Impact of COVID-19 on pre-existing liver disease.

Patients with chronic liver disease of any etiology who become infected with SARS-CoV-2 have been found to have a higher risk of mortality compared to those patients who do not have chronic liver disease. A literature review was conducted in the relationship between COVID 19 and preexistence of liver disease. The proportion of COVID-19 patients with abnormal liver function on admission ranged from 40 % to 75 % and the proportion with liver injury was close to 30%. Current studies show an important association between preexisting liver disease and COVID-19. The presence of cirrhosis is now an independent predictor of severity for COVID-19 and prolonged hospitalization in this group of patients. Patients with cirrhosis have a higher mortality rate, and this rate rises with increasing severity.

Pacientes con enfermedad hepática crónica de cualquier etiología que se infectan con SARS-CoV-2 tienen un mayor riesgo de mortalidad en comparación con aquellos pacientes que no tienen enfermedad hepática crónica. Se llevó a cabo una revisión de la literatura en relación a lo publicado de COVID 19 y enfermedad hepática pre-existente. La proporción de pacientes con COVID-19 con función hepática anormal al ingreso osciló entre el 40 % y el 75 % y la proporción con daño hepático fue cercana al 30 %. Los estudios actuales muestran una asociación importante entre la enfermedad hepática preexistente y la COVID-19. La presencia de cirrosis es ahora un predictor independiente de gravedad para COVID-19 y hospitalización prolongada en este grupo de pacientes. Los pacientes con cirrosis tienen una mayor tasa de mortalidad y esta tasa se incrementa con el aumento de la gravedad de la enfermedad hepática.

Escrutinio para el cáncer de colon: ¿cuál fue el impacto en los primeros 2 años de la pandemia de COVID-19? Experiencia en una clínica privada ambulatoria.

BACKGROUND: COVID-19 pandemic had a negative impact on colorectal cancer (CRC) screening programs. OBJECTIVE: The care strategy was modified throughout the pandemic, this paper evaluates its impact and short-term consequences. METHODS: A retrospective, descriptive and cross-sectional study was carried out in a private ambulatory endoscopic center, in average risk subjects. The study compared two periods: pre-pandemic and pandemic (subdivided into pre-vaccination and vaccination). RESULTS: During this period, 54.4% of scheduled colonoscopies were due to the screening program. The average age was 60.4 ± 7 years. Women were 52.0%. The overall cancellation rate was 41.1%, higher during pre-vaccination period. There were no differences in the degree of colonic cleansing, colonoscope exit time, and patient satisfaction. The adenoma detection rate (38.4% vs. 42.8% vs. 36.4%; p = 0.8) and the total number of adenomas (p = 0.02) was statistically significant during the pre-vaccination period. The rate of adenoma/patient showed a higher trend during this period (p = 0.06). The number of colorectal cancers was 10, without differences between periods. CONCLUSION: In conclusion, the impact of the decrease in screening colonoscopy procedures for CRC detection was similar to what was seen worldwide. In this period no increase in cancer cases, although this effect may be observed in the long term.

ANTECEDENTES: La pandemia de COVID-19 tuvo un impacto negativo en el programa de detección del cáncer colorrectal (CCR). OBJETIVO: La estrategia de atención cambió y se evaluó su impacto a corto plazo. MÉTODO: Se realizó un estudio retrospectivo, descriptivo y transversal, en un centro endoscópico ambulatorio privado, en sujetos con riesgo promedio de CCR. El estudio comparó dos períodos: prepandemia y pandemia (subdividido en prevacunación y vacunación). RESULTADOS: El 54.4% de las colonoscopias fueron por escrutinio. La edad promedio fue de 60.4 ± 7 años. El 52.0% fueron mujeres. La tasa de cancelaciones fue del 41.1%, siendo mayor durante el período prevacunación. No hubo diferencias en el grado de limpieza colónica, el tiempo de salida ni la satisfacción del paciente. La tasa de detección de adenomas (38.4% vs. 42.8% vs. 36.4%; p = 0.8) y el número total de adenomas (p = 0.02) tuvieron una significancia en el período prevacunación. El índice adenoma/paciente fue mayor durante este período (p = 0.06). El número de CCR fue de 10 (1.9%), sin diferencias entre los períodos. CONCLUSIÓN: Se concluye que la repercusión por la disminución en los procedimientos de escrutinio fue similar a lo visto en todo el mundo y no se encontró un aumento de los casos de cáncer, aunque este efecto podrá observarse a largo plazo.

