A low frequency of post infection-IBS in patients attended in a tertiary referral center in México.

BACKGROUND: PI-IBS prevalence is around 10.1%-14.5% ≥ 12 months after infectious gastroenteritis in North America, Europe and Asia. However, there are no studies from Latin America. Two previous studies in Mexico suggest a low incidence of 5%. AIMS: to determine the prevalence of PI-IBS in patients attended in a tertiary-care center, as well as IBS subtypes, severity, other digestive symptoms and red flags vs nPI-IBS. METHODS: seventy IBS patients screened for immunological research completed the Rome III, Spiller's for PI-IBS and IBS-SSS questionnaires. PI-IBS prevalence was determined according to three criteria sets. C1: ≥ 2 episodes of sudden onset, onset while traveling, initial illness with any of the following symptoms, fever, vomiting, bloody diarrhea and a positive stool culture. C2: sudden onset and > 2 episodes of fever, diarrhea, vomiting and bloody diarrhea. C3: sudden onset after an infectious episode such as a positive culture or onset with ≥ 2 episodes of fever, vomiting, diarrhea, rectal bleeding and foreign travel. Items were dichotomized as present or absent and compared using the Fisher's exact and Mann-Whitney U tests. RESULTS: PI-IBS prevalence was as follows. C1: 5.7%, C2: 0 and C3: 1.4%. There were no IBS-C or IBS-M cases. In the C1 group, one case was mild and three were moderate IBS, which was similar to the non PI-IBS group. One case in the C3 group had mild IBS. There were no differences in the frequency of esophageal, gastroduodenal, anorectal, bloating/distension and red flags between PI-IBS and non PI-IBS groups (analyzed only for C3). CONCLUSIONS: in Mexico, there is a very low prevalence of PI-IBS in patients from a tertiary-referral center. However, it varies according to the surrogate-criteria used. The later needs to be taken into account when performing PI-IBS studies.

[Guidelines for diagnosis and treatment of constipation in Mexico. C) Medical and surgical treatment]. / Guías de diagnóstico y tratamiento del estreñimiento en México. C) Tratamiento médico y quirúrgico.

BACKGROUND: There are multiple therapeutic options for the management of constipation, from lifestyle modifications to the use of laxatives and in extreme cases surgery. OBJECTIVES AND METHODS: To establish the clinical guidelines for diagnosis and treatment of chronic constipation in Mexico we conducted a review of the literature regarding medical and surgical treatments for chronic constipation and have made recommendations based on evidence. RESULTS: Low water consumption, physical inactivity and low intake of fiber are conditions associated with chronic constipation, but the evidence to prove these associations is scarce. Bolus forming agents are useful in the management of constipation with normal colonic transit and defecation without dissynergia. Evidence supports the use of lactulose (IB) and polyethylene glycol (IA) as the most safe and effective agents in the long term in adults. The use of stimulant laxatives (docusate, picosulfate, senna) is recommended only for short periods. Tegaserod is an agonist of 5-HT4 receptors and there are many clinical trials supporting its effectiveness in the management of functional constipation (IA). However "their cardiovascular safety has been questioned recently. Biofeedback therapy is the gold standard in the management of constipation associated with pelvic floor dyssynergia. Surgical treatment is reserved for extreme cases of colonic inertia. CONCLUSIONS: The treatment of constipation should be based on the underlying pathophysiological mechanisms and the selection of drugs must be made according to the scientific evidence.

Differences in gastrointestinal symptoms according to gender in Rome II positive IBS and dyspepsia in a Latin American population.

OBJECTIVES: Irritable bowel syndrome (IBS), constipation, and bloating are more prevalent in women than men, but gender differences associated with dyspepsia are inconsistent.The aim of this study was to determine gender differences in the prevalence of symptoms diagnostic for functional gastrointestinal disorders (FGIDs) in subjects with IBS and dyspepsia, as well as in controls in Mexico. METHODS: A database of 1,021 subjects (61% women) who completed the Rome II Modular Questionnaire (RIIMQ) in Spanish Mexico was analyzed. Gender differences in the frequency of all symptoms included in the RIIMQ between those fulfilling criteria for IBS (28.9%), dyspepsia (4.0%) and controls without any FGIDs (38.2%) were studied. Subjects fulfilling criteria only for other FGIDs were excluded. RESULTS: There were higher proportions of women with IBS (67.8%) and dyspepsia (85.4%) compared with the control group (55.9%) (P<0.001). In IBS, women more frequently reported changes in the number of bowel movements (BMs) associated with the onset of abdominal discomfort/pain, fewer than three BMs/week and abdominal fullness/bloating/swelling than men. Men with IBS more frequently reported swallowing air to belch and abdominal pain that improved after a BM than women. In controls, burping and hard or lumpy stools were both more frequent in men. CONCLUSIONS: In Mexico, gender differences in FGIDs exist, with both IBS and dyspepsia being more common in women than men. In IBS, symptoms related to constipation and bloating were more common in women, but the dyspepsia group was too small to draw any conclusions. Finally, this is the first study to report that belching is more common in men than women controls not fulfilling criteria for any FGID.

