Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.

Prevention or cure in times of crisis: the case of screening for colorectal cancer.

Colorectal cancer is a serious health problem in which screening is capable of reducing both the mortality and the incidence of the disorder. Colonoscopy, the mainstay of this type of screening, allows to establish an early diagnosis and also to eliminate malignant precursor lesions. The screening test which is performed in Spanish programs is the determination of fecal occult blood using the immunochemical method which gives around 70% of positive values for colonoscopy for any type of neoplasia. As a result, in 2009 the National Health System set as an objective that these programs cover 50% of the population by 2015. It is well known that colon screening is highly cost effective with a ratio of around 2500€ per QALY, much lower than ratios of other programs. Only the direct costs of colon and rectal cancer in Spain can be estimated at more than one thousand million euros per year. Early diagnosis and the cancers avoided thanks to screening can reduce these costs by 40%. The impact that the introduction of this screening has on health services can be lessened if the indications for colonoscopy are followed adequately. In conclusion, there is no justification for not acting to prevent CRC and this is especially so in times of crisis as there is no better social cost invested than that which saves suffering, deathsand even money.

Recognition and management of hereditary colorectal cancer syndromes.

Over 1,900 colorectal tumors will arise in association with a hereditary colorectal cancer syndrome in Spain in 2009. The genetic defects responsible for the most common syndromes have been discovered in recent years. Genetic testing helps diagnose affected individuals and allows identification of individuals at-risk. Colonoscopy and prophylactic colectomy decrease colorectal cancer incidence and overall mortality in patients with hereditary colon cancer. Extracolonic tumors are frequent in these syndromes, so specific surveillance strategies should be offered.

[Synchronous neoplastic lesions in colorectal cancer. An analysis of possible risk factors favouring presentation]. / Lesiones neoplásicas sincrónicas en el cáncer colorectal. Análisis de posibles factores que favorezcan su presentación.

AIM: few data have been published regarding the causes of synchronous lesions in patients with colorectal cancer. The aim of our study was to identify potential factors that might be implicated in the development of multicentric lesions, since this knowledge could be useful for tailored follow-up once initial synchronous lesions have been removed. METHODS: we retrospectively reviewed 382 colorectal cancer cases diagnosed by total colonoscopy and histological study of surgical specimens. We divided our population into 2 groups, based on whether they had synchronous lesions or otherwise. Several data related to personal and family history, habits, symptoms, and tumor characteristics were assessed. Univariate and multivariate statistical analyses were performed. RESULTS: 208 (54.5%) patients had synchronous adenomas and 28 (7.3%) had synchronous cancer. A multivariate analysis showed that the following parameters were consistently related to the presence of multicentric lesions--male gender: OR = 1.97; CI = 1.13-3.45; p = 0.017; age = 59 years: OR = 2.57; CI = 1.54-4.29; p < 0.001; personal history of colonic adenomas: OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructive tumors: OR = 0.48; CI = 0.27-0.85; p = 0.012. CONCLUSION: our results show that several parameters that are easy to measure could be considered risk factors for the development of multicentric lesions. These factors need to be confirmed with follow-up studies analyzing their role in patients with and without metachronic lesions once all synchronous lesions have been removed.

[Capsule endoscopy interpretation: the role of physician extenders]. / Interpretación de la cápsula endoscópica: el papel del personal no especializado.

BACKGROUND AND AIMS: capsule endoscopy (CE) allows for a new era in small-bowel examination. Nevertheless, physicians time for CE-interpretation remains longer than desirable. Alternative strategies to physicians have not been widely investigated. The aim of this study was to evaluate the accuracy of physician extenders in CE-interpretation. MATERIAL AND METHODS: one CE-experienced gastroenterologist and two physician extenders reviewed independently 20 CE-procedures. Each reader was blinded to the findings of their colleagues. A consensus formed by the readers and a second CE-experienced gastroenterologist was used as gold standard. Number, type and location of images selected, character of CE-exams and their relationship with indications were recorded. Gastric emptying time (GEt), small-bowel transit time (SBTt) and time spent by readers were also noted. RESULTS: sensitivity and specificity for "overall" lesions was 79 and 99% for the gastroenterologist; 86 and 43% for the nurse; and 80 and 57% for the resident. All 34 "major" lesions considered by consensus were found by the readers. Agreement between consensus and readers for images classification and procedures interpretation was good to excellent (? from 0.55 to 1). No significant differences were found in the GEt and SBTt obtained by consensus and readers. The gastroenterologist was faster than physician extenders (mean time spent was 51.9 +/- 13.5 minutes versus 62.2 +/- 19 and 60.9 +/- 17.1 for nurse and resident, respectively; p < 0.05). CONCLUSIONS: physician extenders could be the perfect complement to gastroenterologists for CE-interpretation but gastroenterologists should supervise their findings. Future cost-efficacy analyses are required to assess the benefits of this alternative.