Fenotipos de la enfermedad por reflujo gastroesofágico: una visión basada en su fisiopatología.

The advancement of knowledge in pathophysiology and underlying etiologies of gastroesophageal reflux disease (GERD) has allowed the development of the concept of disease beyond the acidity of reflux. The variability in the symptom presentation and the response to treatment cannot be attributed only to reflux composition, since esophageal factors, such as structural, mechanical, biochemical, and physiological aspects, play an important role. The proposed personalized approach to GERD uses a stepwise approach that optimizes performance and phenotypic outcome while minimizing invasiveness, risk, and cost. Throughout the staggered approach to determine the GERD phenotype, clinicians may choose to stop further testing and continue treatment if available information identifies a different GERD phenotype. Since not all phenotypes GERD are the same and not all treatments are appropriate for all patients, therapeutic strategies must be personalized according to their phenotype.

El avance del conocimiento sobre la fisiopatología y la etiología subyacentes a la enfermedad por reflujo gastroesofágico (ERGE) ha permitido que el desarrollo de esta se extienda más allá de la acidez del reflujo. La variabilidad en la presentación de los síntomas y la respuesta al tratamiento no se puede atribuir solo a la composición del reflujo, ya que factores esofágicos, como aspectos estructurales, mecánicos, bioquímicos y fisiológicos, desempeñan un papel importante. El enfoque personalizado propuesto para la ERGE utiliza un método gradual que optimiza el rendimiento y el resultado fenotípico, y minimiza la invasividad, el riesgo y el costo. A lo largo del método escalonado para determinar el fenotipo de la ERGE, los médicos pueden optar por detener las pruebas adicionales y continuar con el tratamiento si la información disponible identifica un fenotipo de ERGE distinto. Dado que la ERGE no es la misma y no todos los tratamientos disponibles para controlarla son apropiados para todos los pacientes, las estrategias terapéuticas deben personalizarse de acuerdo con su fenotipo.

Estudio comparativo de eficacia y seguridad de dexrabeprazol versus esomeprazol en el tratamiento de la enfermedad por reflujo gastroesofágico / Efficacy and safety comparative study of dexrabeprazole vs. esomeprazole for the treatment of gastroesophageal reflux disease

Resumen Introducción: Una encuesta nacional en población abierta mostró que la enfermedad por reflujo gastroesofágico (ERGE) tiene alta prevalencia en México. Objetivo: Comparar la eficacia y seguridad de dos isómeros, dexrabeprazol (10 mg) versus esomeprazol (20 mg), en el tratamiento de la ERGE durante cuatro semanas. Métodos: Ensayo clínico fase III, aleatorizado, multicéntrico, prospectivo, doble ciego, en dos grupos que incluyeron 230 pacientes. Resultados: Con ambos tratamientos se observó disminución estadísticamente significativa en la severidad de los síntomas de ERGE (pirosis, regurgitación, dolor epigástrico y disfagia), evaluados mediante una escala visual análoga. La puntuación promedio de dexrabeprazol en el Cuestionario de Carlsson-Dent a los 28 días fue de 2.12 y la de esomeprazol de 3.02. Ambos tratamientos fueron efectivos, sin diferencia estadísticamente significativa (p < 0.05). En el Cuestionario de Salud SF-36 se observó que ambos mejoraron la puntuación en la calidad de vida, sin diferencia significativa. Ambos medicamentos fueron bien tolerados y el perfil de incidencia de eventos adversos fue bajo. Conclusiones: En el tratamiento de ERGE no erosiva, el uso de 10 mg/día de dexrabeprazol es tan efectivo como 20 mg/día de esomeprazol, con la ventaja de que la dosis es menor con un adecuado perfil de seguridad.

