Extracolonic Cancer in Inflammatory Bowel Disease: Data from the GETECCU Eneida Registry.

OBJECTIVES: The objective of this study was (a) To know the prevalence and distribution of extracolonic cancer (EC) in patients with inflammatory bowel disease (IBD); (b) To estimate the incidence rate of EC; (c) To evaluate the association between EC and treatment with immunosuppressants and anti-tumor necrosis factor (TNF) agents. METHODS: This was an observational cohort study. INCLUSION CRITERIA: IBD and inclusion in the ENEIDA Project (a prospectively maintained registry) from GETECCU. EXCLUSION CRITERIA: Patients with EC before the diagnosis of IBD, lack of relevant data for this study, and previous treatment with immunosuppressants other than corticosteroids, thiopurines, methotrexate, or anti-TNF agents. The Kaplan-Meier method was used to evaluate the impact of several variables on the risk of EC, and any differences between survival curves were evaluated using the log-rank test. Stepwise multivariate Cox regression analysis was used to investigate factors potentially associated with the development of EC, including drugs for the treatment of IBD, during follow-up. RESULTS: A total of 11,011 patients met the inclusion criteria and were followed for a median of 98 months. Forty-eight percent of patients (5,303) had been exposed to immunosuppressants or anti-TNF drugs, 45.8% had been exposed to thiopurines, 4.7% to methotrexate, and 21.6% to anti-TNF drugs. The prevalence of EC was 3.6%. In the multivariate analysis, age (HR=1.05, 95% CI=1.04-1.06) and having smoked (hazards ratio (HR)=1.47, 95% confidence interval (CI)=1.10-1.80) were the only variables associated with a higher risk of EC. CONCLUSIONS: Neither immunosuppressants nor anti-TNF drugs seem to increase the risk of EC. Older age and smoking were associated with a higher prevalence of EC.

Evolution After Anti-TNF Discontinuation in Patients With Inflammatory Bowel Disease: A Multicenter Long-Term Follow-Up Study.

OBJECTIVES: The aims of this study were to assess the risk of relapse after discontinuation of anti-tumor necrosis factor (anti-TNF) drugs in patients with inflammatory bowel disease (IBD), to identify the factors associated with relapse, and to evaluate the overcome after retreatment with the same anti-TNF in those who relapsed. METHODS: This was a retrospective, observational, multicenter study. IBD patients who had been treated with anti-TNFs and in whom these drugs were discontinued after clinical remission was achieved were included. RESULTS: A total of 1,055 patients were included. The incidence rate of relapse was 19% and 17% per patient-year in Crohn's disease and ulcerative colitis patients, respectively. In both Crohn's disease and ulcerative colitis patients in deep remission, the incidence rate of relapse was 19% per patient-year. The treatment with adalimumab vs. infliximab (hazard ratio (HR)=1.29; 95% confidence interval (CI)=1.01-1.66), elective discontinuation of anti-TNFs (HR=1.90; 95% CI=1.07-3.37) or discontinuation because of adverse events (HR=2.33; 95% CI=1.27-2.02) vs. a top-down strategy, colonic localization (HR=1.51; 95% CI=1.13-2.02) vs. ileal, and stricturing behavior (HR=1.5; 95% CI=1.09-2.05) vs. inflammatory were associated with a higher risk of relapse in Crohn's disease patients, whereas treatment with immunomodulators after discontinuation (HR=0.67; 95% CI=0.51-0.87) and age (HR=0.98; 95% CI=0.97-0.99) were protective factors. None of the factors were predictive in ulcerative colitis patients. Retreatment of relapse with the same anti-TNF was effective (80% responded) and safe. CONCLUSIONS: The incidence rate of inflammatory bowel disease relapse after anti-TNF discontinuation is relevant. Some predictive factors of relapse after anti-TNF withdrawal have been identified. Retreatment with the same anti-TNF drug was effective and safe.

Lack of association of ACP1 gene with inflammatory bowel disease: a case-control study.

The red cell acid phosphatease (ACP1) gene, which encodes a low molecular weight phosphotyrosine phosphatase (LMW-PTP), has been suggested as a common genetic factor of autoimmunity. In the present study, we aimed to investigate the possible influence of ACP1 polymorphisms in the susceptibility of inflammatory bowel disease (IBD). A total of 1271 IBD Spanish patients [720 Crohn's disease (CD) and 551 ulcerative colitis (UC)] and 1877 healthy subjects were included. Four single-nucleotide polymorphisms (SNPs), rs10167992, rs11553742, rs7576247 and rs3828329, were genotyped using TaqMan SNP genotyping assays. Common ACP1 alleles (i.e. ACP1*A, ACP1*B and ACP1*C) were determined by two of these SNPs. After the analysis, no evidence of association of the ACP1 genetic variants was found with CD or UC. Therefore, our results suggest that the ACP1 gene may not play a relevant role in the development of IBD.

