Megacolon in inflammatory bowel disease: response to infliximab.

Megacolon is a serious complication of inflammatory bowel disease that often requires a colectomy. Infliximab is a therapeutic alternative when conventional treatment fails, before resorting to surgery. Its use is currently based on the publication of isolated cases. We present a series of 12 patients with megacolon treated with infliximab, five with signs of systemic toxicity. Seventy-five percent of the patients avoided a colectomy during their acute episode after early infliximab treatment, 2.45 days after the megacolon diagnosis. There was a greater risk of surgery among patients with ulcerative colitis and toxicity criteria. Two more patients required follow-up surgery despite long-term infliximab treatment. No patient suffered significant treatment-related adverse effects or significant post-surgery complications.

Downhill varices: an uncommon cause of upper gastrointestinal bleeding.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common condition in gastroenterology, but "Downhill Varices" (DHV) or varices of the upper oesophagus are an uncommon cause of UGIB, with different aetiology from lower third oesophageal varices and different therapeutic implications. CASE REPORT: A 28-year-old male patient, with a history of chronic kidney failure secondary undergoing haemodialysis and superior vena cava syndrome (SCVS) due to multiple catheter replacements, was admitted to the Emergency Department with haematemesis secondary to a varicose vein rupture in the proximal third of oesophagus, treated initially with ethanolamine. Subsequent diagnostic studies showed the collateral circulation secondary to the SCVS. No further endoscopic or endovascular therapy could be performed and the patient will finally undergo a surgical bypass. DISCUSSION: DHVs are a very uncommon condition and endoscopic band ligation emerges as the appropriate therapeutic approach for the bleeding event. The definitive therapy continues to be that for the cause of the SVCS.

Treatment with adalimumab in a patient with regenerative nodular hyperplasia secondary to azathioprine.

INTRODUCTION: regenerative nodular hyperplasia (RNH) is a rare liver disease with an etiology that is not well understood. Among the etiological factors are purine-analogue drugs such asazathioprine. CASE REPORT: we present a case of a 47-year-old patient diagnosed with Crohn´s disease in treatment with azathioprine due to corticosteroid dependency who developed RNH with clinical and laboratory signs of portal hypertension one year after starting treatment. After discontinuation of azathioprine, the patient started treatment and, given the poor disease progression, started treatment with adalimumab. This was continued with an excellent response and without deleterious effects on the liver. DISCUSSION: the relevance of this case is twofold: First, this is a rare and early side effect of azathioprine treatment and this is an irreversible disease with potentially serious complications. Second, because treatment was carried out with biological drugs (adalimumab) despite the patient having advance liver disease with portal hypertension without any evidence of it worsening, nor signs of deleterious effects or complications, given that there is scarce or no experience with adalimumab treatment in this type of situation.

[An unusual cause of obstructive jaundice: giant gastroduodenal artery aneurysm]. / Una causa infrecuente de ictericia obstructiva: aneurisma de la arteria gastroduodenal de grandes dimensiones.

Visceral artery aneurysms are rare vascular lesions. Hepatic aneurysms are the second most common type of visceral aneurysm after those of the splenic artery. These aneurysms often have a nonspecific clinical presentation and are difficult to diagnose before rupture. Because the natural course of hepatic aneurysms leads to rupture, with a high rate of morbidity and mortality, their early diagnosis is essential for surgical correction. We report a case of obstructive jaundice caused by a 7-cm gastroduodenal artery aneurysm in which the diagnosis was suggested by abdominal computed tomography and magnetic resonance cholangiography and was confirmed by angiography. The patient was surgically treated. In the following 48 h he presented ischemic-based acute hepatic failure and underwent left hepatic lobe resection. The patient finally died from a pulmonary thromboembolism.

