Cardiorespiratory complications directly related to endoscopy: associated or not with sedation?

With the advent of routine sedation in digestive endoscopy, specifically the use of propofol, multiple reports have focused on the complications that may potentially emerge because of sedation, and whether administration is safer by anesthetists or trained gastroenterologists. Complications associated with endoscopy itself, whether diagnostic or therapeutic, have also been described. However, the fact that both upper and lower endoscopy per se may be accompanied by complications, both during the procedure or thereafter, is usually overlooked.

Gastric ulcers with upper gastrointestinal bleeding in patients with severe SARS-CoV-2.

A new coronavirus, SARS-CoV-2, was identified earlier this year and spread rapidly globally. The clinical manifestations that it produces have gradually become known and the typical clinical picture is respiratory. Although gastrointestinal symptoms have been described in several communications, information on endoscopic findings in these patients is practically zero. We describe two cases of upper gastrointestinal bleeding in patients with COVID-19. In both cases, the presence of gastric ulcers was identified in an unusual location, the gastric fundus. After ruling out malignancy, our suspicion was an ischemic etiology that is consistent with terminal gastric vascularization at the gastric fundus level and increased thrombotic phenomena in patients with COVID-19.

Gastrointestinal lesions in chronic kidney disease patients with anaemia. / Lesiones gastrointestinales en pacientes con enfermedad renal crónica y anemia.

INTRODUCTION: Despite the frequency with which anaemia is present in patients with chronic kidney disease (CKD), its relationship with gastrointestinal lesions has not been studied. METHOD: A cross-sectional, analytical, observational study involving one year of recruitment was carried out to determine the prevalence of endoscopic gastrointestinal lesions and associated risk factors in asymptomatic patients with chronic kidney disease stages 1-5 and anaemia who had a positive qualitative immunochemical faecal occult blood test. RESULTS: A total of 9,658 patients with CKD were analysed, of which 286 (2.9%) had anaemia; 198 had a positive faecal occult blood test (47% male, 71.1±11.8 years). The endoscopic study revealed 255 lesions, with at least one lesion in 68.2% of patients, with the most prevalent being: adenomatous colorectal polyps (39.6%), acute lesions of the gastric mucosa (22.6%), neoplastic lesions 15.1%), angiodysplasia (14.4%), oesophagitis (8.4%), inflammatory bowel disease (4.8%) and ischaemic colitis (3.1%). Uraemia and acetylsalicylic acid were identified as risk factors for acute gastric mucosal lesions. Angiodysplasia was associated with alcoholism, a more advanced stage of chronic kidney disease, anaemia, and lack of response to erythropoiesis-stimulating agents. Age and refractory anaemia were risk factors for adenomatous polyps and colorectal cancer. CONCLUSION: Renal patients with anaemia could benefit from an endoscopic study due to their high prevalence of gastrointestinal lesions, particularly adenomatous polyps and colorectal cancer, which are more common in those over 50 years of age with CKD stages 3-5.

Economic evaluation of endoscopic radiofrequency ablation for the treatment of dysplastic Barrett's esophagus in Spain.

BACKGROUND AND STUDY AIMS: To assess the cost-effectiveness of introducing endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection in selected patients into the standard of care of Barrett's esophagus patients with high-grade dysplasia or low-grade dysplasia in Spain. METHODS: The disease evolution was modeled via a semi-Markov model. The treatment strategies compared included endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection and the Standard of Care (esophagectomy or palliative chemoradiotherapy according to disease status for high-grade dysplasia and endoscopic surveillance for low-grade dysplasia). Efficacy rates, transition probabilities and utility values were obtained from the literature. Clinical management patterns and resource use were modeled according to Spanish clinical expert opinion. Costs were expressed in euros (€) from 2016 reflecting the Spanish National Health System perspective. Sensitivity analyses were performed to assess the robustness of the model. RESULTS: With respect to the Spanish Standard of Care, endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection was a dominant strategy for high-grade dysplasia patients. When a willingness-to-pay threshold of €30,000 per quality-adjusted life-years gained was considered, this was cost-effective for low-grade dysplasia patients (€12,865 per quality-adjusted life-years gained). The sensitivity analyses supported the base case analysis results and pointed towards the main drivers of uncertainty in the model. CONCLUSIONS: From a health care decision-maker, endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection is the intervention of choice for dysplasic Barrett's esophagus patients in Spain.

