Results of a survey about specific inflammatory bowel disease units in Andalusia.

BACKGROUND: Inflammatory bowel disease (IBD) has become one of the most prevalent pathologies in Gastroenterology Units, which added to its clinical outcome, treatment, the complexity of affected patients and the need to be continuously updated for the correct management of the disease, have made essential the presence of specific IBD units in each hospital. OBJECTIVES: The primary aims of this study were: a) to reveal the existence of these units in our area and how they work; and b) to draw conclusions regarding the necessary resources in these units and their aims. MATERIAL AND METHODS: In order to analyse the presence of these specialized units and the available resources in Andalusian hospitals, a 24-question survey was designed, being answered by 11 hospitals. The evaluated questions included the number of days patients are attended and the number of physicians attending the unit, the number of available healthcare assistants, if emergencies are attended or not, if there is an activated telephone number for patient consultation, if a day care unit is available and if new treatments are easily accessible. RESULTS: A specific IBD unit is present in all studied hospitals attending more than 11 patients each, although in the 63.4% of the cases patients are not attended more than 3 days per week. On the other hand, the 81.8% of the included hospitals attend emergencies although only the 54.5% of them had a specific telephone number for patient attendance. CONCLUSIONS: A specific IBD unit is present in many Andalusian hospitals, although some deficiencies can be observed. The general opinion of this Group is that these units are necessary in order to properly attend, monitorize and treat patients affected by IBD.

[A high-resolution gastroenterology clinic in Andalusia: what is it, and how should it work]. / Consulta de alta resolución de digestivo en Andalucía: qué es y cómo debe funcionar?

INTRODUCTION: The present concept in our healthcare system is that medical care should be given on an outpatient basis with hospitalization occurring only when essential. We therefore put forth the development of the "all in one" outpatient office or "high resolution" outpatient clinic. For such purpose we administered a questionnaire to various Andalusian hospitals to define and determine those aspects necessary in the development of the aforementioned outpatient office. MATERIALS AND METHODS: The questionnaire was filled out by 10 Andalusian hospitals. This is a prospective-descriptive study of responses from all 10 participating hospitals. The 27 questions inquired on the existence of such an outpatient office and the infrastructure needed to develop this service: How many patients are seen, where is it physically located, where do patients come from, criteria for assigning patients to this medical office, condition of incoming patients, whether ultrasound scans are performed, whether an integrated hospital computer system exists, nursing staff, how many visits are required before coming to a diagnosis, and finally whether this type of outpatient office is needed, and if so, why. RESULTS: Of all 10 hospitals, 5 of them had this type of clinic. All of them considered this type of outpatient service essential. The number of patients treated should be "10", in the hospital itself. There are differences as to whether patients should come from the emergency room or a primary care physician. It seems logical to assume that only patients who can be diagnosed via ultrasounds or endoscopy should be chosen. To allow an ultrasonogram the patient should visit the outpatient office in a state of "fasting" and with standard blood counts from the primary care physician. The outpatient clinic should have a computer system and its own nurse. According to participating hospitals this type of outpatient visits is very useful in our present healthcare system, as it allows higher levels of collaboration between Primary Care and the specialist; it also provides a rapid orientation regarding patient pathology, and acts as a "filter" for the rest of the healthcare system. CONCLUSIONS: The outpatient office should be tended to by an attending specialist in the field (FEA) with knowledge and experience in ultrasounds and gastrointestinal endoscopy, as well as user competency with the required computer programs. In our present-day system this can be considered a modality of high-resolution outpatient services and a model of efficiency.

[Musculoskeletal hydatidosis: an unusual location]. / Hidatidosis musculoesquelética: una localización atípica.

Hydatidosis is a zoonosis with a continuing high prevalence in our environment. The most commonly affected organs are the lungs and the liver, with the musculoskeletal location being considered an unusual one. We comment the case of a patient who presented a series of lesions in his left iliac crest and middle left buttock with spontaneous fistulization to the skin surface. In this case a combined treatment was given; prior to the surgical operation we administered a cycle of albendazol. Following removal of the lesion, the patient was given two further cycles of albendazol in order to minimize the risk of a recurrence of the illness. This patient is currently free of any symptoms relating to this illness.

[Spontaneous intramural dissection of the esophagus]. / Perforación intramural espontánea del esófago.

