography and magnetic resonance imaging were obtained. The diagnosis was made by VCE and double balloon enteroscopy with biopsy. Asymptomatic capsule retention was resolved after corticosteroid therapy. The patient showed a favorable clinical and endoscopic response, confirmed through a second VCE after 3 months of treatment.

Diagnosis and management of patients with an intermediate probability of choledocholithiasis.

We thank Dr. Dib for his interest in our prospective study, in which we assessed the accuracy of the American Society for Gastrointestinal Endoscopy guidelines for the prediction of choledocholithiasis (CL). The guidelines suggest the option of using a less-invasive initial test including endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) in patients with intermediate probability of CL. However, there is a paucity of published literature supporting this recommendation. Furthermore, in the study by Adams et al. (3) such a recommendation is not supported by their data. Additionally, because the prevalence of CL varies among ethnic groups, we did not consider performing pre-ERCP (endoscopic retrograde cholangiopancreatography) imaging studies in our study.

Lack of compliance with consensus recommendations on the diagnosis of eosinophilic esophagitis (EoE) in published prevalence studies. A clinical and systematic review.

OBJECTIVE: According to consensus recommendations, the presence of esophageal symptoms, >15 eosinophils/high-power field and unresponsiveness to proton pump inhibitors are required for a diagnosis of eosinophilic esophagitis (EoE). Nevertheless, inconsistency in using these guidelines has been reported in recent publications. The objective of this study was to assess compliance with EoE diagnostic guidelines in published studies on EoE prevalence and to evaluate other clinical and methodological parameters. METHODS: A systematic review was conducted in articles published between 2008 and 2015 on the prevalence of EoE in unselected adults. Studies using EoE diagnostic definitions were judged to be compliant if they included all three components of the definition, partially compliant if they included two and non-compliant if they included one or none. Esophageal biopsy protocol differences and descriptions of patients' characteristics were determined. RESULTS: Among the 20 studies included, eight were performed in a hospital setting and 12 in the general population. Only 40.0% of studies were compliant, 35.0% were partially compliant and 25.0% were non-compliant with the EoE diagnostic definition guidelines. In 60.0% of the studies a proton pump inhibitor trial was not administered. Only 30.0% adhered to the recommendations in the esophageal biopsy protocol. A lack of description of the history of atopia and endoscopic characteristics was observed in many studies. CONCLUSIONS: Partial or non-compliance with the EoE diagnostic definition was observed in most of the published prevalence studies after the publication of the first consensus. The results of these studies might be interpreted taking into account this context.

Accuracy of ASGE criteria for the prediction of choledocholithiasis.

BACKGROUND/AIMS: Few studies have validated the performance of guidelines for the prediction of choledocholithiasis (CL). Our objective was to prospectively assess the accuracy of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL. METHODS: A two-year prospective evaluation of patients with suspected CL was performed. We evaluated the ASGE guidelines and its component variables in predicting CL. RESULTS: A total of 256 patients with suspected CL were analyzed. Of the 208 patients with high-probability criteria for CL, 124 (59.6%) were found to have a stone/sludge at endoscopic retrograde cholangiopancreatography (ERCP). Among 48 patients with intermediate-probability criteria, 21 (43.8%) had a stone/sludge. The performance of ASGE high- and intermediate-probability criteria in our population had an accuracy of 59.0% (85.5% sensitivity, 24.3% specificity) and 41.0% (14.4% sensitivity, 75.6% specificity), respectively. The mean ERCP delay time was 6.1 days in the CL group and 6.4 days in the group without CL, p = 0.638. The presence of a common bile duct (CBD) > 6 mm (OR 2.21; 95% CI, 1.20-4.10), ascending cholangitis (OR 2.37; 95% CI, 1.01-5.55) and a CBD stone visualized on transabdominal US (OR 3.33; 95% CI, 1.48-7.52) were stronger predictors of CL. The occurrence of biliary pancreatitis was a strong protective factor for the presence of a retained CBD stone (OR 0.30; 95% CI, 0.17-0.55). CONCLUSIONS: Irrespective of a patient's ASGE probability for CL, the application of current guidelines in our population led to unnecessary performance of ERCPs in nearly half of cases.

Hepatogenous diabetes: Is it a neglected condition in chronic liver disease?

Diabetes mellitus (DM) that occurs because of chronic liver disease (CLD) is known as hepatogenous diabetes (HD). Although the association of diabetes and liver cirrhosis was described forty years ago, it was scarcely studied for long time. Patients suffering from this condition have low frequency of risk factors of type 2 DM. Its incidence is higher in CLD of viral, alcoholic and cryptogenic etiology. Its pathophysiology relates to liver damage, pancreatic dysfunction, interactions between hepatitis C virus (HCV) and glucose metabolism mechanisms and genetic susceptibility. It associates with increased rate of liver complications and hepatocellular carcinoma, and decreased 5-year survival rate. It reduces sustained virological response in HCV infected patients. In spite of these evidences, the American Diabetes Association does not recognize HD. In addition, the impact of glucose control on clinical outcomes of patients has not been evaluated. Treatment of diabetes may be difficult due to liver insufficiency and hepatotoxicity of antidiabetic drugs. Notwithstanding, no therapeutic guidelines have been implemented up to date. In this editorial, authors discuss the reasons why they think that HD may be a neglected pathological condition and call attention to the necessity for more clinical research on different fields of this disease.

