EUS-guided tissue acquisition in the study of the adrenal glands: Results of a nationwide multicenter study.

BACKGROUND: There are limited data about the role of endoscopic ultrasound-guided tissue acquisition (EUS-TA), by fine needle aspiration (EUS-FNA) or biopsy (EUS-FNB), in the evaluation of the adrenal glands (AG). The primary aim was to assess the diagnostic yield and safety. The secondary aims were the malignancy predictors, and to create a predictive model of malignancy. METHODS: This was a retrospective nationwide study involving all Spanish hospitals experienced in EUS-TA of AGs. Inclusion period was from April-2003 to April-2016. Inclusion criteria: all consecutive cases that underwent EUS-TA of AGs. EUS and cytopathology findings were evaluated. Statistical analyses: diagnostic accuracy of echoendoscopist's suspicion using cytology by EUS-TA, as gold standard; multivariate logistic regression model to predict tumor malignancy. RESULTS: A total of 204 EUS-TA of AGs were evaluated. Primary tumor locations were lung70%, others19%, and unknown11%. AG samples were adequate for cytological diagnosis in 91%, and confirmed malignancy in 60%. Diagnostic accuracy of the endosonographer's suspicion was 68%. The most common technique was: a 22-G (65%) and cytological needle (75%) with suction-syringe (66%). No serious adverse events were described. The variables most associated with malignancy were size>30mm (OR2.27; 95%CI, 1.16-4.05), heterogeneous echo-pattern (OR2.11; 95%CI, 1.1-3.9), variegated AG shape (OR2.46; 95%CI, 1-6.24), and endosonographer suspicion (OR17.46; 95%CI, 6.2-58.5). The best variables for a predictive multivariate logistic model of malignancy were age, sex, echo-pattern, and AG-shape. CONCLUSIONS: EUS-TA of the AGs is a safe, minimally invasive procedure, allowing an excellent diagnostic yield. These results suggest the possibility of developing a pre-EUS procedure predictive malignancy model.

Estudio comparativo entre un colonoscopio con tecnología RIT (“responsive insertion technology”) y un colonoscopio de rigidez variable convencional / Comparative study of a responsive insertion technology (RIT) colonoscope versus a variable-stiffness colonoscope

Introducción y objetivos: la casa Olympus ha desarrollado recientemente un nuevo endoscopio prototipo, denominado XCFQ180AY2L con tecnología RIT. Esta tecnología supone la incorporación, además de la función de rigidez variable ya conocida, de un segmento con flexión pasiva (PB, de sus siglas en inglés passive bending section) contiguo al segmento móvil del endoscopio, y un tubo de inserción que optimiza la transmisión de la fuerza desde los mandos al extremo distal del aparato (HFT, de sus siglas en inglés high force transmission tube). El objetivo del estudio es comprobar si el uso de este prototipo facilita el procedimiento de inserción del colonoscopio, incrementando la tasa de colonoscopias completas y/o disminuyendo el tiempo de intubación. Material y métodos: estudio observacional y unicéntrico en el que se incluyó de forma prospectiva a 305 pacientes comparando la proporción de colonoscopias completas, los tiempos medios de intubación cecal e ileal, y la necesidad de recibir maniobras específicas durante la colonoscopia, en función del colonoscopio utilizado: el colonoscopio prototipo XCF-Q180AY2L o un colonoscopio convencional, del tipo CFH180AL o CFQ160L, usados como control. Todos los procedimientos fueron realizados bajo sedación con propofol intravenoso. El estudio incluyó finalmente a 288 pacientes y no se observó ninguna complicación. Resultados: la tasa de colonoscopias completas fue del 100 % en ambos grupos. La ileoscopia se realizó en el 98,95 % de los casos. El tiempo medio de intubación fue menor en el grupo del prototipo (4,31 min, DE 2,63 min) que en el grupo control (4,66 min, DE 2,52 min) (p < 0,05). En el grupo del prototipo se utilizó menos la función de rigidez variable (p < 0,05), se necesitó menor número de rectificaciones cuando fue necesario hacer esta maniobra (p < 0,01), y se obtuvo una menor sensación de dificultad al pasar el sigma (p < 0,01). Conclusión: la conclusión fue que el colonoscopio prototipo (XCF-Q180AY2L) facilitó la inserción del colonoscopio, y disminuyó muy ligeramente el tiempo de inserción cecal (AU)