Spontaneous intramural dissection of the esophagus (SIDE) is an unusual clinical entity. It is a benign disease that, despite its alarming endoscopic appearance, usually responds well to conservative management and has an excellent prognosis. Nevertheless, some situations require emergency surgical treatment. These situations include esophageal perforation with mediastinitis, massive bleeding, and abscess, among others. Upper gastrointestinal endoscopy is a useful diagnostic test when radiological examinations (hydrosoluble contrast esophagogram, computed tomography, or magnetic resonance imaging) have excluded perforation. We present the case of a 42-year-old woman who was admitted to our hospital complaining of acute chest pain, dysphagia, and odynophagia. Because of the persistence of symptoms and diagnostic uncertainty (SIDE versus complicated esophageal duplication cyst) surgery was performed. The definitive diagnosis was SIDE.

[MALT lymphoma in a patient with Crohn's disease. A causal or incidental association?]. / Linfoma intestinal tipo MALT en una paciente con enfermedad de Crohn: asociación causal o casual?

We present the case of a 79-year-old woman who had received a diagnosis of Crohn's disease 3 years previously and who developed a mucosa-associated lymphoid tissue (MALT) lymphoma of the right colon while undergoing treatment with mesalazine. The patient had not received immunosuppressive drugs or infliximab. The possible association between Crohn's disease and the development of intestinal lymphomas is analyzed. The incidence, pathogenic mechanisms, diagnostic strategy, treatment and prognosis of these neoplasms are described, mainly with reference to MALT lymphomas of the colon.

[Duodenal perforation due to an endoscopic biliary prosthesis]. / Perforación duodenal por prótesis biliar endoscópica.

Endoscopic biliary drainage through endoscopic retrograde cholangiopancreatography (ERCP) is a widely accepted therapeutic option in malignant biliary obstructions. However, the procedure is not free of complications. Perforation is one possible complication although it is much less frequent (less than 1%) than pancreatitis (5.4%) or hemorrhage (2%). We present 2 cases of duodenal perforation after placement of a biliary prosthesis through ERCP. Both patients had extensive hilar cholangiocarcinoma. Onset of symptoms of perforation occurred a few hours after placement of the prosthesis and the diagnosis was confirmed by computed tomography and laparotomy. We believe that the mechanism through which perforation occurred was proximal adhesion of the prosthesis to the tumor. This increased the intensity of distal trauma produced by the intraduodenal segment, preventing adaptation of the prosthesis to intestinal peristalsis. A good preventive measure would consist of correctly adjusting the length of the prosthesis in relation to the proximal end of the biliary stenosis.

Biliopancreatic tumors: patient survival and quality of life after palliative treatment.

OBJECTIVES: to analyse survival and quality of life of patients with malignant obstructive jaundice after palliative treatment, comparing endoscopic stent insertion and palliative surgical (palliative resection and bypass surgical). PATIENTS AND METHOD: eighty and seven patients were included in a trial. They were distributed to endoscopic stent (50) and palliative surgical (37). It analysed survival, quality of life and comfort index of jaundiced patients. The good quality of life was defined by absence of jaundice, pruritus and cholangitis after the initial treatment. RESULTS: the median survival of the patients treated to endoscopic stent was 9,6 months whereas the patients to surgical treatment survived a median of 17 months. The time free of disease was 4 months in stented patients and 10,5 months in surgical patients. There was no significant difference in comfort index between the two groups (stented 34%, surgical 42,5%) Neither was there significant difference in survival and quality of life between palliative resection and bypass surgery. CONCLUSIONS: despite the survival and time free of disease being better in surgical patients, there was no significant difference in overall quality of life between the two groups. The survival and quality of life are the same after palliative resection as after bypass surgery, for this should not be performed routinely or to justify resection as a debulking procedure.

Failure of endoscopic therapy in upper gastrointestinal hemorrhage due to duodenal ulcers.