[Value of laparoscopy in ascites of undetermined origin]. / Valor de la laparoscopia en la ascitis de origen indeterminado.

OBJECTIVE: To assess the diagnostic accuracy of laparoscopy in the study of patients with ascites of unknown cause, and the frequency of laparoscopy use for that indication after the advent of ultrasonography and computed tomography. DESIGN: A retrospective study of 4.536 laparoscopies performed in 16 years, in two periods of 8 years, and the correlation with the pathologic diagnosis. PATIENTS: 137 patients in whom laparoscopy was indicated for the study of ascites of unknown cause. RESULTS: 63.5% of laparoscopies were performed over the first 8-year period, and 36.5% in the second (p = 0.0001), and for the study of ascites 2.6 and 3.8% respectively. Laparoscopy and biopsy were diagnostic in 98.5% of cases; 51% carcinomatosis, 17.5% liver cirrhosis, 11.7% hepatic neoplasm and others. Two of five cases of peritoneal tuberculosis were considered carcinomatosis at laparoscopy. There were no serious complications. CONCLUSIONS: The advent of new imaging method has reduced the use of laparoscopy, although it is still employed frequently for the study of ascites. Laparoscopy with biopsy when necessary has an excellent effectiveness and accuracy for the diagnosis of ascites of unknown cause.

[HELLP syndrome. Analysis of 2 cases]. / Síndrome de HELLP. Análisis de dos casos.

HELLP syndrome (Hemolysis, Elevated Liver Enzymes, Low Platelets), one of the gestational diseases of the third trimester of pregnancy associated to eclampsia or preeclampsia, has a varied clinical expression, that include poor symptomatic patterns with malaise and/or dyspepsia, even several patterns with fatal outcome. We show two cases with clinical and laboratory criterion of HELLP syndrome, but with different clinical presentations. It's analyzed the pathogenicity, clinical-pathological expression, course and therapeutics options in HELLP syndrome.

[Usefulness of ultrasonography in the early diagnosis of hepatocarcinoma in patients with liver cirrhosis]. / Utilidad de la ecografía en el diagnóstico precoz del hepatocarcinoma en pacientes con cirrosis hepática.

OBJECTIVE: To assess the efficacy of a screening program of ultrasonography (U.S.) every six months in the early diagnosis of HCC in liver cirrhosis patients. PATIENTS AND METHODS: We review retrospectively the 99 HCC detected by U.S. in our service from January 1991 to July 1994. We compared patients in the ultrasonography screening program (Group I) with patients who did not (Group II) and, also with, patients with a previous diagnosis of cirrhosis (Group IIa) and patients with simultaneous HCC diagnosis of and cirrhosis (Group IIb). Liver function, the tumor size and extension, and the chance of treatment at the time of diagnosis were analyzed in each group. RESULTS: Twenty (58%) HCC out of 34 from group I single nodules < 5 cm in diameter vs seven (11%) out of 65 from group II (p < 0.001) were detected and this difference persisted between group I and groups IIa and IIb (p = 0.002 and p < 0.001). Most patients with grade C Child-Pugh's score (24 from 27) in each group showed a > 5 cm or multinodular HCC. Ten patients from group I were treated vs 4 from group II (p = 0.001). CONCLUSIONS: Ultrasonography screening program is useful in the early diagnosis of HCC in liver cirrhosis patients and increases the chances of treatment.

[Juvenile polyposis in 2 patients of the same family]. / Poliposis juvenil en dos pacientes de una misma familia.

Two cases of juvenile familiar polyposis (one 40-year-old male and his 14-year-old daughter) are presented. The girl presented intermittent rectal bleeding since the age of 10 with growth retardation and chronic anemia. The child was treated by colectomy with more than 100 juvenile polyps without adenomatous alterations being observed in the surgical specimen. Juvenile gastric polyps were also endoscopically observed. The father underwent sigmoidectomy for a adenomatous polyp of this localization. Later review of the surgical specimen demonstrated a juvenile polyp with zones of adenomatous alterations. The diagnostic difficulties of this rare entity and the therapeutic options available are discussed.

[Chronic cholestasis as a presentation form of portal cavernoma]. / Colestasis crónica como forma de presentación de una cavernomatosis portal.

A 37 year-old-woman was evaluated in 1993 for a chronic asymptomatic cholestasis. An endoscopic retrograde cholangiopancreatography showed the biliary tract compressed, and a mesenteric angiogram disclosed that the cause of biliary obstruction was a portal cavernoma. In addition, large esophageal varices with "red spots" were observed at endoscopy. Propranolol and ursodeoxicolic acid were started and the patient has remained asymptomatic to date. The biliary features of portal cavernoma are reviewed, as well as its pathogenesis, diagnosis and management. Portal cavernoma should be considered in the differential diagnosis of chronic cholestasis.