[Treatment of chronic anal fissure with botulinic toxin type A]. / Tratamiento de la fisura anal crónica con toxina botulínica tipo A.

UNLABELLED: Anal fissure is a disease that generally affects to young people, but it can present at any age. PURPOSE: To show our experience in the treatment of chronic anal fissure with botulinum toxin type A. MATERIAL AND METHODS: This is a prospective, experimental and longitudinal study realized in the Coloproctology Unit in the General Hospital of Mexico City and in Medical North of Monterrey, Mexico, between June 2002 and November 2004. Direct variable was healing with 25 units of botulinum toxin. Secondary variables: age, sex, symptomatology, evolution time, localization of fissure, evolution after application of botulinum toxin, complications and time ofhealing. RESULTS: 35 (67.30%) were female and 17 (32.69%), male; age range, 21 to 64 years, with a medium of 43. At twelve months of toxin, application of 34 (65.38%) patients were asymptomatic, but in four fissure persisted. The other 18 patients were operated on due to persistence of the fissure. In a follow up of 18 months, 30 patients cured (57.69%), 4 improved (7.69%) and 18 (34.61%) were failures; one died by myocardial infarction and there were no recurrences. CONCLUSIONS: Botulinum toxin type A is a good alternative in the treatment of chronic anal fissure. Healing or improved with the application of 25 units of botulinum toxin was 65.38%.

[Results and analysis of Ferguson-type hemorrhoidectomy]. / Resultados y análisis de la hemorroidectomía tipo Ferguson.

BACKGROUND: We undertook this study to demonstrate the experience with Ferguson hemorrhoidectomy in the Coloproctology Unit in the Gastroenterology Service of the General Hospital in Mexico City. METHODS: A prospective, descriptive and observational study was designed and included patients with hemorrhoidal disease submitted to hemorrhoidectomy with Ferguson technique, from May 1999 to April 2004. Preoperative data included in the patient's chart was as follows: sex, age, time of evolution of symptoms, classification of hemorrhoids, associated disease, operative duration, immediate and late surgical complications and their management and healing duration. RESULTS: Five hundred eighty six patients fulfilled the inclusion criteria; 342 were male (58.36%) and 244 (41.69%) female. Average age was 43 years (range: 20-78 years). Occupation was not reported. Classification of hemorrhoids was 46 (7.85%), grade II; 396 (67.57%), grade III; 82 (13.99%), grade IV; and 62 (10.59%), massive hemorrhoid thrombosis. CONCLUSIONS: Results of this series conclude that perioperative morbidity is lower than reported in other series and that hemorrhoidectomy with Ferguson technique continues as the gold standard for treatment of this disease.

[Incidence, diagnosis and treatment of colovesical fistula]. / Incidencia, diagnóstico y tratamiento de la fístula colovesical.

BACKGROUND: Enterovesical fistula, also known as vesicoenteric fistula, is an abnormal communication of the vesical bladder with a segment of the digestive tract. We undertook this study to describe diagnostic and therapeutic methods to treat colovesical fistula (CVF) in patients who attended the Coloproctology Unit of the Gastroenterology Service of the General Hospital in Mexico City. METHODS: This is a descriptive study in CVF patients carried out from January 2001 to June 2006; descriptive statistics were used for analysis of information. RESULTS: Eleven patients were identified (10 males and 1 female). Average age was 54.72 years (range: 39-73 years). Time from onset of symptoms to diagnosis was on average 11.9 months. The most frequent signs and symptoms were fecaluria, pneumaturia, dysuria, hematuria and chronic abdominal pain in hypogastric and left iliac regions. Nine patients were submitted to sigmoidectomy and primary colorectal anastomosis. Hartmann procedure was carried out in one patient with restoration of intestinal transit 6 weeks later. In one patient, a loop colostomy was built as a first operation, with sigmoidectomy with fistula resection as a second operation, and restoration of intestinal transit as the third. CONCLUSIONS: Surgery is the only treatment that assures cure and avoids relapses. Sigmoidectomy and primary anastomosis must be considered as the treatment of choice. Mortality, although low, continues being a negative factor when surgery is indicated in these patients.

