Endoscopic suspect of subacute occlusive mesenteric ischemia.

A 74-year-old patient presented to our emergency department with melena for 24 hours, associated with postprandial abdominal pain, predominantly in the epigastrium, for one month. Urgent gastroscopy showed a pale mucosa with loss of vascular pattern in the gastric antrum, as well as several superficial ulcers, Forrest III, at that level and in the duodenal bulb highly suggestive of ischaemia. An abdominal computed tomography angiography (CTA) revealed a filiform celiac trunk, with calcified atherosclerotic plaques in the ostium, superior mesenteric artery and both renal arteries, with absence of enhancement in a large part of the intestinal wall, suggestive of ischaemia. An exploratory laparoscopy confirmed patchy ischaemia of the small intestine, as well as of the cecum, ascending colon, and portion of the transversus. Atherosclerosis is the most common cause of occlusive chronic mesenteric ischaemia. The 'classic triad' consisting of postprandial pain, weight loss and abdominal bruit, is found in only a minority of patients, with a significant percentage of paucisymptomatic patients due to abundant colateral circulation, making diagnosis difficult. The endoscopic finding of edema, erythema or signs of mucosal atrophy, as well as gastric or duodenal ulcers, not justified by other causes can guide us in the diagnosis. However, more distal sections of the digestive tract which are not accessible with the conventional endoscope can often be affected, and the absence of these findings, does not exclude the diagnosis. Abdominal CTA is the gold-standard imaging test. Early diagnosis of mesenteric ischaemia is a challenge in clinical practice. Recognizing its endoscopic signs can facilitate its early diagnosis and treatment.

Involvement of the digestive system in covid-19. A review. / Afectación del aparato digestivo en la covid-19. Una revisión sobre el tema.

The SARS-CoV-2 pandemic is leading to high mortality and a global health crisis. The primary involvement is respiratory; however, the virus can also affect other organs, such as the gastrointestinal tract and liver. The most common symptoms are anorexia and diarrhea. In about half of the cases, viral RNA could be detected in the stool, which is another line of transmission and diagnosis. covid19 has a worse prognosis in patients with comorbidities, although there is not enough evidence in case of previous digestive diseases. Digestive endoscopies may give rise to aerosols, which make them techniques with a high risk of infection. Experts and scientific organizations worldwide have developed guidelines for preventive measures. The available evidence on gastrointestinal and hepatic involvement, the impact on patients with previous digestive diseases and operating guidelines for Endoscopy Units during the pandemic are reviewed.

COVID-19 y aparato digestivo / COVID-19 and gastrointestinal tract

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Afectación del aparato digestivo en la covid-19. Una revisión sobre el tema / Involvement of the digestive system in covid-19. A review

La pandemia por el SARS-CoV-2 está conllevando una elevada mortalidad y suponiendo una crisis sanitaria a nivel mundial. La afectación fundamental es respiratoria; sin embargo, el virus también puede afectar a otros órganos, como el tracto gastrointestinal y el hígado. Los síntomas más habituales son anorexia y diarrea. Aproximadamente, en la mitad de los casos se podría detectar ARN viral en heces, lo que constituye otra línea de transmisión y diagnóstico. La covid-19 tiene peor pronóstico en pacientes con comorbilidades, aunque no existe evidencia suficiente en caso de enfermedades digestivas previas. Las endoscopias digestivas pueden originar aerosoles, lo que las convierte en técnicas con elevado riesgo de infección. Expertos y organizaciones científicas a nivel mundial han elaborado guías de funcionamiento para adoptar medidas de prevención. Se revisan las evidencias disponibles sobre la afectación gastrointestinal y hepática, la repercusión en pacientes con enfermedades digestivas previas y las guías de funcionamiento para las unidades de endoscopia durante la pandemia

The SARS-CoV-2 pandemic is leading to high mortality and a global health crisis. The primary involvement is respiratory; however, the virus can also affect other organs, such as the gastrointestinal tract and liver. The most common symptoms are anorexia and diarrhea. In about half of the cases, viral RNA could be detected in the stool, which is another line of transmission and diagnosis. covid19 has a worse prognosis in patients with comorbidities, although there is not enough evidence in case of previous digestive diseases. Digestive endoscopies may give rise to aerosols, which make them techniques with a high risk of infection. Experts and scientific organizations worldwide have developed guidelines for preventive measures. The available evidence on gastrointestinal and hepatic involvement, the impact on patients with previous digestive diseases and operating guidelines for Endoscopy Units during the pandemic are reviewed

Prevalence of celiac disease in primary care: the need for its own code.