[Analysis of possible influence of synchronous neoplastic lesions on prognosis of resected colorectal cancer]. / Análisis de la posible influencia de las lesiones sincrónicas en el pronóstico del cáncer colorrectal resecado.

AIM: To analyze the relationship between synchronous lesions in patients with colorectal cancer and their prognostic value. PATIENTS AND METHODS: We have retrospectively reviewed 369 patients with resected colorectal cancer. We compared the rate of apparently curative surgery, progression and tumoral relapse, development of extracolonic cancer and mortality between patients with and without synchronous cancer. Afterwards, we analyzed the same parameters in colorectal cancer with and without synchronous adenomas. Finally, we repeated the analysis after stratification of cancers in 2 groups according to pTNM staging: 0-I-II stage vs III-IV. RESULTS: We found synchronous adenomas in 54.7% of our patients and synchronous cancers in 7.6%. Follow-up period of groups with and without synchronous lesions were: 70.8 +/- 22.9 and 67.2 +/- 24.5 months (p = 0.55) respectively. Synchronous cancers showed higher mortality: 35.7 vs. 14.4%: p = 0.006; OR = 3.31 (1.33-8.13), higher tumoral progression : 39.3 vs. 19.1%: p = 0.011; OR = 2.75 (1.14-6.56) and higher relapse rate: 10.7 vs. 3.5%: p = 0.096. Stratifying according to stage, patients with stage 0-I-II and synchronous cancer showed worse prognosis: mortality = 27.7 vs. 8.1%, p = 0.019; OR = 4.45 (1.2-15.1), tumoral progression = 27.8 vs. 8.5%, p = 0.02; OR = 4.12 (1.14-14.19), and extracolonic cancer = 16.7 vs. 6.4% p = 0.095. There were no statistical differences between cases with and without synchronous adenomas. CONCLUSIONS: Synchronous cancers showed worse prognosis after resection, with higher rate of tumoral progression and mortality. This difference is focused on the cases diagnosed in stage 0-I-II, not being found in III-IV. The presence of synchronous adenomas doesn't influence prognosis.

[New applications of capsule endoscopy: PILLCAMTM ESO]. / Nuevas aplicaciones de la cápsula endoscópica: PILLCAM ESO.

Capsule endoscopy has opened a new era in small bowel examination. Its indications are now well-defined and currently, wireless capsule endoscopy is considered as the first-line imaging tool for the diagnosis of small bowel diseases. ECE has been shown to be feasible, safe and a good alternative technique in patients refusing conventional endoscopy. Although results reported in both GERD and cirrhotic patients are encouraging, great differences in terms of accuracy (particularly in GERD patients) have been found in published studies. These differences have been attributed to study designs, the lack of adequate experience and inconvenience of ingestion protocols. In summary, more large-scale studies evaluating the new 14-fps capsule, adequate ECE-experience and new modified ingestion protocols are still needed.

Superoxide dismutase in patients with chronic hepatitis C virus infection.

