Monitoring endoscopic postoperative recurrence in Crohn's disease after an ileocecal resection. Does capsule endoscopy have a role in the short and long term?

Background: Small bowel capsule endoscopy (SBCE) is a noninvasive method to detect endoscopic postoperative recurrence (POR) after an ileocolonic resection in Crohn's Disease (CD). Few studies have evaluated the role of SBCE in the early POR (= 12 months). Data for detection of late POR (>12 months) and evaluation of treatment response in previous POR is scarce. We aimed to assess the SBCE performance in the three scenarios (early-POR, late-POR, and previous-POR). Methods: Retrospective 11-year cohort study of SBCE procedures performed on CD patients with ileocolonic resection. Disease activity by Rutgeerts score (RS), correlation with biomarkers, and therapeutic changes were recorded. Results: We included 113 SBCE procedures (34 early-POR, 44 late-POR, and 35 previous-POR). 105 procedures (92.9%) were complete and 97 SBCE (85.5%) were conclusive with no differences between groups. Relevant POR (RS ≥i2) was more frequent in the early-POR group compared to late-POR (58.8% vs 27.3%, p=0.02). In the previous-POR, RS improved in 43.5% of procedures, worsened in 26%, and remained unchanged in 30.5%. Fecal calprotectin (FCP) value of 100µg/g displayed the best accuracy: sensitivity 53.8%, specificity 78.8%, positive predictive value 66.7% and negative predictive value 68.4%. SBCE guided therapeutic changes in 43 patients (38%). No adverse events occurred in our cohort. Conclusion: SBCE is a safe and effective method to assess POR in the early and late setting in clinical practice, and for the evaluation of treatment response to previous POR. FCP is an accurate surrogate marker of POR and 100µg/g value had the best overall accuracy.

High preoperative serum vascular endothelial growth factor levels predict poor clinical outcome after curative resection of gastric cancer.

BACKGROUND: Tumour vascular endothelial growth factor (VEGF) and tumour urokinase-type plasminogen activator (uPA) are prognostic factors in gastric cancer but surgical specimens are required for testing. The prognostic value of preoperative serum VEGF (s-VEGF) and serum uPA (s-uPA) levels was evaluated in patients undergoing potentially curative (R0) gastric cancer resection. METHODS: Concentrations of s-VEGF and s-uPA were measured 97 patients with gastric cancer and 20 controls. Angiogenesis was measured in vitro based on human endothelial cell tube formation. RESULTS: Levels of s-VEGF were higher in patients with gastric cancer than controls (median 288 versus 189 pg/ml respectively; P = 0.002). They were associated with pathological tumour node metastasis (pTNM) stage, pT, pN, lymph node ratio and perineural invasion, and correlated with platelet counts. In multivariable analysis, s-VEGF over 320 pg/ml was the only preoperative predictor of both recurrence and disease-specific survival. Serum from patients with raised s-VEGF levels enhanced angiogenesis in vitro significantly more than serum from those with a s-VEGF level of 320 pg/ml or less. CONCLUSION: High preoperative s-VEGF level is an independent prognostic factor for recurrence and survival after R0 resection of gastric cancer. This may provide a useful guide to decision making regarding neoadjuvant and adjuvant therapies.

Influence of Helicobacter pylori infection and eradication on blood lipids and fibrinogen.

BACKGROUND: An association between Helicobacter pylori infection and heart disease has been suggested. A potential mechanism may be inflammation-induced atherogenic changes of lipoproteins, but epidemiological studies have provided conflicting results. METHODS: In a prospective multicentre study, 830 patients submitted for endoscopy and H. pylori testing were evaluated. Of the 686 H. pylori-positive patients, 487 received and 199 did not receive eradication treatment. Serum lipids and plasma fibrinogen were measured at baseline in all patients and 3 months later in those initially positive for H. pylori. RESULTS: H. pylori had no influence on baseline lipid or fibrinogen levels. Increases in high-density lipoprotein cholesterol were observed in 368 patients who received eradication treatment and in 193 untreated patients: 0.06 mmol/L (P=0.000) and 0.07 mmol/L (P=0.009), respectively. Similar minor increases in total cholesterol and triglycerides occurred in both groups. Lipid changes were related to symptom relief and a reduction in smoking. Eradication therapy was associated with a minor decrease in plasma fibrinogen irrespective of the resolution of infection. CONCLUSIONS: H. pylori has no influence on blood lipids or fibrinogen. Both the eradication of infection and symptomatic treatment without eradication are associated with minor lipid changes related to symptom relief and lifestyle modifications. Thus, the inflammatory changes associated with H. pylori are unlikely to affect lipoprotein or fibrinogen metabolism.