BACKGROUND: Celiac disease (CD) is an autoimmune chronic enteropathy of the small intestine caused by exposure to gluten in genetically predisposed individuals. CD is not easy to diagnose due to its unspecific symptomatology, especially in adults, a diagnosed/undiagnosed ratio of 1:7 is estimated. CD does not have its own code in the International Classification of Primary Care (ICPC) but it is coded under code D99 "Disease digestive system, other", which hinders diagnosis, intervention and research. The aim of this study is to investigate the prevalence of CD in Aragón, Spain, using the information available from Primary Care, as well as to discuss the difficulties involved in determining prevalence of CD from data collected at this level of medical intervention. METHODS: We designed an epidemiological cross-sectional study and analysed 26,964 electronic clinical records from the Aragonese Health Service under code ICPC D99 collected up to December 31st, 2016. The clinical records were classified by their editable field "descriptor" according to their probability of being related to CD. Analyses of gender, age, age at diagnosis, province and health sector were carried out. RESULTS: We found 4534 clinical records under 293 different descriptors with a high probability of referring to CD. Prevalence in Aragón was estimated to be 0.35% ranging from 0.24 to 0.81% with important differences among health sectors. CONCLUSIONS: The prevalence of 0.35% is a long way from the generally accepted 1% but within the usually considered ratio 1:7 of diagnosed:undiagnosed cases. Differences among sectors should be carefully analysed. Lacking its own ICPC code, diagnosis of CD in Primary Care Services is not included in a single category, but it is distributed under several descriptors, which makes it difficult to offer any firm diagnosis for treatment and hinders research. Finally, the high prevalence of CD justifies its own ICPC code and the need to withdraw CD from the generic D99 code "Disease digestive system other".

From the intestinal flora to the microbiome.

In this article, the history of the microbiota is reviewed and the related concepts of the microbiota, microbiome, metagenome, pathobiont, dysbiosis, holobiont, phylotype and enterotype are defined. The most precise and current knowledge about the microbiota is presented and the metabolic, nutritional and immunomodulatory functions are reviewed. Some gastrointestinal diseases whose pathogenesis is associated with the intestinal microbiota, including inflammatory bowel disease, irritable bowel syndrome and celiac disease, among others, are briefly discussed. Finally, some prominent and promising data with regard to the fecal microbiota transplantation in certain digestive illness are discussed.

New psychological therapies for irritable bowel syndrome: mindfulness, acceptance and commitment therapy (ACT)

The current goal of treatment in irritable bowel syndrome (IBS) focuses primarily on symptom management and attempts to improve quality of life. Several treatments are at the disposal of physicians; lifestyle and dietary management, pharmacological treatments and psychological interventions are the most used and recommended. Psychological treatments have been proposed as viable alternatives or compliments to existing care models. Most forms of psychological therapies studied have been shown to be helpful in reducing symptoms and in improving the psychological component of anxiety/depression and health-related quality of life. According to current NICE/NHS guidelines, physicians should consider referral for psychological treatment in patients who do not respond to pharmacotherapy for a period of 12 months and develop a continuing symptom profile (described as refractory irritable bowel syndrome). Cognitive behavioral therapy (CBT) is the best studied treatment and seems to be the most promising therapeutic approach. However, some studies have challenged the effectiveness of this therapy for irritable bowel syndrome. One study concluded that cognitive behavioral therapy is no more effective than attention placebo control condition and another study showed that the beneficial effects wane after six months of follow-up. A review of mind/body approaches to irritable bowel syndrome has therefore suggested that alternate strategies targeting mechanisms other than thought content change might be helpful, specifically mindfulness and acceptance-based approaches. In this article we review these new psychological treatment approaches in an attempt to raise awareness of alternative treatments to gastroenterologists that treat this clinical syndrome (AU)

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New psychological therapies for irritable bowel syndrome: mindfulness, acceptance and commitment therapy (ACT).

The current goal of treatment in irritable bowel syndrome (IBS) focuses primarily on symptom management and attempts to improve quality of life. Several treatments are at the disposal of physicians; lifestyle and dietary management, pharmacological treatments and psychological interventions are the most used and recommended. Psychological treatments have been proposed as viable alternatives or compliments to existing care models. Most forms of psychological therapies studied have been shown to be helpful in reducing symptoms and in improving the psychological component of anxiety/depression and health-related quality of life. According to current NICE/NHS guidelines, physicians should consider referral for psychological treatment in patients who do not respond to pharmacotherapy for a period of 12 months and develop a continuing symptom profile (described as refractory irritable bowel syndrome). Cognitive behavioral therapy (CBT) is the best studied treatment and seems to be the most promising therapeutic approach. However, some studies have challenged the effectiveness of this therapy for irritable bowel syndrome. One study concluded that cognitive behavioral therapy is no more effective than placebo attention control condition and another study showed that the beneficial effects wane after six months of follow-up. A review of mind/body approaches to irritable bowel syndrome has therefore suggested that alternate strategies targeting mechanisms other than thought content change might be helpful, specifically mindfulness and acceptance-based approaches. In this article we review these new psychological treatment approaches in an attempt to raise awareness of alternative treatments to gastroenterologists that treat this clinical syndrome.

