Embarazo en enfermedad inflamatoria intestinal: no solo 9 meses de cuidado

The prevalence of inflammatory bowel disease (IBD) increased in the last decades. Thus, the number of pregnant women with the condition is also increasing. Given that active disease itself is the main risk factor for complications during pregnancy, it is necessary to achieve a complete remission before planning a pregnancy. Also, pregnant women with IBD must be monitored noninvasively and be treated proactively, including escalated therapies, if needed, to prevent potential flares during pregnancy. Patients can undergo vaginal delivery in most forms of IBD. However, cesarean delivery is still preferable in women with a history of ileal pouch-anal anastomoses (IPAA) or active perianal disease.

Recomendaciones para el manejo de pacientes con enfermedad Inflamatoria Intestinal (EII) y COVID-19 / Recommendations for the management of patients with Inflammatory Bowel Disease (IBS) and COVID-19

The new Coronavirus (SARS-CoV-2) appeared in China in December 2019. Since then and until April 2020 it spread worldwide affecting more than three million people. Its exponential rise is still growing all over the world, taking thousands of lives. SARS-CoV-2 is very contagious, person to person, by droplets which can generate a respiratory infection known as COVID-19. Some patients are at higher risk: Older people, those with cardiovascular disease, diabetes and hypertension are the most prone to an unfavorable outcome. Our Inflammatory Bowel Disease (IBD) patients are a special cluster, with many of them taking immunosuppressive treatment for long periods, which could pose an important risk. Scientifics societies all over the world have joined efforts to generate data, share experiences and make recommendations for good clinical management. This is a review of the available evidence, expert opinion, and proposed ways of working during the pandemic

El nuevo coronavirus (SARS-CoV-2) apareció en China en diciembre de 2019. Desde su inicio hasta abril de 2020 se ha expandido por todo el mundo, afectando a más de tres millones de personas. Su ascenso exponencial sigue creciendo, generando miles de muertes. Su contagiosidad es persona a persona por gotitas, pudiendo llegar a generar un cuadro clínico de infección respiratoria conocido como COVID-19. Algunos pacientes tienen más riesgos de tener un curso desfavorable; adultos mayores, pacientes con enfermedad cardiovascular, hipertensos y diabéticos. Nuestros pacientes con enfermedad inflamatoria intestinal son un grupo de pacientes con características particulares, muchos de ellos reciben tratamiento inmunosupresor por largos períodos, lo que pudiese suponer un riesgo específico. Las sociedades científicas de Europa y Norteamérica han realizado un esfuerzo conjunto para generar datos, compartir experiencias y dictar recomendaciones de buen manejo clínico. Esta es una revisión de la evidencia disponible, opiniones de expertos y formas de trabajo propuestos durante la pandemia.

Enfermedad de Crohn fistulizante perianal, manejo médico-quirúrgico / Fistulizing perianal Crohn’s Disease, medical and surgical management

Crohn’s disease (CD) and ulcerative colitis (UC) are immunologically mediated chronic digestive diseases, with a trend to progressive damage, which generally have an onset at young age and a course characterized by remission and relapse. Its incidence and prevalence present a steady upward trend globally. CD is characterized by transmural inflammation in the digestive tract and it is a complex disease. The perianal involvement –“p”, abscesses or perianal fistulas– is considered a condition that is different from penetrating phenotype, a condition that indicates an aggressive behavior of CD. Early identification and proper treatment of fistulas, including correct diagnosis and classification are essential elements to establish an appropriate treatment plan. A multidisciplinary approach is essential including medical and surgical approach.

La Enfermedad de Crohn (EC) y la colitis ulcerosa (CU) son enfermedades digestivas crónicas, progresivas, mediadas inmunológicamente, que en general, tienen un inicio durante la edad adulta-joven y un curso que se caracteriza por remisión y recaída. Su incidencia y prevalencia ha presentado una tendencia constante de incremento a nivel global. La EC se caracteriza por comprimo transmural del tracto digestivo y por ser una patología compleja. El compromiso perianal –“p”, abscesos o fístulas perianales– se considera una condición diferente al fenotipo penetrante, señalándose en la actualidad como una variable modificadora del comportamiento de la patología y de gravedad. La identificación dirigida y precoz de trayectos fistulosos, su correcto diagnóstico y clasificación son elementos primordiales para poder establecer un plan terapéutico apropiado. Es imprescindible un abordaje multidisciplinario, en el cual exista integración médico-quirúrgica.