How accurate is preoperative diagnosis by endoscopic biopsies in ampullary tumours?

INTRODUCTION: The benign or malignant nature of ampullary tumours has prognostic and therapeutic implications. On the other hand the difficulty of reaching a correct preoperative diagnosis in these lesions is well known, even when we have a histological study obtained by endoscopic biopsies. MATERIAL AND METHODS: We review all ERCP's in which biopsies of the papilla were taken, performed between January 1991 and September 2000. We analyse the concordance rate between preoperative diagnosis (endoscopic biopsies obtained during ERCP) and definitive diagnosis (surgical specimen) (n = 32), and the possible influence of previous sphincterotomy in our results. RESULTS: In the 32 patients studied global accuracy between pre- and postsurgical diagnosis was 68.7%. This accuracy was markedly higher in the group with ampullary cancer (82.7%) than in the group with ampullary adenoma (50%) (p = 0.12). In the group of patients with sphincterotomy accuracy was 56.25% and increased up to 81.25% in the group of patients without sphincterotomy, although statistical significance was not reached (p = 0.25). CONCLUSIONS: In our series, the accuracy of endoscopic biopsies is higher in the adenocarcinoma group than in the adenoma group, obtaining better results in patients without previous sphincterotomy. The impossibility of a preoperative and absolutely certain confirmation of the benign or malignant nature of ampullary tumours forces us to be cautious in deciding type of surgical resection.

[Giant gastric stromal tumor simulating a focal hepatic lesion]. / Tumor estromal gástrico gigante simulando lesión ocupacional hepática.

Gastrointestinal stromal tumors (GIST), are unusual malignancies regarded for many years as being basically of smooth muscle nature and designated as leiomyomas, leiomyosarcomas or leiomyoblastomas. Histogenesis has been debated, though it is presently accepted that they are characterized by poorly differentiated cells, including tumors showing differentiation towards smooth muscle, neural elements, dual differentiation or lack of differentiation. Another group with ultrastructural and immunohistochemical features similar to those of gastrointestinal autonomic plexus has been described and designated as GAN tumors. Diagnosis and classification of these tumors are not possible using conventional pathological techniques, making ultrastructural and immunohistochemical studies necessary. Accurate classification is clinically essential due to prognostic implications. GIST present with few clinical symptoms even in cases of large tumors and are quite often incidentally found during surgical procedures or in postmortem studies. We report a case of a giant gastric stromal tumor showing differentiation towards smooth muscle which presented as a focal hepatic lesion.

[Endoscopic gastrointestinal findings in patients with human immunodeficiency virus infection]. / Hallazgos endoscópicos gastrointestinales en pacientes infectados por el virus de la inmunodeficiencia humana.

From January 1992 to August 1993, 150 endoscopies (114 fiber gastroscopies, 29 fiber colonoscopies and 7 CPRE) were carried out in a total of 142 anti HIV positive patients. The most frequent clinical manifestations leading to the exploration were dysphagia, epigastric pain, diarrhea and upper or lower gastrointestinal bleeding. Endoscopic alterations were observed in most of the exploration although specific diagnosis was only achieved in approximately one third of the patients with the most frequent being esophagitis by Candida and CMV (21% and 5%, respectively in the fiber gastroscopies performed). Digestive manifestations were varied in the patients in whom esophagitis by Candida was diagnosed while dysphagia and diarrhea were the symptoms commonly observed in the patients with esophagitis or colitis by CMV. The diagnostic profitability of endoscopy was high in patients presenting dysphagia, diarrhea, gastrointestinal bleeding or in those in whom endoscopy was performed for tumoral staging or to evaluate the possible existence of manifestations secondary to the presence of portal hypertension.

