Predictive factors for post-ERCP bleeding. Influence of direct oral anticoagulants.

INTRODUCTION: there is a rising number of patients receiving antiplatelet and anticoagulation therapy who require endoscopic retrograde cholangiopancreatography (ERCP), probably due to the increased morbidity of older patients. Considering the increasing use of direct oral anticoagulants (DOACs), this study aimed to determine the influence of these factors on the possibility of hemorrhage after ERCP in our center. MATERIAL AND METHODS: data were collected from all the examinations carried out in 2017 and 2018, which included 797 examinations on 588 patients. Collected data included personal history of the patients, results of the test and follow-up. RESULTS: the percentage of post-ERCP bleeding was 4.6 % (n = 37). With regard to the severity, the bleeding was mild in 21.6 % (n = 8) of the cases, moderate in 59.5 % (n = 22) and severe in 18.9 % (n = 7). Previous cardiopathy antiplatelet therapy, anticoagulation therapy, treatment with DOACs, having a pancreatic stent and lithiasis removal doubled the risk of bleeding after ERCP. Having a sphincterotomy increased the risk by over five-fold. CONCLUSION: according to the multivariate analysis, a statistically significant increase of bleeding among patients treated with DOACs was observed compared to patients who received anticoagulation with acenocoumarol or low-molecular-weight heparins (LMWH).

Endoscopic ultrasound-guided choledochoduodenostomy after a failed or impossible ERCP.

INTRODUCTION: endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to percutaneous trans-hepatic biliary drainage (PTBD) in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). METHODS: this is a retrospective description of six cases of endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy (EUCD), as well as the clinical characteristics, endoscopic procedure, complications and monitoring. RESULTS: all cases had malignant distal biliary obstruction. The procedure was concluded with good drainage in four out of six patients. Two late complications were recorded that were caused by stent migration and there were no deaths related with the procedure. The average monitoring period was six months. CONCLUSIONS: EUCD can be considered as a valid therapeutic choice in some selected cases and when performed by a team of expert endoscopists in cases of failed ERCP drainage or as an alternative to PTBD. However, the procedure has some associated complications.

Long-term results of linaclotide in the treatment of constipation-type irritable bowel syndrome.

BACKGROUND: constipation-predominant irritable bowel syndrome (C-IBS) is a prevalent, complex and multifactorial disorder that represents a challenge in terms of diagnosis and therapeutic management. OBJECTIVE: to evaluate the effectiveness, safety and treatment satisfaction of linaclotide in C-IBS patients. METHODS: prospective, single-center and observational study conducted in patients diagnosed with C-IBS. The patients were treated with linaclotide (Constella®, Allergan Inc., Irvine, CA), once-daily via an oral capsule of 290-µg, 30 minutes before breakfast. The primary effectiveness endpoint was the number of bowel movements per week. The secondary endpoints included treatment satisfaction and changes from baseline in frequency and severity of symptoms (abdominal pain and bloating). This was assessed via an 11-point visual analog scale (VAS) reported by the patients in a daily register. RESULTS: thirty female patients were consecutively included. The median follow-up time was 18 months. The mean (standard deviation [SD]) number of weekly bowel movements significantly increased from 0.9 (0.6) at baseline to 4.7 (3.9) at the end of follow-up, p < 0.0001. Abdominal pain significantly decreased from 5.7 (2.3) at baseline to 3.1 (2.8) at the end of the follow-up period, p < 0.0001. Similarly, bloating significantly decreased from 6.8 (1.6) to 2.9 (2.5) at the beginning and end of the treatment period, respectively, p < 0.0001. The mean (SD) degree of satisfaction at the end of the study was 6.7 (3.0). CONCLUSIONS: long-term linaclotide treatment in patients with C-IBS is effective and safe in the clinical setting.

Perivascular epithelioid cell tumor of the ileum. A case report.

Perivascular epithelioid cell tumors (PEComa) are tumors of perivascular epithelioid cells with immunohistochemical features of smooth muscle and melanocytic tumors. The PEComa of the gastrointestinal tract is rare. The treatment is surgical, although there are data that suggest a good response to rapamycin.

Increasing incidence of colorectal cancer in the province of Salamanca. Comparison of two periods: 2004-2006 and 2010-2012.