[Complex anal fistula treated with cutting seton]. / Setón de corte en el tratamiento de la fístula anal compleja.

BACKGROUND: Anorectal sepsis is a frequent condition presenting in the office of colorectal specialists. The acute phase presents as an abscess and the chronic phase as a fistula. We undertook this study to report the experience of the Coloproctology Unit of the General Hospital of Mexico in the management of complex anal fistula with cutting seton. METHODS: From May 1999 to April 2004, 11,731 clinical cases were reviewed. Inclusion criteria were patients with complex anal fistula treated using the cutting seton technique and 6 months minimum follow-up after withdrawal of seton. RESULTS: There were 742 fistulous patients among which 50 fulfilled inclusion criteria. There were 44 males and 6 females. Fistulas were classified as high transsphincteric in 41 patients, suprasphincteric in 8 patients, and high intersphincteric in one patient. On average, patients were followed-up during 9.67 postoperative examinations and on average there were 4.55 adjustments. The average permanence of seton was 7.02 months. CONCLUSIONS: Management of complex anal fistula continues to be a challenge for surgeons. Cutting seton is an appropriate surgical option for patients with no alteration of continence and is useful for patients with high transsphincteric, suprasphincteric and, in some cases, extrasphincteric fistula. In women with low anterior transsphincteric fistula, this option must be considered as an alternative.

Maturation Phenotype of Peripheral Blood Monocyte/Macrophage After Stimulation with Lipopolysaccharides in Irritable Bowel Syndrome.

BACKGROUND/AIMS: Abnormal immune regulation and increased intestinal permeability augmenting the passage of bacterial molecules that can activate immune cells, such as monocytes/macrophages, have been reported in irritable bowel syndrome (IBS). The aim was to compare the maturation phenotype of monocytes/macrophages (CD14+) from IBS patients and controls in the presence or absence of Escherichia coli lipopolysaccharides (LPS), in vitro. METHODS: Mononuclear cells were isolated from peripheral blood of 20 Rome II-IBS patients and 19 controls and cultured with or without LPS for 72 hours. The maturation phenotype was examined by flow cytometry as follows: M1-Early (CD11c+CD206-), M2-Advanced (CD11c-CD206+CX3CR1+); expression of membrane markers was reported as mean fluorescence intensity (MFI). The Mann-Whitney test was used and significance was set at P < 0.05. RESULTS: In CD14+ cells, CD11c expression decreased with vs without LPS both in IBS (MFI: 8766.0 ± 730.2 vs 12 920.0 ± 949.2, P < 0.001) and controls (8233.0 ± 613.9 vs 13 750.0 ± 743.3, P < 0.001). M1-Early cells without LPS, showed lower CD11c expression in IBS than controls (MFI: 11 540.0 ± 537.5 vs 13 860.0 ± 893.7, P = 0.040), while both groups showed less CD11c in response to LPS (P < 0.01). Furthermore, the percentage of "Intermediate" (CD11c+CD206+CX3CR1+) cells without LPS, was higher in IBS than controls (IBS = 9.5 ± 1.5% vs C = 4.9 ± 1.4%, P < 0.001). Finally, fractalkine receptor (CX3CR1) expression on M2-Advanced cells was increased when treated with LPS in controls but not in IBS (P < 0.001). CONCLUSIONS: The initial phase of monocyte/macrophage maturation appears to be more advanced in IBS compared to controls. However, the decreased CX3CR1 in patients with IBS, compared to controls, when stimulated with LPS suggests a state of immune activation in IBS.

[Hidradenitis suppurativa]. / Hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa is an inflammatory, chronic and recurrent disease of appocrine glands, located in inguinal, axillar, perineal, perianal areas and scalp. OBJECTIVE: To determine the frequency and therapeutic management. METHODS: A retrospective, transverse, and descriptive study was carried out. All patients with hidradenitis suppurativa, and who were managed by the Coloproctology Unit from the Gastroenterology Service of the General Hospital of Mexico City from January 1995 to December 2004, were included. RESULTS: We reviewed 12,689 files and identified 15 patients (0.12%) with hidradenitis suppurativa; nine fulfilled inclusion criteria. CONCLUSIONS: This is a complex disease with a diagnostic and therapeutic challenge.

