Hipertensión pulmonar y cirrosis hepática / Pulmonary hypertension and hepatic cirrosis

La hipertensión pulmonar es un fenómeno relativamente frecuente en los enfermos con cirrosis hepática y puede aparecer por diversos mecanimos. El escenario más característico que une la hipertensión portal y la hipertensión pulmonar es el síndrome portopulmonar. Sin embargo, la circulación hiperdinámica, la colocación de un TIPS o la insuficiencia cardíaca pueden elevar la presión media de la arteria pulmonar sin incremento de las resistencias. Estas situaciones no serán candidatas a tratamiento con vasodilatadores pulmonares y requieren una terapéutica específica. Una correcta valoración de variables hemodinámicas, ecográficas y clínicas permite el diagnóstico diferencial entre cada situación que produce hipertensión pulmonar en los pacientes cirróticos (AU)

Pulmonary hypertension is a relatively common phenomenon in patients with hepatic cirrhosis and can appear through various mechanisms. The most characteristic scenario that binds portal and pulmonary hypertension is portopulmonary syndrome. However, hyperdynamic circulation, TIPS placement and heart failure can raise the mean pulmonary artery pressure without increasing the resistances. These conditions are not candidates for treatment with pulmonary vasodilators and require a specific therapy. A correct assessment of hemodynamic, ultrasound and clinical variables enables the differential diagnosis of each situation that produces pulmonary hypertension in patients with cirrhosis (AU)

Pulmonary hypertension and hepatic cirrhosis. / Hipertensión pulmonar y cirrosis hepática.

Pulmonary hypertension is a relatively common phenomenon in patients with hepatic cirrhosis and can appear through various mechanisms. The most characteristic scenario that binds portal and pulmonary hypertension is portopulmonary syndrome. However, hyperdynamic circulation, TIPS placement and heart failure can raise the mean pulmonary artery pressure without increasing the resistances. These conditions are not candidates for treatment with pulmonary vasodilators and require a specific therapy. A correct assessment of hemodynamic, ultrasound and clinical variables enables the differential diagnosis of each situation that produces pulmonary hypertension in patients with cirrhosis.

Pernicious anemia. From past to present. / Anemia perniciosa. Del pasado al presente.

Pernicious anemia is currently the most common cause of vitamin B12 deficiency in Western countries. The histological lesion upon which this condition is based is autoimmune chronic atrophic gastritis. The destruction of parietal cells causes a deficiency in intrinsic factor, an essential protein for vitamin B12 absorption in the terminal ileum. Advances in the last two decades have reopened the debate on a disease that seemed to have been forgotten due to its apparent simplicity. The new role of H. pylori, the value of parietal cell antibodies and intrinsic factor antibodies, the true usefulness of serum vitamin B12 levels, the risk of adenocarcinoma and gastric carcinoids and oral vitamin B12 treatment are just some of the current issues analyzed in depth in this review.

[Nutrition acute pancreatitis]. / Nutrición en pancreatitis aguda.

Acute pancreatitis is a common and potentially severe disease where nutritional support does affect its development in a way it may be considered a treatment in severe cases. These include around 20% of patients and present mortality rates of 8%-39%. In mild acute pancreatitis patients are prescribed nil per os at admission and advance diet in a progressive manner the following days. Although early introduction of diet has proven to shorten the length of stay, it is still not clear when and how to introduce diet. Severe disease is a hypercatabolic situation which often appears in already malnourished patients. Early enteral nutrition has shown a significative benefit over parenteral nutrition in terms of infection rates, hyperglycemia and mortality rates. This benefit may be related to a decrease in bacterial intestinal translocation. Nasoyeyunal tube feeding is the preferred site, but there are trials supporting nasogastric tubes, a more feasible election. The following lines offer an up to date review of nutritional management in acute pancreatitis, trying to answer in a clear and practical way to the most frequent problems arising in the day to day management of this disease.

Nutrición en pancreatitis aguda / Nutrition acute pancreatitis

La pancreatitis aguda es una patología frecuente y potencialmente grave en la que el manejo nutricional influye de manera importante en su desarrollo, de tal forma que se puede considerar un tratamiento específico en los casos graves. Éstos suponen aproximadamente el 20% de los pacientes y presentan una mortalidad entre el 8-39%. En los casos leves se suele proceder a un ingreso en dieta absoluta y posterior reintroducción progresiva de la dieta. Aunque se ha demostrado que una reintroducción temprana acorta la duración del ingreso, existe incertidumbre acerca del momento y del tipo de dieta idóneos. Las pancreatitis graves son estados hipercatabólicos que se presentan en pacientes que frecuentemente presentan déficits nutricionales basales. El soporte nutricional iniciado precozmente por vía enteral ha demostrado un beneficio significativo respecto a la vía parenteral en cuanto a tasa de infección, control de glucemia y mortalidad. Este beneficio puede relacionarse con una disminución de la traslocación bacteriana. Si bien tradicionalmente se ha empleado la vía nasoyeyunal, existen estudios que apoyan la vía nasogástrica, mucho más accesible. En el siguiente texto ofrecemos una revisión actualizada del manejo nutricional en la pancreatitis aguda, intentando responder de manera clara y con un enfoque práctico a las preguntas que más frecuentemente se presentan en el manejo de esta patología (AU)