Abstract Introduction: A national survey in the general population showed that gastroesophageal reflux disease (GERD) is highly prevalent in Mexico. Objective: To compare the efficacy and safety of two isomers, dexrabeprazole (10 mg) vs. esomeprazole (20 mg), in the treatment of GERD for four weeks. Methods: Randomized, multicenter, prospective, double-blind phase III clinical trial in two groups that included 230 patients. Results: A statistically significant decrease in the severity of GERD symptoms (heartburn, regurgitation, epigastric pain and dysphagia), evaluated using a visual analogue scale, was observed with both treatments. Mean score for dexrabeprazole on Carlsson-Dent questionnaire at 28 days was 2.12, and for esomeprazole, 3.02. Both treatments were effective, with no statistically significant difference being recorded (p < 0.05). On SF-36 health questionnaire, both were observed to improve the quality-of-life score, with no significant difference being identified. Both drugs were well tolerated, and the adverse event incidence profile was low. Conclusions: In the treatment of non-erosive GERD, the use of dexrabeprazole at 10 mg/day is as effective as esomeprazole 20 mg/day, with the advantage that the dose is lower with an appropriate safety profile.

Efficacy and safety comparative study of dexrabeprazole vs. esomeprazole for the treatment of gastroesophageal reflux disease.

INTRODUCTION: A national survey in the general population showed that gastroesophageal reflux disease (GERD) is highly prevalent in Mexico. OBJECTIVE: To compare the efficacy and safety of two isomers, dexrabeprazole (10 mg) vs. esomeprazole (20 mg), in the treatment of GERD for four weeks. METHODS: Randomized, multicenter, prospective, double-blind phase III clinical trial in two groups that included 230 patients. RESULTS: A statistically significant decrease in the severity of GERD symptoms (heartburn, regurgitation, epigastric pain and dysphagia), evaluated using a visual analogue scale, was observed with both treatments. Mean score for dexrabeprazole on Carlsson-Dent questionnaire at 28 days was 2.12, and for esomeprazole, 3.02. Both treatments were effective, with no statistically significant difference being recorded (p < 0.05). On SF-36 health questionnaire, both were observed to improve the quality-of-life score, with no significant difference being identified. Both drugs were well tolerated, and the adverse event incidence profile was low. CONCLUSIONS: In the treatment of non-erosive GERD, the use of dexrabeprazole at 10 mg/day is as effective as esomeprazole 20 mg/day, with the advantage that the dose is lower with an appropriate safety profile.

INTRODUCCIÓN: Una encuesta nacional en población abierta mostró que la enfermedad por reflujo gastroesofágico (ERGE) tiene alta prevalencia en México. OBJETIVO: Comparar la eficacia y seguridad de dos isómeros, dexrabeprazol (10 mg) versus esomeprazol (20 mg), en el tratamiento de la ERGE durante cuatro semanas. MÉTODOS: Ensayo clínico fase III, aleatorizado, multicéntrico, prospectivo, doble ciego, en dos grupos que incluyeron 230 pacientes. RESULTADOS: Con ambos tratamientos se observó disminución estadísticamente significativa en la severidad de los síntomas de ERGE (pirosis, regurgitación, dolor epigástrico y disfagia), evaluados mediante una escala visual análoga. La puntuación promedio de dexrabeprazol en el Cuestionario de Carlsson-Dent a los 28 días fue de 2.12 y la de esomeprazol de 3.02. Ambos tratamientos fueron efectivos, sin diferencia estadísticamente significativa (p < 0.05). En el Cuestionario de Salud SF-36 se observó que ambos mejoraron la puntuación en la calidad de vida, sin diferencia significativa. Ambos medicamentos fueron bien tolerados y el perfil de incidencia de eventos adversos fue bajo. CONCLUSIONES: En el tratamiento de ERGE no erosiva, el uso de 10 mg/día de dexrabeprazol es tan efectivo como 20 mg/día de esomeprazol, con la ventaja de que la dosis es menor con un adecuado perfil de seguridad.

Recomendaciones para procedimientos quirúrgicos durante la pandemia de COVID-19 (SARS-CoV-2). Liderazgo hacia el retorno a lo electivo.