It has been reported that hepatitis C virus (HCV) may cause oxidative stress in infected cells. Patients with chronic hepatitis C exhibit an increased production of tumor necrosis factor-alpha (TNF alpha), a cytokine that can produce oxidative stress by stimulating the generation of reactive oxygen species (ROS). Cell defense against ROS includes overexpression of Mn-superoxide dismutase (SOD), an inducible mitochondrial enzyme. To investigate cell defense against oxidative stress in HCV infection, we analyzed Mn-SOD mRNA in liver and in peripheral blood mononuclear cells (PBMC) from patients with chronic hepatitis C. Mn-SOD expression in PBMC was significantly increased in patients with HCV infection. Patients with sustained virological and biochemical response after therapy showed significantly lower Mn-SOD than patients with positive viremia. By contrast, Mn-SOD expression was not enhanced in the liver of patients with chronic hepatitis C. The values of Mn-SOD mRNA did not correlate with TNF alpha mRNA expression, viral load, or liver disease activity. Our results indicate that in HCV infection an induction of Mn-SOD was present in PBMC but absent in the liver, suggesting that this organ could be less protected against oxidative damage. Oxidative stress could participate in the pathogenesis of HCV infection.

[Haptoglobin in the biological diagnosis of gastric cancer (author's transl)]. / La haptoglobina en el diagnóstico biológico del cáncer gástrico.

Serum haptoglobin has been determined in a series of 69 patients with metastatic and non-metastatic gastric cancer. In both circumstances a marked increase of haptoglobin levels in comparison to the results in the control group was observed. A significant decrease was noticed in the presence of liver metastasis. Total alpha 2-globulin levels were also high in this patients, but a significant decrease was not observed in cases with liver metastasis. There was no parallelism between the values of haptoglobin and total alpha 2-globulins. The usefulness of these results in the diagnosis and prognosis of gastric cancer is stressed. Radial immunodiffusion using immunoserum anti-haptoglobin 1-1 is the technique of choice.

[Dementia caused by bacterial overgrowth in a patient with Billroth II gastrectomy]. / Demencia por sobrecrecimiento bacteriano en paciente portador de gastrectomía Billroth II.

We report the case of a patient in the Psychiatric Department who complained of progressive impairment of cerebral functions consistent with dementia, diarrhea and fecal incontinence in the last few months. His medical history included a Billroth II gastrectomy for gastric ulcer. Biochemical tests detected cobalamin deficiency, without megaloblastic anemia, and an abnormal Schilling test that was not due to intrinsic factor deficiency. Once other causes of cobalamin deficiency were ruled out, we considered it as a deficiency disease due to blind loop syndrome. Treatment with parenteral vitamin B complex and long term oral antibiotic therapy allowed the complete and permanent resolution of neurologic and digestive symptoms. We consider this case to be interesting because it shows the existence of curable dementias and the usefulness of taking into account bacterial overgrowth, usually underestimated, as an entity that can produce a variety of disorders.

Collagenous colitis and lymphocytic colitis: clinical and endoscopic findings.

OBJECTIVE: collagenous colitis (CC) and lymphocytic colitis (LC) are two entities of unknown cause, characterized by chronic watery diarrhea, grossly normal-appearing colonic mucosa and abnormal histopathological findings in colonic biopsies. The clinical features of the disease are based mainly on case reports or small uncontrolled series. Although normal colonoscopic findings are, as a rule, part of the diagnosis of CC, several cases of macroscopic colitis associated with CC have been reported, and the spectrum of endoscopic mucosal changes has not been described in large series. METHODS: we present a retrospective study of all patients who underwent total colonoscopy and mucosal biopsy in our Endoscopy Unit between 1991 and 1997. Clinical and endoscopic findings in patients diagnosed as having CC or LC were recorded. RESULTS: of 676 patients studied, 398 suffered from chronic diarrhea. Collagenous colitis was diagnosed in 22 patients and LC in 10. Eleven per cent of the patients with CC and 20% of those with LC did not have diarrhea. Macroscopic colitis was observed in 6 out of 22 patients with CC (27%) and in 4 out of 10 with LC (40%). Macroscopic lesions included edema, erythema, abnormal vascular pattern, superficial erosions or ulcerations and hemorrhagic lacerations. In this series 7.03% of the patients with chronic diarrhea were diagnosed as having CC or LC. CONCLUSIONS: collagenous colitis and LC are two entities that should be considered in the differential diagnosis of chronic diarrhea. Total colonoscopy with multiple biopsies that include the right colon are mandatory. The presence of macroscopic lesions on endoscopy does not rule out a diagnosis of either entity. We identified patients who fulfilled the histopathological criteria for CC or LC but who did not have diarrhea.