Acute pancreatitis is a common and potentially severe disease where nutritional support does affect its development in a way it may be considered a treatment in severe cases. These include around 20% of patients and present mortality rates of 8%-39%. In mild acute pancreatitis patients are prescribed nil per os at admission and advance diet in a progressive manner the following days. Although early introduction of diet has proven to shorten the length of stay, it is still not clear when and how to introduce diet. Severe disease is a hypercatabolic situation which often appears in already malnourished patients. Early enteral nutrition has shown a significative benefit over parenteral nutrition in terms of infection rates, hyperglycemia and mortality rates. This benefit may be related to a decrease in bacterial intestinal translocation. Nasoyeyunal tube feeding is the preferred site, but there are trials supporting nasogastric tubes, a more feasible election. The following lines offer an up to date review of nutritional management in acute pancreatitis, trying to answer in a clear and practical way to the most frequent problems arising in the day to day management of this disease (AU)

Impact of endoscopic ultrasonography on the management of a prospective cohort of 700 consecutive patients referred for diagnostic endoscopic ultrasonography.

BACKGROUND: endoscopic ultrasonography (EUS) is a high accuracy technique for the study of many digestive diseases. The degree of knowledge about the impact of EUS on the management of these patients is inadequate. AIM: to determine the therapeutic impact of endoscopic ultrasonography (EUS) on a prospective cohort of patients. METHODS: all patients referred for EUS over a period of 2 years were prospectively evaluated in order to asses: 1. EUS provides new information not previously known; 2. theoretic impact of EUS on patient management; 3. real impact of EUS on final therapy; 4. changes in the aggressiveness of the therapeutic decision after EUS. RESULTS: 700 patients were included. Preoperative assessment of digestive tumors was the commonest indication. EUS provided "new information" in the 89% of the patients. With regard to endoscopist opinion, these findings should alter the management in 79% of patients ("theoretic impact"). However, EUS prompted a change in the management in 67% of patients ("real impact"). Final therapy post-EUS was less aggressive in 34% of patients. Changes in therapeutic decision were associated with EUS findings, alcohol intake and age ≥ 57 years old. CONCLUSIONS: 1) EUS findings, advanced age, and alcohol intake are associated with a change in the management in 2 out of every 3 patients referred for EUS. 2) Therapeutic decision (post-EUS) is less aggressive in a third of these patients, what should represent a significant economic saving.

Impacto de la ultrasonografía endoscópica en el manejo terapéutico de una cohorte prospectiva de 700 pacientes consecutivos referidos para USE diagnóstica / No disponible

Antecedentes: la ultrasonografía endoscópica (USE) es una técnica de gran precisión para el estudio de diferentes patologías digestivas. El grado de conocimiento sobre el impacto de la USE en el tratamiento de estos pacientes es escaso. Objetivo: determinar el impacto terapéutico de la USE en una cohorte prospectiva de pacientes. Material y métodos: estudio que evalúa de forma prospectiva a todos los pacientes remitidos para USE en un periodo de 2 años. Se analiza: a) si la USE aporta información no conocida previamente; b) el impacto teórico de la USE en el tratamiento; c) el impacto final/real de USE en el tratamiento; d) la variación en la decisión terapéutica tras realizar la USE. Resultados: se incluyeron 700 pacientes. La indicación más frecuente de USE era el estudio preoperatorio de tumores digestivos. La USE aportó “información nueva” en el 89% de los casos. En opinión del ecoendoscopista estos hallazgos deberían suponer un cambio terapéutico en el 79% de los pacientes (“impacto teórico”). Sin embargo, el tratamiento sólo se modificó en el 67% de los casos (“impacto real”). La estrategia terapéutica post-USE fue menos agresiva en el 34% de los casos. Los cambios en la actitud terapéutica se asociaban con los hallazgos de USE, ingesta de alcohol y edad > 57 años. Conclusiones: – Los hallazgos de la USE, la edad avanzada y el consumo de alcohol, se asocian con un cambio terapéutico en 2 de cada 3 pacientes remitidos a una unidad de USE. – La decisión terapéutica final (post-USE) es menos agresiva en un tercio de estos pacientes, lo que podría representar un ahorro económico significativo(AU)