Current Concepts in Diabetes Mellitus and Chronic Liver Disease: Clinical Outcomes, Hepatitis C Virus Association, and Therapy.

Hereditary type 2 diabetes mellitus is a risk factor for chronic liver disease, and ~30 % of patients with liver cirrhosis develop diabetes. Diabetes mellitus has been associated with cirrhotic and non-cirrhotic hepatitis C virus liver infection, can aggravate the course the liver infection, and can induce a lower sustained response to antiviral treatment. Evidences that HCV may induce metabolic and autoimmune disturbances leading to hypobetalipoproteinemia, steatosis, insulin resistance, impaired glucose tolerance, thyroid disease, and gonadal dysfunction have been found. Prospective studies have demonstrated that diabetes increases the risk of liver complications and death in patients with cirrhosis. However, treatment of diabetes in these patients is complex, as antidiabetic drugs can promote hypoglycemia and lactic acidosis. There have been few therapeutic studies evaluating antidiabetic treatments in patients with liver cirrhosis published to date; thus, the optimal treatment for diabetes and the impact of treatment on morbidity and mortality are not clearly known. As numbers of patients with chronic liver disease and diabetes mellitus are increasing, largely because of the global epidemics of obesity and nonalcoholic fatty liver disease, evaluation of treatment options is becoming more important. This review discusses new concepts on hepatogenous diabetes, the diabetes mellitus­hepatitis C virus association, and clinical implications of diabetes mellitus in patients with chronic liver disease. In addition, the effectiveness and safety of old and new antidiabetic drugs, including incretin-based therapies, will be described.

Subclinical abnormal glucose tolerance is a predictor of death in liver cirrhosis.

AIM: To determine if subclinical abnormal glucose tolerance (SAGT) has influence on survival of non-diabetic patients with liver cirrhosis. METHODS: In total, 100 patients with compensated liver cirrhosis and normal fasting plasma glucose were included. Fasting plasma insulin (FPI) levels were measured, and oral glucose tolerance test (OGTT) was performed. According to OGTT results two groups of patients were formed: those with normal glucose tolerance (NGT) and those with SAGT. Patients were followed every three months. The mean follow-up was 932 d (range of 180-1925). Survival was analyzed by the Kaplan-Meyer method, and predictive factors of death were analyzed using the Cox proportional hazard regression model. RESULTS: Of the included patients, 30 showed NGT and 70 SAGT. Groups were significantly different only in age, INR, FPI and HOMA2-IR. Patients with SAGT showed lower 5-year cumulated survival than NGT patients (31.7% vs 71.6%, P = 0.02). Differences in survival were significant only after 3 years of follow-up. SAGT, Child-Pugh B, and high Child-Pugh and Model for End-Stage Liver Disease (MELD) scores were independent predictors of death. The causes of death in 90.3% of cases were due to complications related to liver disease. CONCLUSION: SAGT was associated with lower survival. SAGT, Child-Pugh B, and high Child-Pugh and MELD scores were independent negative predictors of survival.

The prevalence and clinical characteristics of glucose metabolism disorders in patients with liver cirrhosis. A prospective study.

AIMS: To define the prevalence and clinical characteristics of glucose metabolism disorders (GMD) in patients with compensated liver cirrhosis (LC). MATERIAL AND METHODS: Fasting plasma glucose (FPG) levels were measured to 130 patients with clinically stable LC. Oral glucose tolerance tests (OGTT) and fasting plasma insulin determinations were performed to patients with normal FPG. Insulin resistance (IR) was calculated with HOMA2-IR index. GMD were classified according to FPG and OGTT tests results and to the chronologic relation between diagnosis of diabetes mellitus (DM) and LC as follows: type-2 DM (T2DM), hepatogenous diabetes (HD) and impaired glucose tolerance. Patients from all groups were compared. RESULTS: The prevalence of GMD were as follows: T2DM in 25 patients (19.2%, 95% CI 12.5-25.9), HD in 28 (21.5%, 95% CI 14.5-28.5) and IGT in 36 (38.5%, 95% CI 30.1-46.7). The total of patients with GMD was 79.2% (95% CI 72.3-86.1). In 41% of cases GMD were subclinical and 48.7% of patients had IR. Patients with T2DM had a higher number of variables with significant differences compared with the other groups (more marked compared to the patients without GMD). The only differences between the patients with T2DM and HD were hypercreatininemia: 1.14 ± 0.53 vs. 0.84 ± 0.22 mg/dL (p = 0.005) and family history of DM: 8 (32%) vs. 2 (7%) (p = 0.02). CONCLUSION: Almost 80% of patients with compensated LC had GMD. Half of them were subclinical. The patients with T2DM had marked clinical differences compared to patients from the other groups, particularly renal impairment.