In late December 2019, COVID-19, a new emerging disease, quickly spread in Wuhan, China. The WHO formally declared it a pandemic and a health emergency on March 11th, 2020. The objective of this article is to specify and list key points in relation to the recommendations issued by the different colleges, and global surgical societies, for the benefit of the Mexican medical and surgical community. Based on scientific evidence, we make recommendations for medical consultations, surgical and endoscopic procedures, hospital infrastructure, and surgical services, in addition to a proposal to reopen surgical services and elective procedures related to the COVID-19 pandemic. The time to take leadership in healthcare where the national health system together with academic societies, universities and private initiative join forces to combat the pandemic has arrived. It is convenient to form collaboration groups of experts in the different specialties that through innovation in health and education, with evidence-based medicine, efficiency of operational costs and tools such as telemedicine, allow us to return to daily surgical procedures, reestablishing the surgery services as soon as possible.

A finales de diciembre de 2019, la COVID-19, una nueva enfermedad emergente, rápidamente se propagó en Wuhan, China. La Organización Mundial de la Salud la declaró formalmente una pandemia y emergencia sanitaria el 11 de marzo de 2020. El objetivo de este artículo es precisar y enumerar los puntos clave en relación a las recomendaciones emitidas por los distintos colegios, y sociedades quirúrgicas globales, para beneficio de la comunidad médica y quirúrgica mexicana. De acuerdo con la evidencia científica, se realizan recomendaciones para las consultas médicas, los procedimientos quirúrgicos y endoscópicos, la infraestructura hospitalaria y los servicios de cirugía, además de una propuesta a la reapertura para procedimientos quirúrgicos en torno a la pandemia de COVID-19. El momento de tomar el liderazgo en salud en el que el sistema nacional de salud y las sociedades académicas, las universidades y la iniciativa privada sumen esfuerzos para combatir la pandemia ha llegado. Es conveniente formar grupos de colaboración de expertos en las distintas especialidades que, por medio de innovación en salud y educación, apego a la medicina basada en la evidencia, eficiencia de costos operacionales y herramientas como la telemedicina, permitan regresar a los procedimientos quirúrgicos cotidianos y la operación de los servicios de cirugía se reestablezca a la brevedad.

El daño colateral de la atención de la pandemia de COVID-19.

Throughout history, pandemics have had a major impact on humanity. The measures used to combat them cause collateral damage. During the COVID-19 pandemic, the actions taken to reduce the exposure, the number of infections, and the case fatality rate focus on reducing mortality, however, the collapse of the health system can cause an even greater number of deaths. At the same time, both medical personnel and patients are affected by the economic slowdown and the "effect of negativity". In this review article the different tools available for pandemic control, their development in a historical context, and how they may impact risk stratification for vulnerable patients (elderly, patients with chronic degenerative and oncological diseases) were analyzed.

A lo largo de la historia, las pandemias han tenido un gran impacto para la humanidad. Las medidas utilizadas para combatirlas causan daño colateral. En la pandemia por COVID-19, las acciones generadas para disminuir la exposición, el número de contagios y la tasa de letalidad conllevan un enfoque en la reducción de la mortalidad, sin embargo el colapso del sistema de salud puede provocar un número aún mayor de muertos. A su vez, tanto el personal médico como los pacientes se ven afectados por la desaceleración económica y el "efecto de la negatividad". En este artículo de revisión se analizaron las diferentes herramientas para el control de la pandemia, su desarrollo en un contexto histórico y como impactan en la estratificación del riesgo para pacientes vulnerables (ancianos, pacientes con enfermedades crónico degenerativas y oncológicos).

Evaluation of the satisfaction of the patient undergoing screening colonoscopy and quality of the procedure.

BACKGROUND: Screening colonoscopy requires quality parameters to determine its efficacy to detect cancerous or precancerous lesions. Limitations of the procedure are the patient's rejection, difficulty for its preparation or lack of preparation. OBJECTIVE: To assess whether patient satisfaction correlates with the quality of the procedure. METHOD: 100 consecutive patients for a screening colonoscopy were included, they were randomized to use a preparation with polyethylene glycol (PEG) or sodium picosulfate (P). In addition, a second parameter evaluated was related to a follow-up phone call performed to half of the patients prior to the study, during the preparation time. RESULTS: P was better tolerated and qualified, however, there was no difference with the quality of preparation, adenomatous polyps detection rate, cecum insertion rate and patient satisfaction. A difference was found in whom had a follow-up phone call. DISCUSSION: A good colon preparation is a key factor to have a quality colonoscopy, and it has been shown important that a good relationship for explain the doubts and follow the preparation. CONCLUSION: It was found that the type of preparation and patient follow-up during the study correlate with the quality of the study and patient satisfaction.