Enough discussions about who should use propofol in gastrointestinal endoscopy.

Reflections in order to agree on who should be responsible for the deep sedation with propofol in gastrointestinal endoscopies, after so many squabble between anaesthesiologists and endoscopists.

Revisión del papel de los probióticos en la patología gastrointestinal del adulto / Review of the role of probiotics in gastrointestinal diseases in adults

Antecedentes: Los probióticos pueden actuar como agentes biológicos que modifican la microbiota intestinal y ciertos perfiles de citoquinas, lo que puede conllevar una mejoría en ciertos procesos gastrointestinales. Objetivos: Realizar una revisión basada en la evidencia del papel de los probióticos en determinadas patologías gastrointestinales del adulto. Métodos de búsqueda: Revisión realizada utilizando los descriptores, filtros y límites adecuados en la base de datos PubMed (MEDLINE). Criterios de selección: Se han empleado los términos MeSH Probiotics [en el título] AND Gastrointestinal Diseases, con los siguientes límites o filtros: tipos de estudios: Systematic Reviews, Meta-Analysis, Guideline, Practice Guideline, Consensus Development Conference (y Consensus Development Conference NIH), Randomized Controlled Trial, Controlled Clinical Trial y Clinical Trial; edad: adultos (19 o más a˜nos); idioma: en inglés y español; en humanos, y que dispusieran, al menos, de un abstract. Recogida y análisis de datos: Se recuperaron los textos completos de todas las revisiones sistemáticas y metaanálisis directamente relacionados con el objetivo de la revisión, así como los ensayos clínicos aleatorizados de los estudios que se consideraron relevantes y de calidad para realizar esta revisión. Resultados principales: Determinados probióticos, diferentes para cada proceso, se han demostrado eficaces y beneficiosos en caso de diarrea aguda infecciosa, diarrea asociada a antibióticos, diarrea asociada a Clostridium difficile, pouchitis y en la erradicación de la infección por Helicobacter pylori. Conclusiones de los autores: Hay ciertas patologías gastrointestinales en las que se puede recomendar el uso de los probióticos, verdaderos agentes biológicos, y otras en las que no se ha demostrado beneficio (AU)

Background: Probiotics may act as biological agents that modify the intestinal microbiota and certain cytokine profiles, which can lead to an improvement in certain gastrointestinal diseases. Objectives: To conduct a review of the evidence of the role of probiotics in certain gastrointestinal diseases in adults. Search methods: Review conducted using appropriate descriptors, filters and limits in the PubMed database (MEDLINE). Selection criteria: The MeSH terms used were Probiotics [in the title] AND Gastrointestinal Diseases, with the following limits or filters: Types of study: Systematic Reviews, Meta-Analysis, Guideline, Practice Guideline, Consensus Development Conference (and Consensus Development Conference NIH), Randomized Controlled Trial, Controlled Clinical Trial and Clinical Trial; age: adults (19 or older); language: English and Spanish; in humans, and with at least one abstract. Data collection and analysis: Full texts of all the Systematic Reviews and meta-analyses directly related to the review’s objective were obtained, as well as the Randomised Controlled Trials of the studies that were considered relevant and of sufficient quality for this review. Main results: Certain probiotics, different for each process, have proven to be effective and beneficial in cases of acute infectious diarrhoea, antibiotic-associated diarrhoea, Clostridium difficile-associated diarrhoea, pouchitis and Helicobacter pylori infection eradication. Authors’ conclusions: Although some probiotics have not demonstrated any benefit, there are certain gastrointestinal diseases in which the use of probiotics, true biological agents, can be recommended (AU)

Combined endoscopic resolution of iatrogenic stricture in an ureterosigmoidostomy.

Ureteroenterostomy allows the replacement of the bladder role after radical cystectomy. Anastomotic stricture is a relatively common complication that may require surgical repair. We report a case of iatrogenic stricture in a Mainz-II ureterosigmoidostomy that was satisfactorily resolved using a combined endoscopic-urological approach.

Resolución endoscópica combinada de una estenosis yatrógena en una ureterosigmoidostomía / Combined endoscopic resolution of iatrogenic stricture in an ureterosigmoidostomy

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Review of the role of probiotics in gastrointestinal diseases in adults. / Revisión del papel de los probióticos en la patología gastrointestinal del adulto.