Background and objectives: recently, Olympus developed a new prototype (XCF-Q180AY2L) with responsive insertion technology (RIT), which besides the still known variable stiffness technology, included a passive bending section and a new high force insertion tube. Our objective was to investigate whether the use of this prototype could ease colonoscope insertion, increasing the cecal intubation rate, and/or shortening the cecal intubation time. Material and methods: the study was designed as a prospective observational study in 305 consecutive patients from a colo-rectal cancer screening program. We compared colonoscopies performed with conventional colonoscopes (CFH180AL/CFQ160L) with those performed with the prototype XCF-Q180AY2L. End points were mean cecal and terminal ileal intubation times, cecum intubation rate, and need for specific maneuvers. All colonoscopies were performed under sedation with intravenous propofol. Finally, 288 patients were included. Results: no complications were observed. Complete cecal intubation rate was 100 % in both groups. The ileum could be reached in 98.95 % of cases. Mean time required to reach the cecum was shorter in the prototype endoscope group (4.31 min, SD 2.63 min) than in the conventional endoscope group (4.66 min, SD 2.52 min) (p < 0.05). Compared with the standard colonoscope group, we observed in the prototype group less subjective sensation of difficulty in the passage of the sigma (p < 0.01), fewer maneuvers when it proved necessary to straighten the scope (p < 0.01), and less frequent need to modify the stiffness of the endoscope (p < 0.05). Conclusion: we concluded that the prototype endoscope (XCFQ180AY2L) facilitated colonoscope insertion, requiring slightly less time to reach the cecum than a standard colonoscope (AU)

[Capsule endoscopy interpretation: the role of physician extenders]. / Interpretación de la cápsula endoscópica: el papel del personal no especializado.

BACKGROUND AND AIMS: capsule endoscopy (CE) allows for a new era in small-bowel examination. Nevertheless, physicians time for CE-interpretation remains longer than desirable. Alternative strategies to physicians have not been widely investigated. The aim of this study was to evaluate the accuracy of physician extenders in CE-interpretation. MATERIAL AND METHODS: one CE-experienced gastroenterologist and two physician extenders reviewed independently 20 CE-procedures. Each reader was blinded to the findings of their colleagues. A consensus formed by the readers and a second CE-experienced gastroenterologist was used as gold standard. Number, type and location of images selected, character of CE-exams and their relationship with indications were recorded. Gastric emptying time (GEt), small-bowel transit time (SBTt) and time spent by readers were also noted. RESULTS: sensitivity and specificity for "overall" lesions was 79 and 99% for the gastroenterologist; 86 and 43% for the nurse; and 80 and 57% for the resident. All 34 "major" lesions considered by consensus were found by the readers. Agreement between consensus and readers for images classification and procedures interpretation was good to excellent (? from 0.55 to 1). No significant differences were found in the GEt and SBTt obtained by consensus and readers. The gastroenterologist was faster than physician extenders (mean time spent was 51.9 +/- 13.5 minutes versus 62.2 +/- 19 and 60.9 +/- 17.1 for nurse and resident, respectively; p < 0.05). CONCLUSIONS: physician extenders could be the perfect complement to gastroenterologists for CE-interpretation but gastroenterologists should supervise their findings. Future cost-efficacy analyses are required to assess the benefits of this alternative.

[Synchronous neoplastic lesions in colorectal cancer. An analysis of possible risk factors favouring presentation]. / Lesiones neoplásicas sincrónicas en el cáncer colorectal. Análisis de posibles factores que favorezcan su presentación.