'Downhill varices': una causa poco frecuente de hemorragia digestiva alta / Downhill varices: an uncommon cause of upper gastrointestinal bleeding

Introducción: la hemorragia digestiva alta (HDA) es una entidad común en gastroenterología, pero las ‘Downhill varices’ (DHV) son una causa infrecuente de HDA, con diferente etiología de las varices esofágicas de tercio inferior y con diferentes implicaciones terapéuticas. Caso clínico: varón de 28 años de edad, con antecedentes de insuficiencia renal crónica sometido a hemodiálisis y síndrome de vena cava superior(SVCS) debido a múltiples sustituciones catéter, acude a urgencias por hematemesis secundaria a ruptura de una variz en tercio proximal de esófago, que inicialmente se trata con etanolamina. El estudio diagnóstico posterior demostró la circulación colateral secundaria al SVCS. No se pudo realizar terapia endoscópica o endovascular y el paciente finalmente se someterá a un bypass quirúrgico. Discusión: las DHV son una entidad infrecuente y la ligadura endoscópica con bandas se erige como el abordaje terapéutico apropiado para el evento hemorrágico. La terapia definitiva sigue siendo la de la causa del SVCS (AU)

Background: Upper gastrointestinal bleeding (UGIB) is a common condition in gastroenterology, but ‘Downhill Varices’ (DHV) or varices of the upper oesophagus are an uncommon cause of UGIB, with different aetiology from lower third oesophageal varices and different therapeutic implications. Case report: A 28-year-old male patient, with a history of chronic kidney failure secondary undergoing haemodialysis and superior vena cava syndrome (SCVS) due to multiple catheter replacements, was admitted to the Emergency Department with haematemesis secondary to a varicose vein rupture in the proximal third of oesophagus, treated initially with ethanolamine. Subsequent diagnostic studies showed the collateral circulation secondary to the SCVS. No further endoscopic or endovascular therapy could be performed and the patient will finally undergo a surgical bypass. Discussion: DHVs are a very uncommon condition and endoscopic band ligation emerges as the appropriate therapeutic approach for the bleeding event. The definitive therapy continues to be that for the cause of the SVCS (AU)

Correlación entre la localización del depósito amiloide y las manifestaciones endoscópicas y clínicas en amiloidosis digestiva sintomática / Correlation between location of amyloid deposits and endoscopic and clinical manifestations in symptomatic gastrointestinal amyloidosis

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Megacolon en la enfermedad inflamatoria intestinal: respuesta a infliximab / No disponible

El megacolon es una complicación grave de la enfermedad inflamatoria intestinal que con frecuencia requiere colectomía. Infliximab sería una alternativa terapéutica cuando fracasa el tratamiento convencional, antes de la cirugía. En la actualidad, su uso se basa en la publicación de casos aislados. Presentamos nuestra serie de 12 pacientes con megacolon (cinco con signos de toxicidad sistémica) tratados con infliximab. El 75% de los pacientes evitaron la colectomía durante el episodio agudo tras la instauración precoz del tratamiento con infliximab (2,45 días desde el diagnóstico del megacolon), apreciando un mayor riesgo de cirugía entre los pacientes con colitis ulcerosa y criterios de toxicidad. Pese a mantener infliximab a largo plazo, dos pacientes más requirieron cirugía en el seguimiento. Ningún paciente sufrió efectos adversos relevantes en relación con el tratamiento ni complicaciones posquirúrgicas significativas

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Listeria monocytogenes y su relación con terapia no biológica en la enfermedad inflamatoria intestinal / Listeria monocytogenes and its relationship with non-biological therapy in inflammatory bowel disease

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Tratamiento con inmunosupresores en paciente con enfermedad de Crohn e inmunodeficiencia común variable / Treatment with immunosupressants in a patient with Crohn's disease and common variable immunodeficiency

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Influencia del control de la actividad inflamatoria del colon en la respuesta a infliximab de la anemia hemolítica autoinmune asociada a colitis ulcerosa / inflammatory activity in the colon on the response to infliximab of autoimmune haemolytic anaemia associated with ulcerative colitis

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Gastroduodenal involvement in patients with familial adenomatous polyposis. Prospective study of the nature and evolution of polyps: evaluation of the treatment and surveillance methods applied.

