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BACKGROUND AND AIMS: Protein-losing enteropathy (PLE) after Fontan surgery carries significant morbimortality. Its pathophysiology and association with other Fontan complications are poorly understood. Our aims were to examine whether Fontan-PLE is associated with greater liver damage and to assess the presence of systemic and intestinal inflammation. METHODS: Fontan patients with PLE and Fontan controls without PLE matched for age and Fontan surgery procedure were included. Data were prospectively compiled on blood and stool tests, liver imaging, elastography, cardiac-MRI and cardiac catheterization. RESULTS: Twenty-nine Fontan patients were enrolled (14 with PLE and 15 controls without PLE). Patients with PLE had more advanced liver disease estimated by non-invasive methods: blunt liver margins on ultrasonography (71.4% vs 26.7%, P = .027), greater median liver stiffness (25.4 vs 14.5 kPa, P = .003) and higher FIB-4 (P = .016). Portal hypertension-related signs were more common in patients with PLE including ascites (P = .035), larger spleen size (P = .005), oesophageal varices/splanchnic collateral shunts (P = .03), higher liver stiffness-spleen size-to-platelet ratio risk score (P < .001) and lower platelet count (P = .01). Systemic proinflammatory cytokines (TNF-α, interleukin-6), biomarkers of intestinal permeability (intestinal fatty-acid binding protein) and faecal calprotectin concentrations were also significantly increased in Fontan-PLE (P < .05). Faecal calprotectin directly correlated with alpha-1 antitrypsin clearance and inversely with cardiac index, total serum proteins and body mass index. CONCLUSION: Fontan-PLE is associated with advanced liver disease and increased markers of systemic inflammation and intestinal permeability. Faecal calprotectin is elevated and correlates with Fontan-PLE severity. Liver assessment is mandatory in all Fontan patients, and especially in those with PLE.
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Técnica de Fontan , Hepatopatias , Enteropatias Perdedoras de Proteínas , Técnica de Fontan/efeitos adversos , Humanos , Hepatopatias/etiologia , Enteropatias Perdedoras de Proteínas/etiologia , UltrassonografiaRESUMO
BACKGROUND & AIMS: Cellulitis is a common infection in patients with cirrhosis but its impact on progression of liver disease has been hardly addressed. This study examines the incidence of acute kidney injury (AKI), predictive factors and its impacts on mortality in cirrhotic patients hospitalized for cellulitis. METHODS: Retrospective data from cirrhotic patients hospitalized for cellulitis over the period January 2006 to September 2015 were analysed. AKI was defined according to revised criteria of the International Club of Ascites. RESULTS: A total of 101 episodes of cellulitis were examined (70.3% men; mean age 60.6 ± 13.6 years). Of patients, 27% met criteria for acute on chronic liver failure (ACLF) (grade 1: 63%; grade 2: 22%; grade 3: 15%). AKI was recorded in 50.5% (type 1: 67%; type 2: 19%; type 3: 14%). AKI was present on admission in 21 of the 51 patients (41%) who developed it. In the remaining 30 patients (59%), AKI appeared during hospitalization and its development was associated with a MELD score >14 (70% vs 30%, P=.024). In-hospital mortality was 10% and all patients who died had AKI. A high MELD score on admission, AKI and ACLF were associated with in-hospital mortality (P<.05). One-month transplant-free survival was 84% (70% vs 98% in patients with and without AKI, P=.001). CONCLUSIONS: In cirrhotic patients, cellulitis is a serious infection that often leads to AKI and ACLF. AKI is a strong predictor of mortality in this setting.