OBJECTIVES: To compare incidence, mortality and epidemiological characteristics of patients diagnosed with colorectal cancer (CRC) in the province of Salamanca over two different periods: 2010-2012 and 2004-2006. METHODS: Retrospective observational study. We include all diagnosed cases of CRC according to histopathological criteria from 01/01/2004 to 31/12/2006 and from 01/01/2010 to 31/12/2012. The studied variables were sex, age, date of diagnosis and tumor location. Cumulative incidence and specific incidence in different age groups were measured and compared between the two periods. The age rates were adjusted to the standard world population so that the results could be compared with those of other populations. RESULTS: We detected 38% more cases of CRC in the 2010-2012 period than in 2004-2006. Variables distribution (sex, age at diagnosis and location) was similar in both groups. More than twice as many colonoscopies were performed in 2010-2012 than in 2004-2006. Population mortality due to CRC also increased, although much less importantly than the incidence of this condition. CONCLUSIONS: There has been a clear increase in CRC incidence in the province of Salamanca from 2004-2006 to 2010-2012 which is not related to the ageing of the population. The remarkable increase in colonoscopies may have been an important factor for the increased detection.

Endoscopic treatment of duodenal varices with cyanoacrylate.

BACKGROUND: the duodenum is the most common location for ectopic varices. Bleeding is rare, but when it appears, it is massive and difficult to control. MATERIAL AND METHODS: retrospective description of five clinical cases of digestive bleeding secondary to duodenal varices that we observed between the years 2011 and 2012, together with their clinical characteristics, endoscopic diagnosis, endoscopic treatment with cyanoacrylate injection and the posterior follow-up and assessment of new bleeding. RESULTS: all five patients were treated with an endoscopic cyanoacrylate injection and two of the patients experienced a digestive rebleeding. Three of the patients died during the follow-up period, only one due to cause digestive bleeding. CONCLUSION: in conclusion we can state that endoscopic treatment of duodenal varices with cyanoacrylate is technically possible, and it permits us to control the first bleeding before doing other definitive treatments, if the patient condition allows it.

Endoscopic evaluation and histological findings in graft-versus-host disease.

BACKGROUND: the gastrointestinal (GI) tract is the major target site of the graft-versus-host disease (GVHD). Diagnosis is based on endoscopic and histological findings. MATERIAL AND METHODS: we performed a retrospective study from January 1st, 1990 to December 31st, 2008 on 338 upper gastrointestinal endoscopies (gastroscopies) performed to 197 patients that underwent an allogeneic transplant with clinical suspicion of GI-GVHD. RESULTS: endoscopic findings to the diagnosis of GVHD have a sensitivity (S) of 34%, specificity levels (SP) of 65%, a positive predictive value (PPV) of 73% and a negative predictive value (NPV) of 48%. The histological study of the endoscopic biopsies has a global sensibility of 85.6% SP = 34.6% PPV = 64.2% and NPV = 63.7%. Histological grade was correlated with the clinical grade of acute GVHD (p = 0.018). CONCLUSION: upper gastrointestinal endoscopy is useful for the diagnosis of GVHD, as it allows biopsies that can ultimately lead to the diagnosis, but with limited accuracy because the histological findings have low sensitivity and specificity, while the endoscopic findings are generally nonspecific.

Helicobacter pylori infection and graft-versus-host disease.

The gastrointestinal (GI) tract is the main target site of graft-versus-host disease (GVHD). Diagnosis is based on endoscopic and histological findings. Helicobacter pylori (HP) is a Gram-negative spiral bacterium linked to gastritis, peptic ulcer disease, gastric mucosa-associated lymphoid tissue lymphoma, and adenocarcinoma and is frequently observed on endoscopy in patients who have undergone transplantation. The role, if any, played by HP infection in the development of acute GVHD is unknown. We conducted a retrospective study between January 1, 1990, and December 31, 2008, of 338 upper GI endoscopies (gastroscopies) performed on patients who underwent allogeneic stem cell transplantation with clinical suspicion of GVHD (198 patients). Acute and chronic GVHD were confirmed from histological features in 97 patients (51.3%) and 68 patients (36%), respectively. HP infection was detected in 69 patients (35%) and had a negative modulating effect on the development of acute GVHD (relative risk [RR], 0.60; 95% confidence interval, 0.46-0.79; P = .001) and chronic GVHD (RR, 0.75; 95% confidence interval, 0.61-0.92; P = .016). Furthermore, the presence of HP was inversely correlated with the histological severity of GVHD (P = .003). Our findings suggest that infection with HP may have a negative modulating effect on GVHD.

[Autoimmune enteropathy in an adult patient]. / Enteropatía autoinmune en un paciente adulto.

Autoimmune enteropathy (AIE) is an infrequent cause of malabsorption that is usually associated with the presence of circulating autoantibodies and a predisposition to autoimmune disorders. This disease is more frequent in children. The diagnosis of this disorder is based on five criteria: chronic diarrhea (>6 weeks), malabsorption, specific histological findings, exclusion of similar disorders, and the presence of specific antibodies such as anti-enterocyte and anti-goblet cell antibodies. We present the case of a 63-year-old patient with chronic diarrhea, weight loss and significant deterioration of nutritional status.