AIM: few data have been published regarding the causes of synchronous lesions in patients with colorectal cancer. The aim of our study was to identify potential factors that might be implicated in the development of multicentric lesions, since this knowledge could be useful for tailored follow-up once initial synchronous lesions have been removed. METHODS: we retrospectively reviewed 382 colorectal cancer cases diagnosed by total colonoscopy and histological study of surgical specimens. We divided our population into 2 groups, based on whether they had synchronous lesions or otherwise. Several data related to personal and family history, habits, symptoms, and tumor characteristics were assessed. Univariate and multivariate statistical analyses were performed. RESULTS: 208 (54.5%) patients had synchronous adenomas and 28 (7.3%) had synchronous cancer. A multivariate analysis showed that the following parameters were consistently related to the presence of multicentric lesions--male gender: OR = 1.97; CI = 1.13-3.45; p = 0.017; age = 59 years: OR = 2.57; CI = 1.54-4.29; p < 0.001; personal history of colonic adenomas: OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructive tumors: OR = 0.48; CI = 0.27-0.85; p = 0.012. CONCLUSION: our results show that several parameters that are easy to measure could be considered risk factors for the development of multicentric lesions. These factors need to be confirmed with follow-up studies analyzing their role in patients with and without metachronic lesions once all synchronous lesions have been removed.

Interpretación de la cápsula endoscópica: el papel del personal no especializado / No disponible

Introducción y objetivos: la cápsula endoscópica (CE) hasupuesto una nueva era en el estudio del intestino delgado. Noobstante, el tiempo empleado por el gastroenterólogo en esteprocedimiento es mayor del deseable y no se han evaluado completamentealternativas al personal especializado. El objetivo deeste estudio es evaluar la precisión de personal no especializadoen la interpretación de la CE.Material y métodos: un gastroenterólogo con experienciaen CE y personal no especializado revisaron independientemente20 procedimientos. Los hallazgos de cada participante eran desconocidospor el resto. Un consenso formado por los participantesy un segundo gastroenterólogo fue empleado como gold standard.Se analizaron número, tipo y localización de las imágenesseleccionadas y tiempo de evacuación gástrica (tEG), tiempo detránsito en intestino delgado (tTID) y tiempo empleado por losparticipantes.Resultados: la sensibilidad y la especificidad global fueron del79 y 99% para el gastroenterólogo; del 86 y 43% para la enfermera;y del 80 y 57% para el residente. Las 34 lesiones “mayores”consideradas por consenso fueron detectadas por los tresparticipantes. El acuerdo entre consenso y participantes para clasificare interpretar las imágenes fue de buena a excelente (k de0,55 a 1). No se encontraron diferencias estadísticamente significativasen el tEG y tTID obtenido por consenso y participantes. Elgastroenterólogo fue el más rápido en revisar los procedimientos(51,9 ± 13,5 minutos versus 62,2 ± 19 y 60,9 ± 17,1 para enfermeray residente, respectivamente; p < 0,05).Conclusiones: el personal no especializado podría ser elcomplemento perfecto al gastroenterólogo en la interpretación dela CE, aunque este debería supervisar sus hallazgos. Los beneficiosde esta alternativa deberían ser contrastados en el futuro poranálisis coste-efectividad