OBJECTIVES: to evaluate the efficacy of endoscopic treatment in patients with upper gastrointestinal (UGIH) due to duodenal ulcer with high risk of persistent or recurrent bleeding and to determine the associated failure factors of this procedure. PATIENTS AND METHOD: three hundred and thirty-six patients with UGIH due to duodenal ulcer requiring endoscopic treatment were analyzed between January 1992 and December 2001. The patients were classified according to the endoscopic findings: a) patients with limited bleeding; and b) patients with persistent and/or recurrent bleeding due to therapeutic failure. The clinical guidelines followed in patients with endoscopic treatment failure were previously established in the internal protocol. The variables that obtained statistical significance in the univariate analysis were included in the logistic regression model to identify those with an independent predictive value for failure of the endoscopic treatment. RESULTS: mean age of the patients was 60 +/- 17 years, 271 (81%) were male. Bleeding with severe hemodynamic affectation was detected in 82 patients (24%). The most common location of the duodenal ulcer was on the anterosuperior part of the duodenal bulb (227 patients, 68%). In 43 patients (13%) the ulcer was larger than 2 cm. The bleeding stigmata were classified as: Forrest I in 125 (38%) and Forrest II in 211 (62%). It was initially reached in 297 patients (88%). Twenty-two patients required emergency surgery (6,5%) and the global mortality rate was 3%. Severe hemodynamic affectation at admission (OR 11.8, p>0.001), ulcers exceeding 2 cm (OR 6.95, p = 0.019) and the presence of active bleeding during endoscopy (Forrest I) (OR 3.55, p = 0.08) were the variables included in the multivariate analysis independently associated to endoscopic therapy failure. CONCLUSION: endoscopic therapy is an efficient treatment of upper gastrointestinal bleeding due to duodenal ulcer. By means of a clinical variable, the hemodynamic status and two endoscopies, bleeding stigmata and the size of the ulcer, a group of patients with high risk of endoscopic treatment failure can be selected.

[Factors associated with failure of endoscopic therapy in gastric ulcer bleeding]. / Factores asociados al fracaso de la terapéutica endoscópica en la hemorragia digestiva por úlcera gástrica.

INTRODUCTION: Endoscopic therapy is an effective technique in the control of bleeding due to peptic ulcer. However, bleeding persists or recurs in as many as 10-30% of patients. Gastric and duodenal ulcers present different clinical and endoscopic features and consequently the efficacy of endoscopic therapy and the factors associated with its failure should be studied separately. OBJECTIVES: To analyze the efficacy of endoscopic therapy in patients at high risk of persistent or recurrent bleeding due to gastric ulcer and to identify the factors associated with the failure of this technique. PATIENTS AND METHODS: We performed a retrospective study based on a clinical intervention protocol. Two hundred eight patients admitted for bleeding secondary to gastric ulcer with active bleeding or stigmas of recent bleeding who received endoscopic therapy between January 1992 and December 2001 were analyzed. Clinical, laboratory and endoscopic variables on admission, as well as the medical treatment and endoscopic procedure applied, were registered. Endoscopy was performed within 12 hours of admission. Patients were classified according to their response to endoscopic therapy: a) patients with limited bleeding, and b) patients with persistent or recurrent bleeding due to therapeutic failure. Intervention in patients with therapeutic failure was performed according to a previously established protocol. Variables that were statistically significant in the univariate analysis were included in a logistic regression model to identify those with an independent predictive value for failure of endoscopic therapy. RESULTS: Definitive hemostasis was achieved after initial therapy in 181 patients (87%). The efficacy of a second procedure increased the percentage of hemostasis to 91% of the patients. In the logistic regression model, the only variables that were independently associated with initial therapeutic failure were: hemodynamic status on admission (p = 0.016; OR = 3.99), the need for transfusion of blood products prior to endoscopy (p = 0.025; OR = 3.48), upper localization of the gastric ulcer (p = 0.050; OR = 3.08) and unsatisfactory endoscopic therapy (p = 0.009; OR = 17.39). CONCLUSION: These variables could contribute to the early identification of a subgroup of patients, which would enable us to increase medical-surgical surveillance and offer them other therapeutic alternatives.

[Role of early colonoscopy in severe acute lower gastrointestinal bleeding]. / Rendimiento de la colonoscopia precoz en la hemorragia digestiva baja aguda grave.