[Non-surgical alternative management of hemorrhoidal disease]. / Manejo alternativo no quirúrgico de la enfermedad hemorroidaria.

UNLABELLED: Clinical manifestations of hemorrhoidal disease depend on its location (internal or external) and the presence or not of complications. PURPOSE: To describe the results of the three most common alternatives for non-surgical procedures treating internal hemorrhoids: rubber band ligation, esclerotherapy and infrared photocoagulation. MATERIALS AND METHODS: A retrospective, longitudinal and descriptive study from January 1998 to December 2002 was carried out, including variables like age, gender, clinical manifestations and date of initiation, type of non-surgical alternative treatment, complications, management and stage of the illness. RESULTS: In 9,103 charts reviewed this study included 2,701 patients with hemorrhoidal disease, with an annual incidence of 540.20 patients; 1,388 (51.39%) were male and 1,313 (48.62%) were female; ages between 17 and 78 years, 44.10 as a mean age. Rubber band ligation was used in 516 patients (67.45%), esclerotherapy in 177 (23.13%) and infrared photocoagulation in 72 cases (9.41%). CONCLUSIONS: Rubber band ligation is mainly indicated for internal hemorrhoids II degree, the esclerotherapy is indicated in the suppression of acute hemorrhage, but in the long term, this method has the poorest results. Infrared photocoagulation has its best results in internal hemorrhoids I degree because it causes less pain and complications and patients accept it better.

[Surgical alternatives in the treatment of anal abscesses]. / Alternativas en el tratamiento quirúrgico de los abscesos anales.

INTRODUCTION: Anal abscess is a pus collection localized in some of the regions around the anus and rectum. We reviewed the experience in the management of abscesses in Coloproctology Unit at the Gastroenterology Service in the General Hospital of Mexico. MATERIAL AND METHODS: This is a retrospective, longitudinal and descriptive study in patients diagnosed as carriers of an anal abscess during the period from January 1998 to December 2002. RESULTS: During this period, 9,233 first consultations took place, 241 fulfilled inclusion criteria: 197 (81.74%) were male and 44 (18.25%) were female. Perianal abscesses affected 156 patients (64.73%), 51 ischiorectal abscesses (21.16%), 17 horseshoe (7.05%), 14 intersphincteric (5.80%) and 3 has supralevator abscesses (1.24%). CONCLUSIONS: There were 96.68% nonspecific anal abscesses. Simple drainage is an initial adequate management. Most patients (73%) were attended in the office. Pain was the most common symptom (99%). Perianal and ischiorectal localizations were the most frequently classified and there was no mortality.

[Surgical management of anal fistula]. / Manejo quirúrgico de la fístula anal.

UNLABELLED: Anal fistula has been known since the beginning of medical history and is defined as a duct of fibrous infected walls that runs from anal crypt to skin or rectal lumen. Internal orifice is called primary or internal, while cutaneous orifice is referred to as secondary or external. Several techniques have been developed for surgical management of anal fistula, including fistulotomy, fistulectomy with or without sphincter repair, placement of sedal cutting or seton drainage, endorectal advancement flap, and fibrin glue, among others. GENERAL OBJECTIVE: Our aim was to demonstrate the experience in management of anal fistula at the Coloproctology Unit, Gastroenterology Service, of the Mexico City General Hospital. MATERIALS AND METHODS: We conducted a retrospective, longitudinal, and descriptive study in patients with anal fistula. All patients had complete clinical and proctologic studies and pre-operative laboratory analysis. RESULTS: A total of 8,816 files were reviewed from January 1997 to December 2001; 642 (7.28%) patients were carriers of a fistula, but only 595 satisfied inclusion criteria; 500 (84.03%) were male and 95 (15.97%), female, with annual incidence of 119. Average global age was 34 years (37 years in males and 28 years in females). Age range was 17 to 80 years; most frequent decades were 31 to 40 years in 197 patients (33.11%) and 41 to 50 years in 140 patients (23.53%). Anal fistula was intersphincteric in 351 (59%) and transsphincteric in 149 (25.04%). Fistulectomy was carried out in 422 patients (70.92%), fistulotomy in 108 (18.15%), seton division in 22 (3.69%), sedal in 10 (1.68%), seton drainage in two (0.33%), endorectal advancement flap in five (0.84%), fistulectomy with sphincter repair in 14 (2.35%) patients, and in 12 (2.0%) patients it was impossible to know what type of treatment had been carried out. DISCUSSION: The fundamental aims to accomplish in treatment of anal fistula include curing, preserving anal continence, minimizing healing defects, and offering to the patient a quick recovery.