Antecedents: endoscopic ultrasonography (EUS) is a high accuracy technique for the study of many digestive diseases. The degree of knowledge about the impact of EUS on the management of these patients is inadequate. Aim: to determine the therapeutic impact of endoscopic ultrasonography (EUS) on a prospective cohort of patients. Methods: all patients referred for EUS over a period of 2 years were prospectively evaluated in order to asses: 1. EUS provides new information not previously known; 2. theoretic impact of EUS on patient management; 3. real impact of EUS on final therapy; 4. changes in the aggressiveness of the therapeutic decision after EUS. Results: 700 patients were included. Preoperative assessment of digestive tumors was the commonest indication. EUS provided “new information” in the 89% of the patients. With regard to endoscopist opinion, these findings should alter the management in 79% of patients (“theoretic impact”). However, EUS prompted a change in the management in 67% of patients (“real impact”). Final therapy post-EUS was less aggressive in 34% of patients. Changes in therapeutic decision were associated with EUS findings, alcohol intake and age >= 57 years old. Conclusions: 1) EUS findings, advanced age, and alcohol intake are associated with a change in the management in 2 out of every 3 patients referred for EUS. 2) Therapeutic decision (post- EUS) is less aggressive in a third of these patients, what should represent a significant economic saving(AU)

Training model for teaching endoscopic submucosal dissection of gastric tumors

Introduction: the elevated risk of complications and technicalcomplexity of endoscopic submucosal dissection (ESD) has limitedits implementation in our medical system.Objective: to design and evaluate a training program forlearning the ESD technique.Methods: four endoscopists with no experience with ESD underwenta 4-step training program: 1) review of the existing literature,didactic material, and theoretical aspects of ESD; 2) ESDtraining in an ex-vivo animal model; 3) ESD training in an in-vivoanimal model (supervised by ESD expert); and 4) ESD performancein a patient. A standard gastroscope and an ESD knife (IT,Flex or Hook-knife Olympus®) were employed. The classical ESDtechnique was performed: rising of the lesion, circumferential incision,and submucosal dissection.Results: ex-vivo animal model: 6 x swine stomach/esophagus–cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) andfundus/cardia (n = 1)–; size of resected specimen: 4-10 cm; ESDduration: 105-240 minutes; therapeutic success: 100%; complications:perforation (1/6: 16%) sealed with clips. In-vivo animalmodel: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size:2-5 cm; duration: 40-165 minutes; success: 100%; complications:0%. Patient: ESD of a gastric lesion located in theantrum/body; size: 3 cm; duration 210 minutes; a complete resectionwas achieved; no complications.Conclusions: the results of the present study support the usefulnessof this model for learning ESD in our system(AU)

Masa mediastínica en paciente cirrótico / No disponible

No disponible

“Enfermedad de las tres mentiras”: síndrome de la úlcera rectal solitaria / “The three-lies disease”: Solitary rectal ulcer syndrome

El síndrome de la úlcera rectal solitaria es una entidad benignapoco común cuyos síntomas más frecuentes son la rectorragia y eldolor anal. Los hallazgos anatomopatológicos son típicos. Se sueleevidenciar engrosamiento de la mucosa, elongación y distorsiónde las glándulas, una lámina propia edematosa con gran cantidadde colágena y engrosamiento de la muscularis mucosae. El diagnósticose realiza mediante endoscopia con toma de biopsias. Nosiempre se trata de lesiones ulceradas. Se suele localizar preferentementeen la cara rectal anterior y/o lateral, aunque hasta un30% de las lesiones son múltiples, existiendo casos de afectacióndel colon sigmoide y descendente. Por tanto, la presentación puedeser heterogénea y este es el motivo por el que esta entidad estambién conocida como la “enfermedad de las tres mentiras”.Presentamos un caso de síndrome de la ulcera rectal solitaria manifestadoendoscópicamente como una placa eritematosa localizadaen la cara lateral izquierda del recto

Solitary rectal ulcer syndrome is an uncommon benign conditioncharacterized by rectal bleeding, passage of mucus, and pain.Histological features are well established as obliteration of thelamina propria by fibrosis and smooth-muscle fibers extendingfrom a thickened muscularis mucosa to the lumen. Diagnosis canusually be made on sigmoidoscopy, and biopsies should always betaken. Ulceration is not universally present, and polypoid, non-ulceratedlesions and erythematous areas are also seen. The lesionor lesions are most often found on the anterior or anterolateralwall of the rectum, although they can also be located in the leftcolon and be more extensive or even circumferential. Lesions aremultiple in 30 percent of cases. These are the reasons why thisentity is also known as “the disease of three lies”. We report acase of solitary rectal ulcer syndrome presenting at endoscopywith an erythematous area on the left side wall of the rectum (AU)

["The three-lies disease": solitary rectal ulcer syndrome]. / "Enfermedad de la tres mentiras": síndrome de la úlcera rectal solitaria.