[Treatment of ascites in cirrhotic patients]. / Tratamiento de la ascitis en pacientes cirróticos.

Ascites is the most frequent complication of hepatic cirrhosis and its appearance brings a reduction of survival. The treatment aims to mobilise the intraperitoneal liquid and to prevent its reaccumulation. The first step of treatment includes rest in bed, a hyposodic and spironolactone diet, alone or in combination with furosemide or torasemide. However, 10-20% of patients do not respond to treatment or develop adverse effects that limit its use, which is termed refractory ascites. These patients must be considered as possible candidates for a liver transplant and, when this is not possible, the chosen treatment is total paracentesis with an intravenous infusion of albumin. In patients who do not tolerate paracentesis, or who require its realisation with great frequency, other therapeutic options can be evaluated, such as surgical anastomoses, intrahepatic portosystemic percutaneous derivation and, in the final instance, peritoneo-venous shunt.

[Acute hepatitis C virus infection]. / Infección aguda por el VHC.

Acute hepatitis C virus infection produces clinical and biochemical features that is non-specific and indistinguishable from those caused by other hepatotropic viruses. The specific diagnosis of acute hepatitis C virus infection is based on the detection of serum RNA-HCV through a technique of PCR whose result will be positive after 1-2 weeks of the initial contact with the virus. The anti-bodies against HCV are detected later (after 7-8 weeks on average), and are not useful, as an isolated determination, in distinguishing acute infection from chronic infection or in clearing the virus (spontaneous or following treatment). Fifty-five to eighty-five percent of patients with acute HCV infection do not clear the virus and develop a chronic infection with risk of evolution to cirrhosis and of developing hepatocellular carcinoma. For this reason, the present tendency is to treat with interferon all those patients in whom RNA-HCV remains positive after 3-4 months following diagnosis of acute infection

[Treatment of chronic hepatitis C virus infection]. / Tratamiento de la infección crónica por el VHC.

At present the treatment of chronic hepatitis C virus infection is based on the combination of pegylated interferon (PEG-INF) and rivabirin (RBV) and basically attempts to eradicate the viral infection (sustained viral response). The pattern depends above all on the viral genotype, hence, patients with genotype 1, 4 and 5 require 48 weeks of treatment and high doses of RBV, while those with genotype 2 and 3 require 24 weeks of treatment and low doses of RBV. All patients with chronic C infection are possible candidates for antiviral therapy. However, given that the response to treatment is variable, that the treatment has secondary effects and supposes a high economic cost, it is recommendable in patients with hypertransaminasemia and moderate-severe chronic hepatitis in the histological study, as long as there are no counter-indications. This does not exclude other groups of patients who should be evaluated individually. In those patients with compensated hepatic cirrhosis, treatment can stabilise the disease and reduce the risk of complications appearing, although the rate of response is lower and some adverse effects are more frequent. In patients who have received previous antiviral treatment with standard interferon, alone or in association with RBV, without response to this or with response but later relapse, the decision on treatment must be individual. In patients with coinfection by human immunodeficiency virus (HIV), special attention must be paid to the degree of evolution of the disease due to HCV and to HIV, as well as the possible hepatoxicity of the antiretroviral treatment and the risk of secondary effects.

[Chronic hepatitis C virus infection]. / Infección crónica por el VHC.