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Injúria Renal Aguda/epidemiologia , Celulite (Flegmão)/epidemiologia , Hospitalização , Cirrose Hepática/epidemiologia , Injúria Renal Aguda/microbiologia , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/terapia , Idoso , Celulite (Flegmão)/microbiologia , Celulite (Flegmão)/mortalidade , Celulite (Flegmão)/terapia , Progressão da Doença , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Cirrose Hepática/microbiologia , Cirrose Hepática/mortalidade , Cirrose Hepática/terapia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Fatores de TempoRESUMO
BACKGROUND: Helicobacter pylori antibiotic resistance is an increasing problem worldwide. Pylera® may be an option as salvage therapy. AIM: To assess the effectiveness, safety, and tolerance of Pylera® as a third-line in clinical practice. MATERIALS AND METHODS: This was a multicenter, observational, prospective database study in four Spanish hospitals. Consecutive H. pylori-infected individuals treated with Pylera® and a proton-pump inhibitor (PPI) were invited to participate if they had failed to respond to PPI-clarithromycin-amoxicillin as first-line and to levofloxacin-amoxicillin-PPI as second-line therapy. Eradication was tested 4-8 weeks after Pylera® using a C13 -urea breath test. Treatment-related adverse effects (TRAEs) were assessed through a questionnaire and by reviewing databases. A questionnaire on patient satisfaction was completed in the last visit. RESULTS: Of 103 subjects fulfilling the selection criteria, 101 were included in the intention-to-treat (ITT) analysis and 97 in the per-protocol (PP) analysis. A 10 day course was prescribed in all patients. Esomeprazole 40 mg b.i.d. was the most used PPI regimen (ITT=94.1%). Ninety-seven individuals (ITT=96.04%) completed more than 90% of the treatment. Overall eradication rates were ITT=80.2% (95% confidence interval [CI]: 72.3%-88.1%) and PP=84.4% (95% CI: 76.8%-91.8%). One or more TRAEs were experienced by 67.3% (95% CI: 57.7%-75.7%), all mild or moderate. TRAEs and the number of pills were the main complaints. CONCLUSION: In an area of high antibiotic resistance to H. pylori, 10-day Pylera® plus double-dose PPI emerged as an alternative as third-line therapy, although not achieving optimal eradication rates. TRAEs were common but were neither severe nor did they condition compliance.
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Anti-Infecciosos/administração & dosagem , Bismuto/administração & dosagem , Infecções por Helicobacter/tratamento farmacológico , Helicobacter pylori/isolamento & purificação , Terapia de Salvação/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Testes Respiratórios , Quimioterapia Combinada/métodos , Feminino , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Prospectivos , Inibidores da Bomba de Prótons/administração & dosagem , Espanha , Inquéritos e Questionários , Resultado do Tratamento , Ureia/análise , Adulto JovemRESUMO
INTRODUCTION: Recurrent Clostridium difficile infection (CDI) is common and often difficult to manage. Faecal microbiota transplant (FMT) is an effective therapeutic tool in these cases, although its applicability and effectiveness in Spain is currently unknown. AIM: To analyse the technical aspects, safety and effectiveness of the first consolidated FMT programme in Spain. METHODS: Retrospective descriptive study of all patients with recurrent CDI treated with FMT performed by colonoscopy in a tertiary centre after the implementation of a multidisciplinary protocol between March 2015 and September 2016. RESULTS: A total of 13 FMT were performed in 12 patients (11/12; 91.7% women) with a median age of 84.6 years (range: 38.2-98.2). Recurrence of CDI was the indication for FMT in all cases. Patients had suffered a median of 3 previous episodes of CDI (range: 2-6) and all had failed treatment with fidaxomicin. All procedures were performed by colonoscopy. Effectiveness with one session of FMT was 91.7% (11/12; 95% CI: 64.6 to 98.5%). In the non-responder patient, a second FMT was performed 17 days after the first procedure, with disappearance of symptoms. No side effects related to the endoscopic procedure or the FMT were recorded after a median follow-up of 6.5 months (range: 1-16 months). Two patients died during follow-up due to causes unrelated to FMT. CONCLUSION: FMT by colonoscopy is an effective and safe therapeutic alternative in recurrent CDI. It is a simple procedure that should be implemented in more centres in Spain.
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Infecções por Clostridium/terapia , Colonoscopia , Transplante de Microbiota Fecal/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Transplante de Microbiota Fecal/efeitos adversos , Feminino , Humanos , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Proton-pump inhibitors (PPIs) are one of the most active ingredients prescribed in Spain. In recent decades there has been an overuse of these drugs in both outpatient clinics and hospitals that has lead to a significant increase in healthcare spending and to an increase in the risk of possible side effects. It is important for health professionals to know the accepted indications and the correct doses for the use of these drugs. On the market there are different types of PPI: omeprazole, pantoprazole, lansoprazole, rabeprazole and esomeprazole. Omeprazole is the oldest and most used PPI, being also the cheapest. Although there are no important differences between PPIs in curing diseases, esomeprazole, a new-generation PPI, has proved to be more effective in eradicating H. pylori and in healing severe esophagitis compared to other PPIs. In recent years the use of generic drugs has spread; these drugs have the same bioavailability than the original drugs. In the case of PPIs, the few comparative studies available in the literature between original and generic drugs have shown no significant differences in clinical efficacy.