[Emphysematous pancreatitis: Conservative or surgical treatment?]. / Pancreatitis enfisematosa. ¿Tratamiento conservador o quirúrgico?

Emphysematous pancreatitis is a severe and rare complication of acute pancreatitis. This entity is diagnosed on clinical grounds and on the basis of the radiologic finding of gas in the retroperitoneum. Infected pancreatic necrosis is potentially lethal, with mortality rates of more than 35%. Surgery is associated with significant morbidity and mortality in these critically ill patients. Endoscopic ultrasonography techniques, laparoscopic surgery and percutaneous drainage have the potential to offer a safe and effective alternative treatment modality. However, the precise role of these procedures requires further investigation. The treatment of these patients should be individualized, dynamic and multidisciplinary. We present two cases of emphysematous pancreatitis with distinct therapeutic management.

Ustekinumab for the Treatment of Refractory Crohn's Disease: The Spanish Experience in a Large Multicentre Open-label Cohort.

BACKGROUND: Ustekinumab is a fully human monoclonal antibody against IL-12/23. Ustekinumab induced clinical response and maintained higher rate of response than placebo in patients with Crohn's disease (CD). This study aims to assess the effectiveness and safety of ustekinumab in refractory patients with CD in real-life practice. METHODS: Consecutive patients with CD who were treated with subcutaneous ustekinumab between March 2010 and December 2014 were retrospectively included in a multicenter open-label study. Clinical response was defined by Harvey-Bradshaw index score and assessed after the loading doses, 6, 12 months, and last follow-up. RESULTS: One hundred sixteen patients were included, with a median follow-up of 10 months (interquartile range: 5-21). Clinical response after loading ustekinumab was achieved in 97/116 (84%) patients. The clinical benefit at 6, 12 months, and at the end of the follow-up was 76%, 64%, and 58%, respectively. Dose escalation was effective in 8 of 11 (73%) patients. Perianal disease also improved in 11 of 18 (61%) patients with active perianal fistulae. The initial response to ustekinumab and previous use of more than 2 immunosuppressant drugs were associated with a clinical response to ustekinumab maintenance therapy. In contrast, previous bowel resection predicted a long-term failure with ustekinumab. Adverse events were reported in 11 (9.5%) patients, but none required ustekinumab withdrawal. CONCLUSIONS: Subcutaneous ustekinumab is effective and safe in a high proportion of patients with CD that were resistant to conventional immunosuppressant and antitumor necrosis factor drugs.

Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion.

AIM: To analyze the effectiveness of the endoscopic therapy and to identify prognostic factors for recurrent bleeding. METHODS: Retrospective study of patients with gastrointestinal bleeding secondary to Dieulafoy's lesion (DL) from 2005 to 2011. We analyzed the demographic characteristics of the patients, risk factors for gastrointestinal bleeding, endoscopic findings, characteristics of the endoscopic treatment, and the recurrence of bleeding. We included cases in which endoscopy described a lesion compatible with Dieulafoy. We excluded patients who had potentially bleeding lesions such as angiodysplasia in other areas or had undergone other gastrointestinal endoscopic procedures. RESULTS: Twenty-nine patients with DL were identified. Most of them were men with an average age of 71.5 years. Fifty-five percent of the patients received antiaggregatory or anticoagulant therapy. The most common location for DL was the stomach (51.7%). The main type of bleeding was oozing in 65.5% of cases. In 27.6% of cases, there was arterial (spurting) bleeding, and 6.9% of the patients presented with an adherent clot. A single endoscopic treatment was applied to nine patients (31%); eight of them with adrenaline and one with argon, while 69% of the patients received combined treatment. Six patients (20.7%) presented with recurrent bleeding at a median of 4 d after endoscopy (interquartile range = 97.75). Within these six patients, the new endoscopic treatment obtained a therapeutic success of 100%. The presence of arterial bleeding at endoscopy was associated with a higher recurrence rate for bleeding (50% vs 33.3% for other type of bleeding) [P = 0.024, odds ratio (OR) = 8.5, 95% CI = 1.13-63.87]. The use of combined endoscopic treatment prevented the recurrence of bleeding (10% vs 44.4% of single treatment) (P = 0.034, OR = 0.14, 95% CI = 0.19-0.99). CONCLUSION: Endoscopic treatment of DL is safe and effective. Adrenaline monotherapy and arterial (spurting) bleeding are associated with a high rate of bleeding recurrence.