[Hemorrhoidal desarterialization guided by Doppler. A surgical alternative in hemorrhoidal disease management]. / Desarterialización hemorroidaria guiada por Doppler. Una alternativa quirúrgica en el manejo de la enfermedad hemorroidaria.

BACKGROUND: Hemorrhoidal disease is a common condition that includes 30% of patients seen for the first time at the Colon and Rectal Unit of the Gastroenterology Service, Hospital General in Mexico City. This study shows experience with hemorrhoidal desarterialization guided by Doppler in patients with internal hemorrhoidal disease stages II or III in the Coloproctology Units of the Hospital General in Mexico City and at the North Medical Unit in Monterrey, Nuevo Leon, Mexico. MATERIALS AND METHODS: A prospective, longitudinal, and descriptive study was performed in 56 patients with diagnosis of internal hemorrhoids stages II or III, not complicated, and treated by hemorrhoidal artery ligation guided by Doppler between July 1, 2002 and April 31, 2003. RESULTS: 49 patients were included, 32 male (66%) and 17 female (34%), aged between 21 and 75 years with mean age of 43.5 years; 40 patients had internal hemorrhoids stage II (82%) and nine, stage III (18%). With a follow-up of 4 months or longer, all patients were symptomless: bleeding and hemorrhoidal prolapse disappeared. CONCLUSIONS: Doppler-Guided hemorrhoidal desarterialization is indicated in patients with internal hemorrhoids stages II or III; it is a simple technique that requires a short learning curve, minimal anesthetic and surgical materials, and pain after the procedure is mild and short-lived in the majority of patients.

[Management of the rectovaginal fistula. A review of five years at the Colon and Rectal Unit of the General Hospital of Mexico City]. / Manejo de la fístula rectovaginal. Revisión de cinco años en la unidad de coloproctología del Hospital General de México.

BACKGROUND: Rectovaginal fistula, although infrequent, produces considerable discomfort to the patients and disables them in their social life. OBJECTIVES: To review and report the experience in the management of rectovaginal fistula in the Colon and Rectal Unit of the General Hospital of Mexico City, from January 1997 to December 2001. MATERIAL AND METHODS: A retrospective, observational and descriptive study was designed including all patients diagnosed with rectovaginal fistula, who had not been previously operated for this condition in the Colon and Rectal Unit of the General Hospital of Mexico City from January 1977 to December 2001. RESULTS: Thirty-eight patients were included, aged between 17 and 70 years with a mean age of 24. The etiology of the rectovaginal fistulas was: obstetric trauma in 21 patients (55.2%), post-surgical in 5 (13.1%), traumatic in 5 (13.1%), after radiotherapy in 5 (13.1%) and malignant in 2 (5.2%). DISCUSSION: Rectovaginal fistula treatment relies on fistula classification (simple or complex), its location, and damage or not to the sphincter mechanisms and prior surgical repair. CONCLUSIONS: The most frequent surgical approach was the creation of a fourth degree perineum laceration and reconstruction (45.7%), followed by the advancement flap (25.7%). Complex fistulas were handled with a stoma. The surgical approach of rectovaginal fistula must rely on etiologic, anatomic and physiologic basis.

Quality of life in ostomized patients.

BACKGROUND: Ostomized patients usually have some concerns such as absence of sphincter control, noisy bowel movements, changes in passage of gas, social discomfort due to odors, concerns about bag filling, peristomal and skin irritation as well as psychological changes such as body image distortion, among others, that will determine quality of life. We undertook this study to measure quality of life in ostomized patients attending the Coloproctology Unit in Hospital General de México. METHODS: We carried out a cross-sectional descriptive study from January 1, 2009 to May 29, 2009 in ostomized patients. Two scales were used to determine quality of life. The first was quality of life SF-36 (version 2) with 36 items that measured eight aspects. The other scale used was the Montreux scale. RESULTS: For the Montreux scale, quality of life section, a range between 60.8 and 81.2 points was obtained. The results obtained with the quality of life scale SF36 were as follows: physical function, 67.04; physical role, 56.06; physical pain, 68.28; general health, 57.16; with an overall average of 62.14 points. For mental aspects, results were as follows: vitality, 68.37; social function, 71.53; emotional role, 71.48; and mental health, 68.67; with an overall average of 70.01 points. CONCLUSIONS: Quality of life of subjects included was classified as good. Fear of stoma leaks and sexual function were the aspects that most affected the patients, and those are responsible for a decrease in quality of life in this study.