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Conduta do Tratamento Medicamentoso , Inibidores da Bomba de Prótons/uso terapêutico , Animais , Medicamentos Genéricos , Refluxo Gastroesofágico/prevenção & controle , Gastroenteropatias/tratamento farmacológico , Humanos , Inibidores da Bomba de Prótons/farmacologiaRESUMO
In this article we present the case and images of an infrequent submucosal gastric tumor: an inflammatory fibroid polyp or Vanek´s tumor. When the tumor size exceeds the centimeter, it may be difficult to differentiate from malignant lesions. Endoscopic removal may be feasible and curative.
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Tumores do Estroma Gastrointestinal/patologia , Neoplasias Gástricas/patologia , Úlcera Gástrica/patologia , Idoso , Feminino , Mucosa Gástrica/patologia , Tumores do Estroma Gastrointestinal/diagnóstico por imagem , Tumores do Estroma Gastrointestinal/cirurgia , Humanos , Neoplasias Gástricas/diagnóstico por imagem , Neoplasias Gástricas/cirurgia , Úlcera Gástrica/diagnóstico por imagem , Úlcera Gástrica/cirurgia , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. OBJECTIVE: The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. MATERIAL AND METHODS: A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. RESULTS: Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. CONCLUSIONS: PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.
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Inibidores da Bomba de Prótons/efeitos adversos , Interações Medicamentosas , Medicina Baseada em Evidências , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/etiologia , Humanos , Infecções/epidemiologia , Cirrose Hepática/complicações , Deficiência de Magnésio/induzido quimicamente , Deficiência de Magnésio/epidemiologia , Doenças do Sistema Nervoso/induzido quimicamente , Doenças do Sistema Nervoso/epidemiologia , Inibidores da Bomba de Prótons/administração & dosagem , Inibidores da Bomba de Prótons/uso terapêuticoRESUMO
Hydrochloric acid gastric secretion plays, among its primary physiological foundations, a role as protective barrier against infection with external agents from the diet and also contributes to the digestion of ingested food. However, this secretion is a critical factor shared by a number of highly prevalent diseases involving the upper gastrointestinal tract. Paradigms of such conditions include gastroduodenal peptic ulcer and gastroesophageal reflux disease.
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Inibidores da Bomba de Prótons/uso terapêutico , Uso de Medicamentos , Humanos , Prescrição Inadequada , EspanhaRESUMO
Bacteria can no longer be seen as an enemy. Nowadays, there is enough evidence to place the microbiota as a key element in human homeostasis. Despite initial skepticism, fecal microbiota transplantation (FMT) is a real therapeutic alternative for patients with recurrent Clostridium difficile infection. Moreover, this procedure has shown promising results in ulcerative colitis and other non-gastrointestinal disorders. There is still a lack of knowledge and clinical trials with long- term follow-up. Therefore, the available data should be interpreted with caution. In this document we provide a detailed review of the literature on the intestinal microbiota and FMT.
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Transplante de Microbiota Fecal , Animais , Ensaios Clínicos como Assunto , Clostridioides difficile , Enterocolite Pseudomembranosa/microbiologia , Enterocolite Pseudomembranosa/terapia , Transplante de Microbiota Fecal/efeitos adversos , Transplante de Microbiota Fecal/métodos , Transplante de Microbiota Fecal/normas , Vida Livre de Germes , Humanos , Doenças Inflamatórias Intestinais/microbiologia , Doenças Inflamatórias Intestinais/terapia , Intestinos/imunologia , Intestinos/microbiologia , Síndrome Metabólica/microbiologia , Síndrome Metabólica/terapia , MicrobiotaRESUMO
Syphilis is a chronic systemic infection mainly transmitted through sexual contact that shows a great variety of clinical manifestations. Liver involvement is an unusual complication mainly reported in HIV patients. In this case report we present a case of a 42-year-old immunocompent man with acute cholestatic hepatitis who was finally diagnosed of luetic hepatitis. Liver disease was the only manifestation of syphilis infection difficulty it's diagnostic. We emphasize the importance of including syphilis in the differential diagnosis of abnormal liver function tests in patients at risk of sexually transmitted diseases due to its resolution with appropriate antibiotic treatment.