OBJECTIVES: Analysis of the incidence rate and the evolution of duodenal and stomach polyps in our familial adenomatous polyposis (FAP) patients, the suitability of the surveillance method and the cancer-preventing treatment applied and the analysis of the complications arising from each procedure employed. MATERIALS AND METHODS: Twenty-nine patients diagnosed with FAP underwent study and endoscopic surveillance of the upper digestive tract. Front-view and side-view endoscopies were used. Papillary biopsies were performed even when the papilla were macroscopically normal. The Spigelman classification was used to determine the seriousness of the condition and to establish the surveillance and treatment intervals. RESULTS: Duodenal and/or papillary polyps were presented by 79.3% of the patients. Endoscopic polypectomy was performed in 13 patients with duodenal polyps. Endoscopic polypectomies for the papilla were performed in all patients. One patient required a cephalic duodenopancreatectomy and another endoscopic ampullectomy. The condition did not become cancerous in any of the patients who underwent surveillance. We report two complications arising from treatment: one postpolypectomy haemorrhage and one stenosis of the biliary-enteric anastomosis after cephalic duodenopancreatectomy. CONCLUSION: Our study shows a high incidence rate of duodenal polyps in FAP patients. A minute examination of the duodenum and papilla is necessary, using side-view endoscopes and duodenal papilla biopsies even when papilla appears to be normal. None of the patients having completed the surveillance and the prescribed treatment developed cancer and all have a low Spigelman score. This method, therefore, seems to be adequate for the treatment and surveillance of duodenal polyps.

Tratamiento con adalimumab en un paciente con hiperplasia nodular regenerativa secundaria a azatioprina / Treatment with adalimumab in a patient with regenerative nodular hyperplasia secondary to azathioprine

Introducción: la hiperplasia nodular regenerativa (HNR) es una rara enfermedad hepática de etiología no bien conocida. Entre los factores etiológicos se encuentran los fármacos análogos de las purinas, como la azatioprina. Caso clínico: presentamos un caso de un paciente de 47 años de edad diagnosticado de enfermedad de Crohn en tratamiento con azatioprina por corticodependencia que desarrolló una HNR con datos clínicos y analíticos de hipertensión portal al año del inicio del tratamiento. Tras la suspensión de la azatioprina inició tratamiento y dada la mala evolución de su enfermedad se inició tratamiento con adalimumab, el cual mantiene con excelente respuesta y sin efectos deletéreos a nivel hepático. Discusión: la relevancia del caso es doble; primero por ser un efecto secundario raro y precoz del tratamiento con azatioprina y tratarse de una enfermedad irreversible y con complicaciones potenciales graves; segundo por realizarse tratamiento de mantenimiento con fármacos biológicos (adalimumab) a pesar de padecer una hepatopatía avanzada con hipertensión portal sin evidenciarse peor evolución de esta, ni efectos deletéreos o complicaciones, dado que existe escasa o nula experiencia de tratamiento con adalimumab en este tipo de situaciones(AU)

Introduction: regenerative nodular hyperplasia (RNH) is a rare liver disease with an etiology that is not well understood. Among the etiological factors are purine-analogue drugs such as azathioprine. Case report: we present a case of a 47-year-old patient diagnosed with Crohn’s disease in treatment with azathioprine due to corticosteroid dependency who developed RNH with clinical and laboratory signs of portal hypertension one year after starting treatment. After discontinuation of azathioprine, the patient started treatment and, given the poor disease progression, started treatment with adalimumab. This was continued with an excellent response and without deleterious effects on the liver. Discussion: the relevance of this case is twofold: First, this is a rare and early side effect of azathioprine treatment and this is an irreversible disease with potentially serious complications. Second, because treatment was carried out with biological drugs (adalimumab) despite the patient having advance liver disease with portal hypertension without any evidence of its worsening, nor signs of deleterious effects or complications, given that there is scarce or no experience with adalimumab treatment in this type of situation(AU)