Background and aims: capsule endoscopy (CE) allows for anew era in small-bowel examination. Nevertheless, physicians’time for CE-interpretation remains longer than desirable. Alternativestrategies to physicians have not been widely investigated.The aim of this study was to evaluate the accuracy of physicianextenders in CE-interpretation.Material and methods: one CE-experienced gastroenterologistand two physician extenders reviewed independently 20 CEprocedures.Each reader was blinded to the findings of their colleagues.A consensus formed by the readers and a secondCE-experienced gastroenterologist was used as gold standard.Number, type and location of images selected, character of CEexamsand their relationship with indications were recorded. Gastricemptying time (GEt), small-bowel transit time (SBTt) and timespent by readers were also noted.Results: sensitivity and specificity for “overall” lesions was 79and 99% for the gastroenterologist; 86 and 43% for the nurse;and 80 and 57% for the resident. All 34 “major” lesions consideredby consensus were found by the readers. Agreement betweenconsensus and readers for images classification and proceduresinterpretation was good to excellent (k from 0.55 to 1). Nosignificant differences were found in the GEt and SBTt obtainedby consensus and readers. The gastroenterologist was faster thanphysician extenders (mean time spent was 51.9 ± 13.5 minutesversus 62.2 ± 19 and 60.9 ± 17.1 for nurse and resident, respectively;p < 0.05).Conclusions: physician extenders could be the perfect complementto gastroenterologists for CE-interpretation but gastroenterologistsshould supervise their findings. Future cost-efficacyanalyses are required to assess the benefits of this alternative

Lesiones neoplásicas sincrónicas en el cáncer colorrectal. Análisis de posibles factores que favorezcan su presentación / No disponible

Objetivo: en el cáncer colorrectal son poco conocidas las causasdel frecuente desarrollo de lesiones neoplásicas sincrónicas.Pretendemos identificar posibles factores que pudieran influir enla multicentricidad lesional. Su conocimiento sería útil para, tras eltratamiento de las lesiones iniciales, optimizar el seguimiento enlos pacientes que los presentaran.Pacientes y métodos: estudiamos retrospectivamente 382cánceres colorrectales diagnosticados mediante colonoscopiacompleta y estudio de la pieza quirúrgica. Comparamos una seriede parámetros referentes a los antecedentes personales y familiares,hábitos, datos clínicos y del tumor entre los grupos con y sinlesiones neoplásicas sincrónicas, mediante análisis estadístico univariabley multivariable.Resultados: doscientos ocho (54,5%) pacientes presentaronadenomas sincrónicos y 28 (7,3%) carcinoma sincrónico. En el análisismultivariable el sexo masculino: OR = 1,97; IC = 1,13-3,45,p = 0,017; la edad superior a 59 años: OR = 2,57; IC = 1,54-4,29,p < 0,001; el antecedente personal de pólipo colónico: OR = 3,04,IC = 1,04-8,85, p = 0,042 y el carácter obstructivo del cáncer:OR = 0,48; IC = 0,27-0,85, p = 0,012 se asocian significativamentecon la multicentricidad lesional.Conclusión: en los enfermos con cáncer colorrectal, nuestroestudio muestra una serie de parámetros, de fácil determinación,que podrían comportarse como factores de riesgo para el desarrollode multicentricidad lesional. Estos factores deberán confirmarsemediante un estudio de seguimiento, analizando su comportamientoentre los pacientes que presenten o no lesionesmetacrónicas tras la limpieza quirúrgico-endoscópica inicial

Aim: few data have been published regarding the causes ofsynchronous lesions in patients with colorectal cancer. The aim ofour study was to identify potential factors that might be implicatedin the development of multicentric lesions, since this knowledgecould be useful for tailored follow-up once initial synchronous lesionshave been removed.Methods: we retrospectively reviewed 382 colorectal cancercases diagnosed by total colonoscopy and histological study ofsurgical specimens. We divided our population into 2 groups,based on whether they had synchronous lesions or otherwise.Several data related to personal and family history, habits, symptoms,and tumor characteristics were assessed. Univariate andmultivariate statistical analyses were performed.Results: 208 (54.5%) patients had synchronous adenomasand 28 (7.3%) had synchronous cancer. A multivariate analysisshowed that the following parameters were consistently relatedto the presence of multicentric lesions –male gender: OR = 1.97;CI = 1.13-3.45; p = 0.017; age >= 59 years: OR = 2.57;CI = 1.54-4.29; p < 0.001; personal history of colonic adenomas:OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructive tumors:OR = 0.48; CI = 0.27-0.85; p = 0.012 .Conclusion: our results show that several parameters that areeasy to measure could be considered risk factors for the developmentof multicentric lesions. These factors need to be confirmedwith follow-up studies analyzing their role in patients with andwithout metachronic lesions once all synchronous lesions havebeen removed

[Utility of endoscopy in digestive hemorrhage due to vasculitis]. / Utilidad de la endoscopia en la hemorragia digestiva por vasculitis.