Predominio del gen de la hemocromatosis en pacientes con hepatitis tóxicas / HFE genotype prevalence in patients with drug-induced hepatotoxicity

La toxicidad hepática por fármacos y su mecanismo han sido durante mucho tiempo desconocidos. Se ha observado que los pacientes con hepatitis aguda elevan los niveles séricos de ferritina. El objetivo de este estudio es determinar si existe una asociación de hepatotoxicidad por medicamentos y las mutaciones en el gen HFE asociadas con la hemocromatosis hereditaria. Material y métodos: Se analizaron10 pacientes ingresados en nuestro hospital con el diagnóstico de hepatitis aguda inducida por fármacos. A todos se les hicieron pruebas de laboratorio para el estudio de enfermedades hepáticas, la mutación del gen HFE y las características histopatológicas. Resultados: Un paciente con hepatitis secundaria a fármacos era heterocigoto para la mutación C282Y y uno heterocigoto para las mutaciones C282Y y H63D. Hubo un paciente homocigoto para la mutación H63D y seis fueron heterocigotos para la mutación H63D. La prevalencia general de las mutaciones del gen HFE en pacientes con enfermedad hepática inducida por fármacos fue del 90%. Conclusiones: La prevalencia de las mutaciones del gen HFE asociadas con hemocromatosis hereditaria está muy aumentada entre los pacientes que presentan hepatotoxicidad por medicamentos. Las mutaciones del gen HFE podrían estar involucradas en la hepatotoxicidad por fármacos...

ERCP during pregnancy.

BACKGROUND AND AIMS: ERCP during pregnancy is always challenging for the entire team performing the endoscopic intervention. In this study techniques and different interventional aspects used at several centres about the clinical experience on ERCP in pregnant women are analyzed. PATIENTS AND METHODS: the practice on ERCP in pregnant women in six centres during a period of ten years is reported. RESULTS: eleven patients were included in the study. Mean age was 30.6 years. Indication for ERCP was always symptomatic common bile duct stone (CBDS) disease. Before the procedure abdominal ultrasound was performed at all times and magnetic resonance cholangiopancreatography in four occasions. Conscious sedation by means of midazolam and fentanyl or meperidine was applied. Sphincterotomes and guidewires were used for bilary cannulation. Sometimes, rapid exchange platforms with short-length guidewires controlled by the same endoscopist were employed. Biliary cannulation was confirmed in 9 occasions by bile aspiration. In five procedures, a mean of 30 seconds of fluoroscopy was used, both to verify cannulation and to corroborate complete CBDS clearance. These patients had the pelvic zone protected with a lead shield and radiation dose was measured. Ten biliary sphincterotomies were performed followed by CBDS extraction. Two plastic stents were inserted. Relief of biliary obstruction was attained in all circumstances. Only one patient had hyperamylasemia after ERCP. All pregnant women had healthy foetuses with normal deliveries. CONCLUSIONS: with experience, ERCP appears to be a safe technique during pregnancy. With simple measures fluoroscopic time can be diminished or even abolished. It seems that ERCP during pregnancy is underused in our working areas, although it has shown to be a useful technique for relieving biliary obstruction.

Antral localization worsens the efficacy of enteral stents in malignant digestive tumors.

BACKGROUND AND AIMS: Malignant gastric outlet obstruction can be treated by means of enteral stenting or surgical gastrojejunalanatomosis. We evaluated in a prospective and multicentre study the efficacy of the enteral stent on food intake, the quality of life impact, and the relationship between efficacy and determined clinical and technical parameters. PATIENTS AND METHODS: Seventy one patients affected by symptoms arising from gastroduodenal obstruction due to malignant tumors, with criteria of irresecability, metastatic disease or very high surgical risk, were treated by means of self expanding metal stents. We used the GOOSS index to evaluate efficacy, and the Euro Qol-5D index to evaluate quality of life. RESULTS: Before stenting patients with GOOSS 0 and 1 were 68 (98.5%). After stenting patients with GOOSS 2 and 3 (semisolid and solid food) were 58 (84,1%) (P<.0001). The Euro Qol-5D index measured before and a month after stenting were 10.17 and 10.04 respectively (P=.6). The median survival was 91 days (9-552). The enteral stents for localised tumors in the duodenum and the gastrojejunalanastomosis were effective in 26 patients (70.2%) and 13 patients respectively (86.6%), while the enteral stents of tumors in the antrum were effective in only 5 patients (29.4%). CONCLUSIONS: The palliative treatment of malignant gastric outlet obstruction with a uncovered metal stent produces a significant improvement of oral food intake and maintains the overall quality of life index. The antral localization is associated with a lower efficacy of the procedure.

[Reversibility of hepatitis B virus-induced liver cirrhosis after prolonged antiviral therapy]. / Desaparición de cirrosis hepática por VHB tras tratamiento prolongado con antivirales.

Reversibility of liver fibrosis or cirrhosis involves complete restoration of normal liver architecture. This phenomenon has been well documented in chronic liver diseases such as autoimmune hepatitis, biliary obstruction, hemochromatosis, nonalcoholic steatohepatitis, and viral hepatitis. There are very few reports of reversal of cirrhosis after antiviral therapy in patients with chronic hepatitis B virus (HBV) infection. We report a case of disappearance of HBV-induced liver cirrhosis after years of treatment with distinct antiviral drugs, documented by successive biopsy results. This disappearance was accompanied by normalization of platelet count, gammaglobulin titers, and radiologic findings.