BACKGROUND: Severe acute lower gastrointestinal bleeding (SALGIB) accounts for 15% of cases of acute lower gastrointestinal bleeding (ALGIB). The incidence increases with age and comorbidity. Identification of the origin of bleeding may be difficult. Colonoscopy has been proposed as the primary investigative tool. AIM: To assess the role of early colonoscopy as the primary method of evaluation in patients with SALGIB. PATIENTS AND METHOD: Retrospective study based on a guideline for clinical practice approved in our institution. The study included 50 patients with SALGIB admitted to our gastrointestinal bleeding unit between January 1998 and April 2000. SALGIB was suspected when patients fulfilled two or more of the following criteria: 1) significant hemodynamic compromise, 2) decrease in hemoglobin 2 g/dl, and 3) transfusion requirement >= 2 blood units. Early colonoscopy was performed within 24 hours of onset of bleeding. An accurate endoscopic diagnosis was established if a lesion with active bleeding, visible non-hemorrhagic vessel or adherent red clot was identified. A presumptive diagnosis was made when hematochezia or fresh blood localized in a colonic segment, associated with a single, potentially hemorrhagic lesion, was observed and when the results of esophagogastroduodenoscopy were negative. Colonoscopy, esophagogastroduodenoscopy, barium studies, nuclear scan and angiography were performed. RESULTS: Two hundred twenty-two patients were admitted for ALGIB. Fifty patients(22%) fulfilled the SALGIB criteria. The male/female ratio was 1:1. Definitive diagnosis was accurate in 20 patients. The most frequent cause was angiodysplasia (6 patients) and rectal ulcer (6 patients). Eighteen patients had a presumptive diagnosis; of these 14 had diverticulosis. In 12 patients, no cause was identified. Colonoscopy was performed in 45 patients, of which 32 were performed early and 13 electively. Accurate endoscopic diagnosis was more frequently established with early colonoscopy than with elective colonoscopy (15 [47%] vs 2 [15%], p < 0.05). The results of urgent nuclear scans contributed to accurate diagnosis in 5 out of the 10 patients in whom this technique was performed. Angiography was performed in 2 patients. Endoscopic therapy was attempted in 4 patients, all during early colonoscopy. Ten patients (20%) underwent surgery and 3 patients (6%) died. CONCLUSIONS: In 22% of patients with ALGIB admitted to our hospital bleeding was severe. Colonoscopy is the diagnostic tool of choice. When performed within 24 hours of hospital admission, this technique provides more accurate diagnosis than when performed electively.

[Endoscopic drainage with polyethylene endoprosthesis of malignant obstructive jaundice]. / Drenaje endoscópico mediante prótesis de polietileno de la ictericia obstructiva maligna.

AIM: To evaluate the efficacy and complications of endoscopic drainage of malignant obstructive jaundice with plastic endoprosthesis as well as to identify possible factors related with occlusion. PATIENTS AND METHODS: One-hundred and forty patients with malignant obstructive jaundice were retrospectively evaluated. The site of obstruction was proximal in 35 patients (25.0%), distal in 64 (45.7) and ampullary in 41 (29.3). Amsterdam or pigtail polyethylene prostheses of variable caliber and length were used. Drainage was preoperative in 41 patients and palliative in 99. Seventy-seven patients who underwent with palliative drainage were followed up long-term. RESULTS: Drainage was satisfactory in 132 patients (94.2%). Early morbidity was 10.7% (14/140) and early mortality related with the technique was 5% (7/140). Time free of obstruction was 4.6 +/- 1.0 months and in 47/77 (60%) the prostheses were still working at the end of follow-up. The actuarial rate of obstruction at 6 months was 42%, the majority (61%) occurring in the first 3 months. The median survival was 5.9 +/- 1.3 months. Of all the factors analyzed, greater permeability was found only in the ampullary tumors (p < 0.01) and in prostheses of caliber equal or superior to 10 French (p < 0.01). CONCLUSIONS: Endoscopic biliary drainage using plastic prostheses is satisfactory in the majority of patients with malignant jaundice. It has a low complication rate and provides acceptable palliation: the majority of patients do not require prostheses to be replaced and, when they becomes clogged, substitution usually solves the problem. Ampullary tumors and prostheses of higher caliber (> or = 10F) have been associated with greater permeability.

Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease.