Náuseas y vómitos: evaluación y manejo / Nausea and vomiting: assessment and management

Vomiting is a reflex action of motor and autonomous responses, resulting in violent expulsion of gastric contents through the mouth, triggered by humoral and neural stimuli. It must be distinguished from regurgitation or gagging. Nausea, on the other hand, is a subjective uncomfortable feeling that most people have experienced and is generally described as an imminent need to vomit, felt in the epigastrium and throat. These can be symptoms of a series of pathologies, and represent a reason for frequent consultation at emergency health care units. Both acute and chronic occurrence must be assessed carefully to identify its etiological agent in order to administer proper treatment focused on the symptoms. Nausea and vomiting during pregnancy, after chemotherapy, and cyclic vomiting syndrome will be further developed. In addition, nausea and vomiting treatment in the emergency room is reviewed.

El vómito es un reflejo coordinado de respuestas motoras y autonómicas que resulta en la expulsión violenta del contenido gástrico por la boca, activado por estímulos humorales o neuronales. Debe distinguirse de regurgitación o arcadas. La náusea, por otro lado, es una sensación subjetiva desagradable que la mayoría de las personas han experimentado en algún momento de su vida y, por lo general, reconocen como una sensación de inminente vómito, en el epigastrio o garganta. Son un síntoma de una pléyade de diversas patologías, y corresponde a un motivo de consulta frecuente en servicios de urgencia. Tanto su presentación aguda, como crónica deben ser evaluadas en forma integral de modo de identificar la etiología y poder brindar un tratamiento, tanto sintomático como dirigido. Las náuseas y vómitos en el embarazo, en relación a quimioterapia, y el síndrome de vómito cíclico serán abordados en profundidad. Del mismo modo se realiza una revisión del tratamiento de náuseas y vómitos indiferenciados, en el servicio de urgencia.

Aspectos relevantes en la realización de la endoscopia digestiva: propuestas basadas en la evidencia. Curso ACHED 2013 / Relevant aspects of digestive endoscopy. Evidence-based suggestions. Chilean Association of Digestive Endoscopy (ACHED), Course 2013

Digestive endoscopy is a complex tool for diagnosis and treatment, with continuous development both in technical aspects and in their application for the different pathologies where this technique is required. Therefore, a continuous education program is necessary for the practitioner using this technique. With the purpose of reaching an agreement between different aspects of the performance of these procedures and also generating proposals for its application that are useful for the physicians of this area of expertise, during 2013 the Chilean Association of Digestive Endoscopy (ACHED) developed a workshop called ‘Relevant aspects of digestive endoscopy. Evidence-based suggestions’. This workshop was attended by gastroenterologists and trainee practitioners, who worked in groups during a period of two months where they reviewed available evidence to answer several questions relating to milestones and lesions that need to be described in upper gastrointestinal endoscopy, the preparation of the GI endoscopy report, technical aspects and quality measures in colonoscopy. This review resulted in proposals that were analyzed and agreed on in the form of recommendations presented for further analysis and discussion amongst endoscopic teams in our country.

La endoscopia digestiva es una herramienta de diagnóstico y tratamiento médico compleja, en continuo desarrollo tanto en lo técnico como en los conceptos de manejo de las patologías en las que se utiliza.Por lo tanto, es deseable una estrategia de formación continua del profesional que la realiza. Con el objetivode consensuar diferentes aspectos en la realización de estos procedimientos y generar propuestas de manejoque sean de utilidad para todos los médicos involucrados en esta especialidad, la Asociación Chilenade Endoscopia Digestiva (ACHED) realizó durante el año 2013 un curso taller denominado “Aspectosrelevantes en la realización de la endoscopia digestiva. Propuestas basadas en la evidencia”. Este cursoconvocó a gastroenterólogos y médicos en formación de la especialidad que conformaron grupos de trabajoque durante 2 meses revisaron la evidencia disponible para responder diversas preguntas en relación a los hitos y lesiones a describir en endoscopia digestiva alta (EDA), la realización del informe en EDA, aspectos técnicos y medidores de calidad en colonoscopia. La revisión les permitió generar propuestas que fuerondiscutidas y consensuadas en recomendaciones que se proponen para su discusión por los equipos endoscópicos de nuestro país.

Manejo de la colitis ulcerosa grave: experiencia a partir de un hospital ministerial / Management of severe ulcerative colitis: experience from a national health service hospital