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Hepatite/microbiologia , Sífilis/complicações , Doença Aguda , Adulto , Hepatite/diagnóstico , Humanos , Imunocompetência , Masculino , Sífilis/diagnósticoAssuntos
Hérnia Ventral/cirurgia , Herniorrafia , Laparoscopia , Complicações Pós-Operatórias/etiologia , Enteropatias Perdedoras de Proteínas/etiologia , Feminino , Humanos , Hipoalbuminemia/etiologia , Linfangiectasia Intestinal/etiologia , Pessoa de Meia-Idade , Pancreatectomia , Pancreatite/complicações , Pancreatite/cirurgia , Pancreatite/terapia , Nutrição Parenteral , Indução de Remissão , Esplenectomia , Veia Esplênica , Trombose Venosa/etiologiaAssuntos
Antineoplásicos/uso terapêutico , Doença de Crohn/complicações , Interferon-alfa/uso terapêutico , Melanoma/tratamento farmacológico , Neoplasias Cutâneas/tratamento farmacológico , Adulto , Antineoplásicos/administração & dosagem , Antineoplásicos/farmacologia , Terapia Combinada , Doença de Crohn/tratamento farmacológico , Feminino , Seguimentos , Humanos , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Interferon alfa-2 , Interferon-alfa/administração & dosagem , Interferon-alfa/farmacologia , Melanoma/complicações , Melanoma/cirurgia , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/farmacologia , Proteínas Recombinantes/uso terapêutico , Indução de Remissão , Neoplasias Cutâneas/complicações , Neoplasias Cutâneas/cirurgiaRESUMO
Liver injury has been widely described in patients with Coronavirus disease 2019 (COVID-19). We aimed to study the effect of liver biochemistry alterations, previous liver disease, and the value of liver elastography on hard clinical outcomes in COVID-19 patients. We conducted a single-center prospective observational study in 370 consecutive patients admitted for polymerase chain reaction (PCR)-confirmed COVID-19 pneumonia. Clinical and laboratory data were collected at baseline and liver parameters and clinical events recorded during follow-up. Transient elastography [with Controlled Attenuation Parameter (CAP) measurements] was performed at admission in 98 patients. All patients were followed up until day 28 or death. The two main outcomes of the study were 28-day mortality and the occurrence of the composite endpoint intensive care unit (ICU) admission and/or death. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were elevated at admission in 130 patients (35%) and 167 (45%) patients, respectively. Overall, 14.6% of patients presented the composite endpoint ICU and/or death. Neither ALT elevations, prior liver disease, liver stiffness nor liver steatosis (assessed with CAP) had any effect on outcomes. However, patients with abnormal baseline AST had a higher occurrence of the composite ICU/death (21% versus 9.5%, p = 0.002). Patients ⩾65 years and with an AST level > 50 U/ml at admission had a significantly higher risk of ICU and/or death than those with AST ⩽ 50 U/ml (50% versus 13.3%, p < 0.001). In conclusion, mild liver damage is prevalent in COVID-19 patients, but neither ALT elevation nor liver steatosis influenced hard clinical outcomes. Elevated baseline AST is a strong predictor of hard outcomes, especially in patients ⩾65 years.
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Patients with Crohn's disease often develop perianal disease, successfully managed in most cases. However, its most aggressive form, complex perianal disease, is associated with high morbidity and a significant impairment in patients' quality of life. The aim of this review is to provide an updated approach to this condition, reviewing aspects of its epidemiology, diagnosis and therapeutic alternatives. Emerging treatment options are also discussed. A multidisciplinary assessment of these patients with a coordinated medical and surgical approach is crucial.