ANTECEDENTES: La colonoscopia de escrutinio requiere parámetros de calificación para determinar su eficiencia en la detección de lesiones cancerosas o precancerosas. Sus limitantes son su rechazo, la dificultad durante su preparación o la falta de preparación. OBJETIVO: Evaluar la satisfacción del paciente y los criterios de calidad del estudio. MÉTODO: Se incluyeron 100 pacientes enviados para colonoscopia de escrutinio asignados aleatoriamente a uno de dos grupos de preparación colónica: polietilenglicol (PEG) o picosulfato de sodio (P), para evaluar la satisfacción y la limpieza colónica. Otra evaluación fue por medio de llamada de refuerzo al momento de la preparación. RESULTADOS: Con P se tuvieron mejores tolerabilidad y calificaciones de satisfacción, en comparación con PEG. No hubo diferencia para la calidad de la limpieza, la tasa de detección de pólipos adenomatosos ni la intubación cecal. La llamada telefónica de reforzamiento incrementó la satisfacción, la limpieza colónica y la tasa de detección de adenomas. DISCUSIÓN: Una relación estrecha con el paciente durante su proceso de limpieza y explicación del procedimiento se ha visto como uno de los factores más importantes para lograr una colonoscopia de alta calidad. CONCLUSIÓN: El tipo de preparación colónica y la intervención durante la preparación se relacionaron con una mejor calidad del estudio y una mayor satisfacción del paciente.

Acute dysphagia presentation and its association with esophagitis dissecans and concomitant diseases. A diagnostic challenge.

Esophagitis dissecans (ESD) is an uncommon disease that is associated with eosinophilic esophagitis (EoE), candidiasis and/or drugs. We aim to characterize the clinical, endoscopic and histological damage of the mucosal in subjects with dysphagia, its relation to concomitant entities and the treatment response. This is a retrospective observational study in patients with dysphagia and esophageal mucosal damage We included 23 patients (mean age = 55 years) who had GERD symptoms, dysphagia and/or odynophagia. There were 10, 9 and 4 cases of esophagitis dissecans, desquamative/esfacelante (ESD/ES) and fibrostenotic, respectively. ESD/SE is a rare entity with variable clinical, endoscopic and histological spectrum. The association with GERD was frequent.

La esofagitis disecante (ESD) es una enfermedad rara que puede asociarse a esofagitis eosinofílica, candidiásica o medicamentos. Se analizaron las características clinico-endoscópicas e histopatológicas en sujetos con disfagia de corta evolución asociada a afecciones concurrentes. Estudio observacional de cohorte retrospectiva con disfagia y daño mucoso. Se ingresaron 23 pacientes con edad media de 55 años. Todos tuvieron síntomas de reflujo gastroesofágico (ERGE), disfagia y odinofagia. Fueron 10, 9 y 4 casos de ESD, descamativa/esfacelante (ESD/ES) y fibroestenosis, respectivamente. La ESD/SE es una afección rara, con un espectro clínico, endoscópico e histológico variable.

Primary Prophylaxis to Prevent the Development of Hepatic Encephalopathy in Cirrhotic Patients with Acute Variceal Bleeding.

Background and Aim: Variceal bleeding is the second most important precipitating factor related to the development of episodic hepatic encephalopathy; but to date there are no recommendations to prevent this complication. The aim of this study was to compare if primary prophylaxis with lactulose or L-ornithine L-aspartate or rifaximin, in cirrhotic patients with variceal bleeding, is better than placebo for avoiding the development of hepatic encephalopathy. Methods: A randomized, double-blind, placebo-controlled clinical trial (ClinicalTrials.gov identifier: NCT02158182) which included cirrhotic patients with variceal bleeding, without minimal or clinical hepatic encephalopathy at admission. Findings: 87 patients were randomized to one of four groups. The basal characteristics were similar between groups. Comparatively with placebo, the frequency with regard to the development of hepatic encephalopathy was as follows: lactulose (54.5% versus 27.3%; OR = 0.3, 95% CI 0.09-1.0; P = 0.06); L-ornithine L-aspartate (54.5% versus 22.7%, OR = 0.2, 95% CI 0.06-0.88; P = 0.03); rifaximin (54.5% versus 23.8%; OR = 0.3, 95% CI 0.07-0.9; P = 0.04). There was no significant difference between the three groups receiving any antiammonium drug (P = 0.94). In the group receiving lactulose, 59.1% had diarrhea, and 45.5% had abdominal discomfort, bloating, and flatulence. Two patients (10%) treated with lactulose and a patient (4.5%) in the placebo group developed spontaneous bacterial peritonitis due to E. coli; one of them died due to recurrent variceal bleeding. There were no other adverse effects. Conclusions: Antiammonium drugs, particularly L-ornithine L-aspartate and rifaximin, proved to be effective in preventing the development of hepatic encephalopathy in those cirrhotic patients with variceal bleeding.