Solitary rectal ulcer syndrome is an uncommon benign condition characterized by rectal bleeding, passage of mucus, and pain. Histological features are well established as obliteration of the lamina propria by fibrosis and smooth-muscle fibers extending from a thickened muscularis mucosa to the lumen. Diagnosis can usually be made on sigmoidoscopy, and biopsies should always be taken. Ulceration is not universally present, and polypoid, non-ulcerated lesions and erythematous areas are also seen. The lesion or lesions are most often found on the anterior or anterolateral wall of the rectum, although they can also be located in the left colon and be more extensive or even circumferential. Lesions are multiple in 30 percent of cases. These are the reasons why this entity is also known as "the disease of three lies". We report a case of solitary rectal ulcer syndrome presenting at endoscopy with an erythematous area on the left side wall of the rectum.

[Cystic fibrosis presenting as acute recurrent pancreatitis]. / Pancreatitis aguda recidivante como forma de presentación de fibrosis quística.

Cystic fibrosis is a multiorgan autosomal recessive disease resulting from mutations in a gene located on the long arm of chromosome 7. The disease is usually diagnosed in the first few years of life when it typically presents with severe pulmonary manifestations and pancreatic insufficiency; however, a small percentage of patients with less dramatic symptoms is not diagnosed until adolescence or even adulthood. The genotype of each patient seems to influence the various forms of clinical presentation. Although uncommon, acute recurrent pancreatitis can be one of the forms of delayed presentation of cystic fibrosis. We report the case of an 17-year-old man who was diagnosed with cystic fibrosis after presenting 2 episodes of acute pancreatitis without associated pancreatic insufficiency. Subsequent study also revealed nasal polyps.

Pancreatitis aguda recidivante como forma de presentación de fibrosis quística / Cystic fibrosis presenting as acute recurrent pancreatitis

La fibrosis quística (FQ) es una enfermedad multiorgánica autosómica recesiva consecuencia de mutaciones existentes en un gen del brazo largo del cromosoma 7. La mayor parte de los casos se diagnostica durante los primeros años de vida, cuando la enfermedad se presenta de forma típica con manifestaciones pulmonares graves e insuficiencia pancreática, pero un pequeño porcentaje de pacientes no se diagnostica hasta la adolescencia e incluso la edad adulta, por presentar cuadros clínicos menos floridos. El genotipo de cada paciente parece influir en las diferentes formas clínicas de presentación de la enfermedad. La pancreatitis aguda recidivante, aunque poco frecuente, puede ser una de las formas de presentación tardía de la FQ. Presentamos el caso de un varón de 17 años que fue diagnosticado de FQ tras presentar 2 episodios de pancreatitis aguda, sin insuficiencia pancreática asociada. También se detectaron en el estudio posterior pólipos nasales

Cystic fibrosis is a multiorgan autosomal recessive disease resulting from mutations in a gene located on the long arm of chromosome 7. The disease is usually diagnosed in the first few years of life when it typically presents with severe pulmonary manifestations and pancreatic insufficiency; however, a small percentage of patients with less dramatic symptoms is not diagnosed until adolescence or even adulthood. The genotype of each patient seems to influence the various forms of clinical presentation. Although uncommon, acute recurrent pancreatitis can be one of the forms of delayed presentation of cystic fibrosis. We report the case of an 17-year-old man who was diagnosed with cystic fibrosis after presenting 2 episodes of acute pancreatitis without associated pancreatic insufficiency. Subsequent study also revealed nasal polyps

Compresión gástrica extrínseca simulando un tumor submucoso: diagnóstico por ecoendoscopia / Submucosal impression of the stomach like a submucosal tumour: diagnosis by endoscopic ultrasound

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[Presentation of Crohn's disease with esophageal involvement]. / Inicio de la enfermedad de Crohn con afección esofágica.

Inflammatory bowel disease basically consists of two entities: ulcerative colitis (UC) and Crohn's disease (CD). Both processes are characterized by chronic inflammation of the intestine, which in the case of CD may affect the entire digestive tract. We present the case of a young man who was diagnosed with esophageal CD after presenting dysphagia and odynophagia. Intestinal involvement was subsequently found. Esophageal involvement is infrequent and as the first manifestation of CD it is extremely rare. It should, however, be borne in mind in patients with esophageal ulcerations without symptoms or endoscopic signs compatible with peptic etiology, even though other indications of inflammatory disease are absent.

Comentario / Commentary

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