BACKGROUND: The aim of this study was to evaluate the results of endoscopic sphincterotomy in patients with hepatic hydatid cysts that have ruptured into the biliary tract. METHODS: Over a 10-year period, 25 patients (11 men, 14 women, mean age 60 years) underwent treatment; 13 with no prior surgery were treated for biliary obstruction. Postoperative treatment was undertaken in 12 cases because of persistent drainage (8), duct obstruction (3), and postoperative pancreatitis (1). RESULTS: In patients who had not undergone previous surgery, cholangiographic findings were hydatid vesicles in the biliary tract (6), dilation of the biliary tract (3), biliary fistula (2), distal stenosis (1), and purulent bile content after sphincterotomy (1). In all of these cases, sphincterotomy resolved duct obstruction with no complications. All patients with persistent postoperative drainage had a fistula tract between the biliary duct and the cavity, which was resolved by endoscopic treatment in all 8. The 3 patients with postoperative biliary obstruction had hydatid vesicles in the biliary tract, one with a long stenosis resembling sclerosing cholangitis, whereas the patient with postoperative pancreatitis had a distal stenosis. Satisfactory results were obtained with endoscopic sphincterotomy, although 1 patient required a biliary prosthesis. CONCLUSION: Endoscopic sphincterotomy resolves biliary obstruction and postoperative fistulae in most patients with hepatic hydatid cysts that have ruptured into the biliary tract. In some cases, a biliary prosthesis may be required.

[Treatment with endoscopic endoprosthesis in choledocholithiasis]. / Tratamiento con endoprótesis endoscópica de la litiasis de la vía biliar principal.

The results of the placement of endoscopic endoprosthesis in 51 patients with choledocholithiasis from October 1991 to December 1995 are reviewed. In 13 cases the endoprosthesis was provisionally placed. Surgical or endoscopic treatment was electively completed in all the cases. Thirty-eight patients received the endoprosthesis on a permanent basis. During the follow up (mean 15.2 months) extraction was completed and the prosthesis removed in three cases, one by emigration. Six patients presented recurrent biliary obstruction and underwent surgery or replacement of another prosthesis. In the latter cases, another two underwent surgery due to repeated obstructions. The remaining patients remained asymptomatic until the end of follow up or until death (8 cases) due to unrelated causes. Only three mild episodes of cholangitis were observed as complications related to prosthesis placement. The authors conclude that endoscopic endoprosthesis is an effective provisional treatment to solve acute situations and is a permanent alternative for unextracted choledocholithiasis following sphincterotomy in patients who cannot undergo other techniques and who have a short life expectancy.

[Prevention of recurrence of acute biliary pancreatitis by endoscopic sphincterotomy]. / Prevención de la recidiva de la pancreatitis aguda biliar mediante esfinterotomía endoscópica.

The aim of this study was to know if endoscopic sphincterectomy could be an alternative to cholecystectomy in high surgical risk patients that have suffered acute biliary pancreatitis. Between January 1992 to December 1995 endoscopic sphincterectomy was carried out in 52 high surgical risk patients who had suffered an episode of acute biliary pancreatitis. The lithiasic gallbladder was not removed. The mean age was 75.6 years (35-91). After a follow up of 15.9 months (1-46.5), no patient suffered from a new episode of acute pancreatitis. Six patients (12%) required cholecystectomy due to complications derived from the lithiasic gallbladder. Endoscopic sphincterectomy is an effective alternative to cholecystectomy in the prevention of new episodes of acute biliary pancreatitis in patients with lithiasic gallbladder and high surgical risk. The complications of the lithiasic gallbladder in situ after endoscopic sphincterectomy are relatively infrequent.

[Family factors in adolescent suicide attempts]. / Factores familiares en las tentativas de suicidio de adolescentes.

The aim of the present study is the analysis of the family characteristics associated with suicide attempts among adolescents. Subjects were 54 adolescents aged 13-18 referred to hospital after a suicide attempt and 108 normal comparison adolescents. A case-control study design has been used and they have been matched by age, sex and socioeconomic status. Differences between groups are reported as Odds Ratio (OR) with a 95% confidence interval. The results in Odds Ratio are as follows: parental losses (OR = 19.00), mental illness in father (OR = 8.67), mental illness in mother (OR = 6.79), mental illness among brothers and sisters (OR = 3.28), poor membership relations (OR = 3.00), not living with both biological parents (OR = 8.06) and unsatisfactory familial adaptation (OR = 7.50). In conclusion, our findings highlight the importance of the familial risk factors and its implications to develop preventive programs for youngs at risk.

[Portal vein thrombosis in hepatocarcinoma. Demonstration with ultrasound]. / Trombosis de la vena porta en el hepatocarcinoma. Demostración por ultrasonidos.

Six cirrhotic patients underwent ultrasound scans in the course of their disease because of clinical deterioration. Ultrasonography revealed the presence of carcinoma as well as dilatation of the portal vein with hypoechogenic masses in its lumen. The presence of thrombi was confirmed by other techniques such as CAT and/or arteriography.