Introduction: Ulcerative colitis (UC) may present, or evolve as severe crisis. Although guidelines have defined its management and timing in decision-making, this has not been implemented at national level. Objective: To describe the clinical characteristics and management of patients with severe UC in our hospital. Patients and Methods: Retrospective review of medical records of 116 patients with inflammatory bowel disease during the period 1975-2012. Of 97 patients with UC, 21 patients with at least one severe crisis were identified. Results: The median age among patients with UC crisis was 34 years (17-43). Ten patients debuted with severe crisis. Eleven were in maintenance treatment, all with 5-aminosalicylates (5- ASA), eight with systemic steroids and five with immunomodulators. During the crisis, colonoscopy was performed to 13 patients, 11 with extensive involvement and two left colitis. All patients received steroids and 5-ASA, 14 antibiotics, and seven immunomodulators. No patient received medical rescue therapy (cyclosporine/biological therapy). Nine patients required surgery, two due to toxic megacolon and seven due to intravenous-steroid refractory episode. Five patients received parenteral nutrition and six were hospitalized in the critical patients unit. The range of stay in the hospital was 9-51 days. Conclusions: In this study, a significant percentage of patients with CU presented a severe crisis without having a standardized management. It is necessary to establish a consensus for the multidisciplinary management of severe UC. No patient had access to cyclosporine/biological therapy, more than 40 percent of the cases required surgery. These therapeutic strategies should be incorporated into the therapeutic arsenal in hospitals.

La colitis ulcerosa (CU) puede debutar, o evolucionar, como crisis grave. Aunque guías han definido su manejo y temporalidad en la toma de decisiones,esto no ha sido masificado a nivel nacional. Objetivo: Describir las características clínicas y manejo de pacientes con CU grave en nuestro centro. Pacientes y Métodos: Revisión retrospectiva de fichas clínicas de 116 pacientes con enfermedad inflamatoria intestinal, durante el período 1975-2012. De 97 pacientes con CU se identifican 21 pacientes con al menos una crisis grave. Resultados: La mediana de edad en la crisis fue 34 años (17-43). Diez pacientes debutaron con crisis grave. Once estaban en tratamiento de mantención, todos con 5-aminosalicilatos (5-ASA), ocho con esteroides sistémicos y cinco con inmunomoduladores. Durante la crisis, se realizó colonoscopia a 13 pacientes, 11 con compromiso extenso y dos con colitis izquierda. Todos recibieron esteroides y 5-ASA, 14 antibióticos y siete inmunomoduladores. Ningún paciente recibió terapia médica de rescate (ciclosporina/terapia biológica). Nueve pacientes requirieron cirugía, dos por megacolon tóxico y siete por cortico-refractariedad. Cinco pacientes recibieron nutrición parenteral y seis fueron hospitalizados en una Unidad de Pacientes Críticos. El rango de estadía hospitalaria fue de 9-51 días. Conclusiones: En este estudio un porcentaje importante de los pacientes con CU presentó una crisis grave, sin tener un manejo estandarizado. Es necesario establecer un consenso para el manejo multidisciplinario de la CU grave. Ningún paciente tuvo acceso a ciclosporina/ terapia biológica, requiriendo cirugía más de 40 por ciento de los casos. Estas estrategias terapéuticas deben ser incorporadas al arsenal terapéutico hospitalario.

Manejo de accidente laboral exposición a fluidos corporales / Handling of the labor accident with exhibition to corporal fluids

The flowed cut-sharp accidents with of high biological risk constitute a problem of ealth o the personnel wo has an important psycological impact. To know the risk I infect and its suitableaning is fundamental in a Hospital of high complexity.

Los accidentes corto-punzantes con fluidos de alto riesgo biológico constituyen un problema de salud del personal que tiene un importante impacto psicológico. Conocer los riesgos de contagio y su manejo adecuado es fundamental en un hospital de alta calidad.

Angioplastía coronaria en pacientes octogenarios / Coronary angioplasty in octogenarians patients

Introduction: According to international literature, the percutaneus coronary angioplasty (PTCA) can be performed in octogenarian with a high rate of success and favorable long term prognosis. There are no Chilean publications about PTCA in octogenarian patients. Objective: To show our experience in octogenarian patients who underwent PTCA. Material and method: From a serial prospective registration of patients who underwent coronary angiography studies between 1992and 2005, all the octogenarian patients subjected to PTCA were evaluated, being described their pre and in-hospital variables, with emphasis in the results of the PTCA Results: Of a total of 7262 patients, 77 octogenarian patients underwent PTCA (1percent). The average age was 83.2 +/- 3.4 years, 54.5 percent male. They were studied mainly by myocardial infraction (MI) (55.8 percent) and unstable angina (29.8 percent). 59.7 percent were hypertensive and 19.4 percent had diabetes. The angiographic study showed mainly single vessel (37.6 percent) and two vessel disease in 32.4 percent. The PTCA was elective in 57.1 percent, the rest were emergency procedures. The PTCA was successful in 88.3 percent. There were no intra procedure complications, and 7 patients presented smaller post procedure complications. 11 patients (14.3 percent) died; 10 because of MI. 66 were discharged without complications. Conclusion: The PTCA is a feasible procedure to perform in octogenarian patients, with good immediate results.