Metadoxine improves the three- and six-month survival rates in patients with severe alcoholic hepatitis.

AIM: To evaluate the impact of metadoxine (MTD) on the 3- and 6-mo survival of patients with severe alcoholic hepatitis (AH). METHODS: This study was an open-label clinical trial, performed at the "Hospital General de México, Dr. Eduardo Liceaga". We randomized 135 patients who met the criteria for severe AH into the following groups: 35 patients received prednisone (PDN) 40 mg/d, 35 patients received PDN+MTD 500 mg three times daily, 33 patients received pentoxifylline (PTX) 400 mg three times daily, and 32 patients received PTX+MTD 500 mg three times daily. The duration of the treatment for all of the groups was 30 d. RESULTS: In the groups treated with the MTD, the survival rate was higher at 3 mo (PTX+MTD 59.4% vs PTX 33.3%, P = 0.04; PDN+MTD 68.6% vs PDN 20%, P = 0.0001) and at 6 mo (PTX+MTD 50% vs PTX 18.2%, P = 0.01; PDN+MTD 48.6% vs PDN 20%, P = 0.003) than in the groups not treated with MTD. A relapse in alcohol intake was the primary independent factor predicting mortality at 6 mo. The patients receiving MTD maintained greater abstinence than those who did not receive it (74.5% vs 59.4%, P = 0.02). CONCLUSION: MTD improves the 3- and 6-mo survival rates in patients with severe AH. Alcohol abstinence is a key factor for survival in these patients. The patients who received the combination therapy with MTD were more likely to maintain abstinence than those who received monotherapy with either PDN or PTX.

Treatment with metadoxine and its impact on early mortality in patients with severe alcoholic hepatitis.

BACKGROUND & AIM: Despite treatment with glucocorticoids, mortality remains high in patients with severe alcoholic hepatitis. Oxidative stress and depletion of mitochondrial glutathione are implicated factors in liver injury. The aim of this study was to evaluate the impact of the addition of metadoxine, a drug which possesses a multifactorial mechanism of action, including antioxidant properties, to standard treatment with glucocorticoids in patients with severe alcoholic hepatitis. MATERIAL AND METHODS: This randomized open label clinical trial was performed in Mexico's General Hospital (Registry Key DIC/10/107/03/043). We randomized 70 patients with severe alcoholic hepatitis. The first group received prednisone (40 mg/day), and the second group received prednisone (40 mg/day) plus metadoxine tablets (500 mg three times daily). The duration of treatment in both groups was 30 days. Survival at 30 and 90 days, development of complications, adverse events and response to treatment (Lille model) were assessed. RESULTS: In the group receiving metadoxine, significant improvements were observed, as follows: survival at 30 days (74.3 vs. 45.7%, P = 0.02); survival at 90 days (68.6 vs. 20.0%, P = 0.0001). There was less development or progression of encephalopathy (28.6 vs. 60.0%, P = 0.008) and hepatorenal syndrome (31.4 vs. 54.3%, P = 0.05), and the response to treatment (Lille model) was higher in the metadoxine group (0.38 vs. 0.63, P = 0.001; 95% CI 0.11 to 0.40). There were no differences between groups regarding the development or progression of variceal hemorrhage or infection. The incidence of adverse events, mainly gastrointestinal, was similar in both groups. CONCLUSIONS: Addition of metadoxine to glucocorticoid treatment improves the short-term survival of patients with severe alcoholic hepatitis and diminishes the development or progression of encephalopathy and hepatorenal syndrome.