Vasculitides constitute a heterogeneous group of diseases characterized by inflammation of blood vessels. The skin is mainly affected, although the gastrointestinal tract mucosa can also be involved. The contribution of endoscopy in these cases has not been clearly determined. We report three cases of systemic vasculitis (polyarteritis nodosa, Schonlein-Henoch purpura and Behcet's disease) presenting with acute digestive bleeding. Endoscopy was an effective technique for completing the diagnosis and in establishing an effective nonsurgical therapeutic approach in these potentially lethal cases of gastrointestinal hemorrhage.

Pathological and virological findings in patients with persistent hypertransaminasaemia of unknown aetiology.

BACKGROUND: The histopathological spectrum and role of hepatitis viruses in cases of hypertransaminasaemia of unknown aetiology have not been correctly analysed in a sufficiently large number of patients. METHODS: We studied 1075 consecutive patients referred for liver biopsy because of elevation of alanine aminotransferase (ALT) levels for more than six months. From this population we selected those cases in whom the aetiology could not be defined from clinical, biochemical, and serological data obtained before biopsy. In these patients liver biopsies were reviewed, and hepatitis B virus (HBV)-DNA and hepatitis C virus (HCV)-RNA were assayed in serum by polymerase chain reaction (PCR). Serum hepatitis G virus (HGV)-RNA was determined by PCR in 74 patients. RESULTS: Of 1075 patients studied, the cause of the increased serum ALT levels remained elusive after appropriate testing in 109 patients (10.1%). Liver biopsies from these patients showed non-specific changes in 32.7% of cases, non-alcoholic steatohepatitis (NASH) in 15.8%, and chronic hepatitis or cirrhosis in 51.5%. HBV-DNA and/or HCV-RNA was detected more frequently in cryptogenic liver disease than in healthy blood donors (26.7% v 3.4%; p<0.001). HGV-RNA was found in only one patient. The proportion of cases with detectable HBV-DNA or HCV-RNA was 14.3% in patients with non-specific changes or NASH, 30.7% in patients with chronic hepatitis, and 61.5% in patients with cirrhosis. Cirrhosis was found more frequently in patients with positive HBV-DNA and/or HCV-RNA in serum than in those who tested negatively (p=0.005). CONCLUSIONS: In our series, patients in whom biochemical and serological data did not determine the aetiology of the disease represented 10% of all cases referred for liver biopsy for persistent elevation of serum transaminases. Approximately 50% of patients had chronic hepatitis or cirrhosis and the remainder had NASH or non-specific changes. Occult viral infections were found in a high proportion of cases in the first group and in a low percentage of patients in the second.

Collagenous colitis and lymphocytic colitis: clinical and endoscopic findings.