[Effect of Helicobacter pylori eradication on iron deficiency anemia of unknown origin]. / Efecto de la erradicación de Helicobacter pylori en la anemia ferropénica de origen incierto.

UNLABELLED: Iron deficiency anemia of unknown origin is a frequent cause of anemia in which etiological diagnosis is often not achieved, despite currently available diagnostic techniques. Recent studies suggest that, in the absence of digestive tract lesions, Helicobacter pylori infection could be the cause of iron deficiency anemia, due to the alterations produced in gastric iron absorption. OBJECTIVES: To evaluate whether H. pylori eradication resolves iron deficiency anemia and removes the need for oral iron administration. PATIENTS AND METHODS: We performed an observational descriptive study in patients with iron deficiency anemia refractory to treatment with oral iron administration and with out causes that could explain their anemia. Gastroscopy, ileocolonoscopy, intestinal transit study and/or endoscopic capsule were performed. Female patients also underwent gynecological study. All patients were H. pylori-positive and standard eradication therapy was administered until elimination was achieved. The patients were followed-up for a minimum of 3 months after H. pylori eradication and the need for oral iron intake after eradication was evaluated. RESULTS: Ten patients, aged 53+/-8.2 years, were included. Hemoglobin (Hbg) before treatment was 10.06+/-0.53 mg/dl, mean corpuscular volume (MCV) was 75.43+/-6.02 fl and ferritin was 6.1+/-3.28 ng/ml. Eradication therapy was administered until elimination of H. pylori. The mean time before disappearance of anemia was 4.5 months. Laboratory parameters after treatment were as follows: Hgb 12.86+/-0.75 mg/dl, MCV 85.02+/-4.8 fl and ferritin 28+/-22.19 ng/dl. CONCLUSIONS: In the absence of lesions that could explain iron deficiency anemia, this disease can be related to H. pylori infection. Eradication of this infection is closely followed by disappearance of anemia and ferropenia.

Use of self-expanding metal stents to treat malignant colorectal obstruction in general endoscopic practice (with videos).

BACKGROUND: Self-expanding metal stents (SEMS) are being increasingly used to solve malignant colorectal obstruction (MCRO). Patients can then either undergo scheduled surgery or have the stent left in place as a definitive palliative treatment. The majority of reports on the use of SEMS in MCRO come from single centers; therefore, its use in general endoscopic practice is not clearly known. OBJECTIVE: To study the use of SEMS for MCRO in a wide endoscopic practice. DESIGN: Retrospective study. SETTING: A survey was carried out among endoscopists in 13 hospitals in Spain (6 tertiary referral centers and 7 community hospitals). PATIENTS: Those who presented with MCRO. INTERVENTIONS: A total of 175 attempts to insert colorectal SEMS were made during a 12-month period (October 2003 to September 2004). MAIN OUTCOME MEASURES: Technical and clinical success and possible differences according to the type of hospital. RESULTS: There was a mean of 1.2 attempts/mo per center (range, 2-0.5 attempts/mo per center). Insertion success was achieved in 162 (92.6%) and acceptable colonic decompression in 138 of 175 (78.8%) attempts and in 138 of 162 (85.1%) of successfully inserted stents. SEMS served as a bridge to scheduled surgery in 72 of 175 (41%) and as a palliative definitive treatment in 66 of 175 (37.7%). The major complication was perforation, which occurred in 7 of 175 occasions (4%) and led to death in 2 patients (1%). There were other less severe complications (25 [14%]). No significant differences in outcome of stent placement procedures were found between both categories of centers. LIMITATIONS: Retrospective study involving many centers and the possibility of bias for different assessments of outcomes. CONCLUSIONS: In this study, success rates for SEMS placement and colonic decompression in MCRO were acceptable, without substantial differences according to the type of hospital. This procedure appeared to be feasible in general endoscopic practice.

[Intestinal perforation secondary to impaction of a retained endoscopic capsule]. / Perforación intestinal secundaria a impactación de cápsula endoscópica retenida.

We present the first documented case of intestinal perforation due to impaction of an endoscopic capsule. The capsule was used to investigate anemia in an 80-year-old woman and was retained in the intestinal lumen for 2 months without producing symptoms. The patient presented to the emergency service with sudden, intense, diffuse abdominal pain. Hollow viscus perforation was suspected and surgery was performed. The diagnosis was distal ileum perforation secondary to an impacted endoscopic capsule in an area of severe postsurgical adhesions under a subcostal cholecystectomy incision performed 10 years previously. After reviewing the literature, we believe it important to report this exceptional complication of capsule endoscopy and suggest the possible management of capsules retained in the digestive tract.