BACKGROUND: Probiotics may act as biological agents that modify the intestinal microbiota and certain cytokine profiles, which can lead to an improvement in certain gastrointestinal diseases. OBJECTIVES: To conduct a review of the evidence of the role of probiotics in certain gastrointestinal diseases in adults. SEARCH METHODS: Review conducted using appropriate descriptors, filters and limits in the PubMed database (MEDLINE). SELECTION CRITERIA: The MeSH terms used were Probiotics [in the title] AND Gastrointestinal Diseases, with the following limits or filters: Types of study: Systematic Reviews, Meta-Analysis, Guideline, Practice Guideline, Consensus Development Conference (and Consensus Development Conference NIH), Randomized Controlled Trial, Controlled Clinical Trial and Clinical Trial; age: adults (19 or older); language: English and Spanish; in humans, and with at least one abstract. DATA COLLECTION AND ANALYSIS: Full texts of all the Systematic Reviews and meta-analyses directly related to the review's objective were obtained, as well as the Randomised Controlled Trials of the studies that were considered relevant and of sufficient quality for this review. MAIN RESULTS: Certain probiotics, different for each process, have proven to be effective and beneficial in cases of acute infectious diarrhoea, antibiotic-associated diarrhoea, Clostridium difficile-associated diarrhoea, pouchitis and Helicobacter pylori infection eradication. AUTHORS' CONCLUSIONS: Although some probiotics have not demonstrated any benefit, there are certain gastrointestinal diseases in which the use of probiotics, true biological agents, can be recommended.

Psiconeuroinmunología en el síndrome del intestino irritable / Psychoneuroimmunology in irritable bowel síndrome

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Gestión de la endoscopia digestiva de puertas abiertas y calidad asistencial: equipo de mejora con atención primaria / Management of open access gastrointestinal endoscopy and quality of care: collaboration between an improvement team and primary care

Objetivo Creación y puesta en marcha de un equipo de mejora, dentro de un proyecto de mejora de calidad en salud del Gobierno de Aragón, destinado a incrementar la calidad y el grado de idoneidad de las indicaciones de endoscopia digestiva en el sistema de puertas abiertas en un hospital secundario aragonés. Diseño El equipo desarrolló un documento de consenso donde se recogían las indicaciones y cómo hacer un uso adecuado de la endoscopia oral y la colonoscopia, y realizó una serie de reuniones informativas y formativas con todos los médicos de atención primaria implicados sobre el tema. Emplazamiento Centros de salud del Sector I y Hospital Royo Villanova, de Zaragoza. Participantes El equipo de mejora estaba integrado por un digestólogo y 3 médicos de atención primaria, y contó con el apoyo y respaldo de la Gerencia y la Dirección de atención primaria de su sector sanitario. Resultados Se ha conseguido reducir la inadecuación de endoscopia digestiva, particularmente de colonoscopia, del 20 al 11,6%, un importante ahorro en costes sanitarios, reducir significativamente la lista de espera de endoscopia, mejorar la calidad asistencial y seguridad de los pacientes sometidos a dichas exploraciones, mejorar la formación de los médicos de atención primaria en estos temas e implementar la coordinación asistencial atención primaria-especializada. Conclusiones Para que un sistema de endoscopia digestiva de puertas abiertas a atención primaria funcione de forma eficiente es necesaria la creación de un equipo de mejora interdisciplinario y la total implicación de la atención primaria que maneja ese recurso (AU)

Objective To create an improvement team within a healthcare quality improvement project of the Government of Aragon (Spain), aimed at increasing the quality of care and suitability of the indications of gastrointestinal endoscopy in the open access endoscopy system of a secondary hospital in Aragon. Design The team developed a consensus document indicating how to use oral endoscopy and colonoscopy correctly, and held information and training sessions with all the primary care physicians involved in this area. Location Sector I health centers and Royo Villanova Hospital, in Zaragoza. Participants The team consisted of a gastroenterologist and three primary care physicians and, from the outset received the support of the primary care administration and management in the health area. Results Inappropriate use of endoscopy, particularly colonoscopy, was reduced from 20% to 11.6%. Significant savings were achieved in health costs. The endoscopy waiting list was reduced. The quality of care and the safety of patients undergoing these examinations improved. Training of primary care physicians in these procedures was enhanced, and coordination between primary and specialized was implemented. Conclusions To ensure efficient running of an open access gastrointestinal endoscopy system, an interdisciplinary improvement team and the full involvement of the primary care staff managing this resource are required (AU)