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OBJECTIVE: The need for endoscopic investigation in patients with iron deficiency without anemia (ID) is not established. METHODS: Data from patients with ID (serum ferritin ≤20 ng/mL, normal hemoglobin) studied with upper and lower endoscopies were retrospectively analyzed. Patients evaluated for iron deficiency anemia (IDA) served as controls, matched by sex and age in the proportion of 2:1. The groups were compared for the presence, type, location and age distribution of endoscopic findings. RESULTS: Altogether 109 patients (55% women; mean age 59.6 ± 13.5 years; aged <50 years [27.5%]; 50-69 years [43.1%]; ≥70 years [29.4%]) were included in the ID group and 218 matched controls in the IDA group. Lesions were found in a similar proportion of patients (53.2% in the ID group vs 49.1% in the IDA group, P = 0.48) irrespective of age (P = 0.92). The colonoscopy diagnostic yield was low in both the ID and IDA subgroups of aged <50 years (6.3% vs 4.2%, P = 0.76). Multivariate analysis revealed a significant relationship between age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.06) and male sex (OR 2.28, 95% CI 1.18-4.39) with a positive colonoscopy. Malignancy was significantly less frequent in the ID group (1.8% vs 14.2%, P < 0.05). CONCLUSIONS: The prevalence of gastrointestinal lesions in patients with and without anemia was similar but malignancy was eight times less frequent in the ID group. Systematic endoscopic evaluation in patients with ID is therefore questionable.
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Gastroenteropatias/complicações , Gastroenteropatias/diagnóstico , Deficiências de Ferro , Distribuição por Idade , Idoso , Anemia Ferropriva/etiologia , Colonoscopia , Endoscopia do Sistema Digestório , Feminino , Ferritinas/sangue , Gastroenteropatias/sangue , Hemorragia Gastrointestinal/complicações , Neoplasias Gastrointestinais/sangue , Neoplasias Gastrointestinais/complicações , Neoplasias Gastrointestinais/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
La microbiota intestinal se define como el conjunto de microorganismos que habitan de forma natural en el tubo digestivo. Bacterias, hongos y virus se incluyen dentro de este ente fisiológico que va mucho más allá de ser un mero espectador pasivo de la mucosa intestinal. La microbiota interviene de forma activa en la homeostasis y su desregulación se ha relacionado con múltiples enfermedades de naturaleza infecciosa, metabólica y autoinmunitaria. El trasplante de microbiota fecal (TMF) consiste en la introducción de una solución de materia fecal debidamente procesada procedente de un donante sano en el tracto gastrointestinal de otro individuo con el fin de manipular las características de la microbiota del receptor. Aunque pueda parecer algo novedoso, los primeros casos se remontan a la época de la China Imperial; no obstante, no ha sido hasta los últimos 20 años cuando el interés y la actividad investigadora en este campo se han multiplicado de forma exponencial. Fruto de este trabajo el TMF constituye hoy en día una herramienta eficaz y validada en casos refractarios de diarrea por C. Difficile. Aunque la evidencia científica es menor, ya existen ensayos clínicos que evalúan su beneficio en la enfermedad inflamatoria intestinal y en el síndrome metabólico. Lo atractivo de su mecanismo fisiopatológico, la sencillez del procedimiento y su bajo coste lo sitúan como un tratamiento prometedor en múltiples enfermedades extradigestivas. El objetivo de esta revisión es resumir de una forma concisa, rigurosa y actualizada las indicaciones, metodología y seguridad del TMF.
The intestinal microbiota is defined as the set of organisms that live in the digestive tract. Bacteria, fungi and viruses are included in a physiological entity that goes far beyond being a passive spectator of the intestinal mucosa. The microbiota is actively involved in homeostasis and its imbalance has been linked to multiple infectious, metabolic and autoimmune diseases. Fecal microbiota transplantation (FMT) consists in the introduction of a solution made with processed stool from a healthy donor into the gastrointestinal tract of another individual in order to manipulate the characteristics of the receiver microbiota. Although it may seem new, the first cases date back to the days of Imperial China; however, it was not until the past 20 years when the interest and research in this field have grown exponentially. Nowadays, TMF is an effective and validated treatment in refractory cases of C.difficile diarrhea. Although the scientific evidence is less, there are clinical trials evaluating its benefit in inflammatory bowel disease and metabolic syndrome. The appeal of its pathophysiological mechanism, the simplicity of the procedure and its low cost place FMT as a promising treatment for multiple extraintestinal diseases. The objective of this review is to summarize in a concise, thorough and updated form its indications, methodology and safety.