[Colonic involvement in the Klippel-Trenaunay-Weber syndrome]. / Afectación de colon en el síndrome de Klippel Trenaunay Weber.

We report the case of a 12-year-old boy, diagnosed of Klippel Trenaunay Weber syndrome, with hemangiomas and venous varicosities in the right leg, who complaint about incidental hematochezia. In the colonoscopy some violet and plain angiodysplastic lesions like in the skin, were observed in rectum and distal sigmoid colon. We think this case is interesting, because of the unusual affectation of the gut in this disease and the importance of considering the endoscopic procedures in the evaluation of these patients.

[Utility of endoscopy in digestive hemorrhage due to vasculitis]. / Utilidad de la endoscopia en la hemorragia digestiva por vasculitis.

Vasculitides constitute a heterogeneous group of diseases characterized by inflammation of blood vessels. The skin is mainly affected, although the gastrointestinal tract mucosa can also be involved. The contribution of endoscopy in these cases has not been clearly determined. We report three cases of systemic vasculitis (polyarteritis nodosa, Schonlein-Henoch purpura and Behcet's disease) presenting with acute digestive bleeding. Endoscopy was an effective technique for completing the diagnosis and in establishing an effective nonsurgical therapeutic approach in these potentially lethal cases of gastrointestinal hemorrhage.

[Barrett's esophagus]. / Esófago de Barrett.

Barrett's esophagus (BE), a complication of gastroesophageal reflux disease, is the replacement of squamous tissue with specialized intestinal metaplasia. Other noxious factor, as biliary acids, may contribute to the induction of BE. It is a premalignant condition, and adenocarcinoma arises in some cases. An endoscopic surveillance with multiple biopsies is mandatory to detect different grades of dysplasia or intramucosal cancer and allow effective therapy. Since its prevalence is high, current surveillance protocols become expensive and patient's compliance is difficult. The main medical goals are: 1) To stratify individuals without dysplasia as either lower or higher risk, to screen less often those at lower risk. 2) To obtain complete remission or eliminate the risk of cancer and the need for surveillance. Current treatments have not demonstrate complete regression of metaplasia. Recently, new endoscopic approaches to therapy have been developed. Although they remain experimental and larger series are required, initial results are encouraging.

Short- and long-term changes in gastric morphology and histopathology following sleeve gastrectomy in diet-induced obese rats.

BACKGROUND: Sleeve gastrectomy (SG) has been used as a multipurpose surgical procedure for the treatment of morbid obesity. The aim of the study was to analyze gastric morphology and histology at two different time points after SG in rats. METHODS: Thirty-five male Wistar rats were fed ad libitum during 3 months on a high-fat diet to induce obesity. Subsequently, 25 diet-induced obese rats underwent either SG (n = 12) or a sham operation (n = 13). The remaining ten obese animals encompassed the nonoperated control group (Co). Four weeks postoperatively, 15 rats (n = 5 rats/experimental group) were sacrificed, while the remaining 20 rats were sacrificed after 16 weeks (animals/group; Co = 5, sham = 8, SG = 7) to compare the gastric morphological and histopathological changes over time. Body weight and food intake were regularly recorded. RESULTS: For both time periods, the Co groups exhibited the highest body weight, while the rats undergoing the SG showed the lowest weight gain (P < 0.05). Initially, significant differences (P < 0.005) in food intake relative to body weight were observed between the Co rats and animals undergoing surgery, which disappeared thereafter. The actual total stomach size after both experimental periods in the SG group was similar to that of non- and sham-operated rats mainly due to a forestomach enlargement, which was more pronounced after 16 weeks. Traits of gastritis cystica profunda characterized by gastric foveolae elongation with hyperplasia and cystic dilatation of the glands were observed in the residual stomachs of the sleeve-gastrectomized rats. These findings were mostly observed after 16 weeks of performing the SG, although they were also detected occasionally following 4 weeks postoperatively. No intestinal metaplasia was observed. CONCLUSION: After SG gastric macro- and microscopic changes with functional implications in both the short and long term take place.