Following acute hepatitis C virus infection (HCV), a significant percentage of patients do not clear the virus and develop a chronic hepatitis C. The symptoms, when they exist, are usually unspecific. Besides, approximately one third of the patients present extrahepatic manifestations of the infection, basically due to the lymphotropism of HCV. Outstanding amongst these, due to their clear association with HCV, are mixed cryoglobulinaemia and the production of autoantibodies (autoAb). Other diseases such as non-Hodgkin lynphoma (NHL) or autoimmune thyroiditis do not have a clearly established association. Although the majority of patients with chronic hepatitis C have slight or moderately high levels and fluctuations of transaminases, as many as one third of those infected can show persistently normal levels of transaminases. The diagnosis of chronic HCV infection is based on serological tests, which detect the presence of antibodies against HCV, and on virological tests that detect RNA of the HCV, which confirm the existence of active infection. Finally, an important topic of chronic HCV infection, following diagnosis, is to ascertain the stage of fibrosis and the degree of inflammation, since both characteristics are very important for predicting the natural evolution and the need for treatment. Nowadays, this information can only be obtained through liver biopsy, which is recommended in patients with chronic HCV infection and high transaminases. Whether liver biopsy should be performed in patients with normal transaminases is still subject of controversy.

[Upper digestive haemorrhage due to Mallory-Weiss syndrome. Role of endoscopic sclerotherapy]. / Hemorragia digestiva alta por síndrome de Mallory-Weiss. Papel de la escleroterapia endoscópica.

BACKGROUND: Although Mallory-Weiss syndrome is responsible for between 0.5 and 17% of the cases of upper digestive haemorrhage, the information existing on the endoscopic treatment of this syndrome is scarce. MATERIAL AND METHODS: We made a retrospective study of 71 patients with haemorrhage due to Mallory-Weiss syndrome, dividing them into two groups according to the treatment they had received (medical or medical-endoscopic). Hence, 60 patients (30 with clean laceration, 9 with signs of prior haemostasia and 21 with fresh clotting) had been treated with procinetics and/or antisecretories alone, while the 11 remaining (8 with active haemorrhage, 2 with visible vessel and 1 with fresh clotting) had also received endoscopic treatment with sclerotherapy. We compared the clinical and analytical characteristics and the evolution of both groups of patients, analysing the data by means of the Mann-Whitney U and the chi 2 test. RESULTS: The endoscopic sclerosis group showed maelenas more frequently and more severe analytical data of haemorrhage (p<0.01). Endoscopic sclerosis brought initial control of the haemorrhage in all the patients, with a low index of haemorrhage relapse, similar to the group receiving exclusively medical treatment. CONCLUSIONS: In our series, the patients with Mallory-Weiss syndrome with active bleeding or visible vessel presented a haemorrhage with a greater clinical and analytical repercussion. In this group of patients, endoscopic sclerotherapy controlled the haemorrhage and/or prevented rebleeding, in the absence of complications.

Increased blood hemoglobin attenuates splanchnic vasodilation in portal-hypertensive rats by nitric oxide inactivation.

BACKGROUND & AIMS: Nitric oxide, which is quenched by hemoglobin, has been implicated in the pathogenesis of portal hypertension. The aim of this study was to investigate the effects of increasing blood hemoglobin concentration by erythropoietin treatment on the gastrointestinal vasodilation associated with portal hypertension. METHODS: Portal-hypertensive and sham-operated rats treated with erythropoietin were studied 2 weeks after surgery. Hemodynamic and rheological parameters were measured in baseline conditions and after N(G)-nitro-L-arginine methyl ester (L-NAME) or sodium nitroprusside treatment. RESULTS: In portal-hypertensive rats, erythropoietin attenuated the increase in gastric mucosal and superior mesenteric artery blood flows and the decrease in arterial blood pressure and splanchnic vascular resistances. Those parameters were not affected by erythropoietin in sham-operated rats. A direct vascular effect of erythropoietin was ruled out by the lack of changes in blood pressure or mesenteric blood flow after intravenous erythropoietin administration and by a similar in vitro relaxation to acetylcholine in mesenteric artery rings. In portal-hypertensive rats, erythropoietin blunted the blood pressure response to sodium nitroprusside and attenuated the gastric and mesenteric blood flow response to L-NAME. CONCLUSIONS: Gastrointestinal vasodilation associated with portal hypertension can be attenuated by increasing blood hemoglobin concentration. Inactivation of overproduced NO by hemoglobin may account for this effect.