Predictive factors of oxygen desaturation during upper gastrointestinal endoscopy in nonsedated patients.

BACKGROUND: Hypoxemia can occur during upper gastrointestinal endoscopy with or without pharmacologic sedation. We investigated possible predictive factors of severe oxygen desaturation (SaO2 < 90%) in nonsedated patients undergoing endoscopy. METHODS: A total of 481 patients who underwent upper gastrointestinal endoscopy without sedation were monitored with continuous pulse oximetry. Multivariate logistic regression analysis was used to identify factors related to the patient, the examination, and the monitoring data that would predict severe desaturation. RESULTS: Mild desaturation (SaO2 between 90% and 94%) was found in 23.7% of the patients, and severe desaturation (SaO2 < 90%) was found in 6.4%. The variables found to predict severe desaturation were basal SaO2 < 95% (odds ratio 67.7), respiratory disease (odds ratio 30.5), more than one attempt needed for intubation (odds ratio 39.4), emergency procedure (odds ratio 14.9), and American Society of Anesthesiologists score of III or IV (odds ratio 3.9). CONCLUSIONS: The predictive variables analyzed in this study can be used to identify patients who are at increased risk for desaturation. Such patients require very close monitoring (pulse oximetry at a minimum). Endoscopists and assistants should be especially alert to the possibility of respiratory depression in these patients.

Chronic liver injury related to use of bentazepam: an unusual instance of benzodiazepine hepatotoxicity.

Liver injury induced by benzodiazepines is rare and is classified as an unpredictable or idiosyncratic hepatotoxic reaction. Early reports indicated that in most cases the pattern of liver injury was cholestatic. We describe three patients with persistent increases in liver transaminase levels after several weeks of treatment with bentazepam, a benzodiazepine marketed in Spain for anxiety disorders. In all cases withdrawal of the drug was followed by resolution of transaminase level abnormalities. A liver biopsy (done in one patient only) showed histological evidence of severe chronic active hepatitis. In conclusion, these findings, together with two previously published case reports, suggest that a benzodiazepine can cause chronic hepatitis and argue in favor of using liver function tests to monitor all patients taking bentazepam.

Salvemos los futuros colgajos en los parapléjicos / Let us save the cutaneous muscular adjacent flaps for pressure sore treatment

Es importante tener en cuenta que las lesiones por decúbito y las cicatrices excesivas conspiran contra el tratamiento integral del paciente y prolongan los tiempos de cuidado médico intensivo en detrimento del entrenamiento en actividades funcionales que permitan la reinserción en el medio familiar y social. En consecuencia abogamos por la preservación de la piel sana que rodea a la úlcera por presión dado que es innecesario sacrificarla cuando se la puede conservar. Este mismo concepto debe regir la planificación de los colgajos en estos pacientes particularmente recidivantes. Generalmente tenemos preferencias quirúrgicas, sea por experiencia previa o por incllinación a probar técnicas en boga o novedosas y esto nos puede llevar a descuidar lo que le conviene al paciente. En estos pacientes que con seguridad volverán a ulcerarse, la preservación de los futuros colgajos se hace imprescindiblel. La concienzuda elección del colgajo redundará en una operación fácil que aunque rutinaria será ventajosa para el paciente y para el futuro cirujano que tenga que reparar una nueva lesión

Salvemos los futuros colgajos en los parapléjicos / Let us save the cutaneous muscular adjacent flaps for pressure sore treatment

Es importante tener en cuenta que las lesiones por decúbito y las cicatrices excesivas conspiran contra el tratamiento integral del paciente y prolongan los tiempos de cuidado médico intensivo en detrimento del entrenamiento en actividades funcionales que permitan la reinserción en el medio familiar y social. En consecuencia abogamos por la preservación de la piel sana que rodea a la úlcera por presión dado que es innecesario sacrificarla cuando se la puede conservar. Este mismo concepto debe regir la planificación de los colgajos en estos pacientes particularmente recidivantes. Generalmente tenemos preferencias quirúrgicas, sea por experiencia previa o por incllinación a probar técnicas en boga o novedosas y esto nos puede llevar a descuidar lo que le conviene al paciente. En estos pacientes que con seguridad volverán a ulcerarse, la preservación de los futuros colgajos se hace imprescindiblel. La concienzuda elección del colgajo redundará en una operación fácil que aunque rutinaria será ventajosa para el paciente y para el futuro cirujano que tenga que reparar una nueva lesión