How to improve the diagnosis of eosinophilic esophagitis: Experience from a case series in Mexico. / Cómo mejorar el diagnóstico de esofagitis eosinofílica: experiencia de una serie de casos en México.

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic, immune disorder mediated largely by food antigens. It shares nonspecific symptoms with gastroesophageal reflux disease (GERD). EoE is rarely reported in Mexico, perhaps due to the racial characteristics of the population or because of insufficient diagnostic suspicion. AIMS: Our aim was to describe a Mexican cohort with EoE and evaluate the usefulness of the clinical history and endoscopy in the EoE diagnosis, in comparison with GERD patients. MATERIALS AND METHODS: A retrospective study was carried out on the clinical characteristics and endoscopic and histopathologic findings in patients with EoE, along with a case-control study on patients with GERD. The endoscopic images obtained were interpreted in a blind and randomized manner by 4 gastroenterologists, before and after providing them with information on the characteristic alterations of EoE. The esophageal biopsies were also blinded to 2 pathologists that evaluated their diagnostic correlation. The Fisher's exact test and Mann-Whitney U test were used in the statistical analysis. RESULTS: Fourteen patients with EoE were included in the study. Ten (71%) of them were men and the mean age of the patients was 35 years. There were more subjects with a personal history of asthma (p=0.0023) and food impaction (p=0.04) in the EoE group. The initial evaluation of the endoscopic findings showed 53% correct EoE interpretations and rose to 96% in the second revision (sensitivity 100%, specificity 71%, PPV 65%, NPV 100%). CONCLUSIONS: Mexican patients with EoE have similar characteristics to those of patients in western case series. Clinical awareness of the disorder increases endoscopic diagnosis in up to 40% of cases.

The Mexican consensus on nonalcoholic fatty liver disease. / Consenso mexicano de la enfermedad por hígado graso no alcohólico.

Nonalcoholic fatty liver disease (NAFLD) affects nearly one third of the population worldwide. Mexico is one of the countries whose population has several risk factors for the disease and its prevalence could surpass 50%. If immediate action is not taken to counteract what is now considered a national health problem, the medium-term panorama will be very bleak. This serious situation prompted the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología to produce the Mexican Consensus on Fatty Liver Disease. It is an up-to-date and detailed review of the epidemiology, pathophysiology, clinical forms, diagnosis, and treatment of the disease, whose aim is to provide the Mexican physician with a useful tool for the prevention and management of nonalcoholic fatty liver disease.

[Peptic ulcer and Helicobacter pyrlori. Results and consequences of its eradication]. / Ulcera péptica y Helicobacter pylori. Resultados y consecuencias de su erradicación.

Helicobacter pylori (Hp) a known pathogen of peptic ulcer disease (PUD), causes more than 90% of them when non steroidal anti-inflammatory agents (NSAID) are excluded. Prevalence of Hp is greater than 70% within some underdeveloped societies, but yet less than 1% suffer PUD. Such selectivity has been attributed to pathogenic differences of diverse Hp strains, their relative proportion in a given patient, but also to genetic host factors that favors colonization and different immunologic responses that end up in PUD in some, while gastritis is the only consequence in others. Other pathophysiologic factors, independent of Hp such as acid hypersecretion or duodenal bicarbonate hyposecretion may interplay with Hp to provoke PUD. Pepsinogen I levels are better predictors of PUD than Hp is in a given individual. PUD recurrence is less than 2% per year, although some controversies prevail whether Hp should be eradicated in patients requiring NSAID, since eradication does not prevent PUD, does not improves healing of existing ulcers nor decreases risk of bleeding. Even though, bleeding recurrence is less frequent when Hp has been treated. Prevalence of Hp is quite similar in bleeding PUD to that of general population of a given geographic area, Hp it is not a risk factor for this complication. Hp eradication in PUD causes reflux esophagitis in 25% of patients, and reflux medical control is far more difficult. Even worse hypergastrinemia produced by antisecretory agents is further increased under Hp infection, and their use over 1 year is accompanied by ECL hyperplasia in 30% of them. Thus Hp interplay and consequences are diverse and complex. Their knowledge is needed for proper selection of patients that need eradication.

[Therapeutic endoscopy in portal hypertension. When, how and how far in 1998]. / Endoscopia terapéutica en hipertensión portal. Cuándo, con qué y hasta dónde en 1998.

Portal hypertension hemorrhage (PHH) due to esophageal varices (EV) rupture in nearly 80% of cases, or gastric varices (GV) in the remaining 20%, account for one-fifth of the GI tract bleedings in a general hospital. Its frequency, but more importantly, its magnitude, that causes up to one-third of the cirrhotic casualties, deserves constant update in its management. Diverse inherent patient factors influence the course of any PHH, i.e., a) remaining liver function, which is determinant; b) variceal size; c) sepsis, and d) alcohol intake. Mortality due to PHH is 27% during the first week, 41% within 6 weeks and 75% by one year of follow-up after the index hemorrhage. Time of intervention is then of utmost importance. All these key circumstances determine the ultimate course of the bleeding event, in many cases to a greater degree than the opportunity and quality of the specific treatment itself. This diversity of influential factors also jeopardizes adequate patient randomization in trials designed to compare treatment modalities. During the last decade, EV sclerosis, when compared to conventional medical treatment (non-beta blockers), has proved useful to stop active bleeding in 71 vs. 31% of cases, decreasing early and late recurrence from 70 to 40%, and direct bleeding-related mortality from 24 to 9%, even when global mortality remains around 14% per year. Disappointing as it seems, remaining liver function is the determinant issue, but a biased underestimation factor may also play a role, due to greater surgical rescue of patients in the medical branch compared to EV sclerosis, 6 vs. 28%. Minor morbidity in 14% of sclerosis treatment has given way to endoscopic ligation with similar results and less morbidity. Prophylactic EV sclerosis was prohibited by prospective controlled trials, which demonstrated significant increase in bleeding and mortality, even though there might be a subgroup of patients with large varices or endoscopic prognostic signs of bleeding that decrease by 10% their incidence expected 35%/year bleeding. GV bleeding remains a challenge; where cyanoacrylate may be needed to improve immediate control and prevent recurrence of PHH. These patients, as well as those failures to endoscopic treatment are candidates for intrahepatic portosystemic shunt (TIPS), although long-lasting control is achieved, in most cases, by liver transplant.