OBJECTIVE: collagenous colitis (CC) and lymphocytic colitis (LC) are two entities of unknown cause, characterized by chronic watery diarrhea, grossly normal-appearing colonic mucosa and abnormal histopathological findings in colonic biopsies. The clinical features of the disease are based mainly on case reports or small uncontrolled series. Although normal colonoscopic findings are, as a rule, part of the diagnosis of CC, several cases of macroscopic colitis associated with CC have been reported, and the spectrum of endoscopic mucosal changes has not been described in large series. METHODS: we present a retrospective study of all patients who underwent total colonoscopy and mucosal biopsy in our Endoscopy Unit between 1991 and 1997. Clinical and endoscopic findings in patients diagnosed as having CC or LC were recorded. RESULTS: of 676 patients studied, 398 suffered from chronic diarrhea. Collagenous colitis was diagnosed in 22 patients and LC in 10. Eleven per cent of the patients with CC and 20% of those with LC did not have diarrhea. Macroscopic colitis was observed in 6 out of 22 patients with CC (27%) and in 4 out of 10 with LC (40%). Macroscopic lesions included edema, erythema, abnormal vascular pattern, superficial erosions or ulcerations and hemorrhagic lacerations. In this series 7.03% of the patients with chronic diarrhea were diagnosed as having CC or LC. CONCLUSIONS: collagenous colitis and LC are two entities that should be considered in the differential diagnosis of chronic diarrhea. Total colonoscopy with multiple biopsies that include the right colon are mandatory. The presence of macroscopic lesions on endoscopy does not rule out a diagnosis of either entity. We identified patients who fulfilled the histopathological criteria for CC or LC but who did not have diarrhea.

[Colonic involvement in the Klippel-Trenaunay-Weber syndrome]. / Afectación de colon en el síndrome de Klippel Trenaunay Weber.

We report the case of a 12-year-old boy, diagnosed of Klippel Trenaunay Weber syndrome, with hemangiomas and venous varicosities in the right leg, who complaint about incidental hematochezia. In the colonoscopy some violet and plain angiodysplastic lesions like in the skin, were observed in rectum and distal sigmoid colon. We think this case is interesting, because of the unusual affectation of the gut in this disease and the importance of considering the endoscopic procedures in the evaluation of these patients.

Colitis colágena y colitis linfocítica: aspectos clínicos y endoscopicos / Collagenous colitis and lymphocytic colitis: clinical and endoscopic findings

INTRODUCCIÓN: la Colitis Colágena (CC) y la Colitis Linfocítica (CL) son dos entidades de etiología desconocida caracterizadas por diarrea crónica acuosa, mucosa de colon macroscópicamente normal y alteraciones histopatológicas de las biopsias de la mucosa de colon. Las características clínicas de esta enfermedad están fundamentalmente basadas en casos publicados o pequeñas series no controladas. Aunque una mucosa de colon macroscópicamente normal, clásicamente, forma parte del diagnóstico de CC, han sido publicados varios casos de colitis macroscópica asociada con CC, pero el espectro de los cambios endoscópicos de la mucosa no han sido descritos en series importantes. MÉTODOS: presentamos un estudio retrospectivo de todos los pacientes estudiados en nuestra Unidad de Endoscopia mediante colonoscopia completa y biopsias de mucosa entre 1991 y 1997. En los pacientes diagnosticados de CC y CL se revisaron los datos clínicos y endoscópicos. RESULTADOS: de 676 pacientes estudiados, 398 presentaban diarrea crónica. Se diagnosticó CC en 22 casos y CL en diez. Un 11 por ciento de las CC (2/22) y un 20 por ciento de las CL (2/10) no presentaban diarrea. Se observó colitis macroscópica en seis de los 22 casos con CC (27 por ciento) y en cuatro de los diez casos con CL (40 por ciento). Las lesiones macroscópicas incluyen edema, eritema, pérdida del patrón vascular subcutáneo, erosiones o ulceraciones superficiales y sufusión hemorrágica. En nuestra serie, las CC y las CL representan el 7,03 por ciento de los pacientes con diarrea crónica. CONCLUSIÓN: la CC y la CL son entidades a tener en cuenta en el diagnóstico diferencial de la diarrea crónica, que requieren la realización de colonoscopia completa y toma de biopsias múltiples incluyendo colon derecho. La existencia de lesiones macroscópicas durante la endoscopia no excluye su diagnóstico. Existen casos de CC y CL que cumplen criterios histológicos pero no presentan diarrea (AU)

Afectación de colon en el síndrome de Klippel Trenaunay Weber / Colonic afectation in Klippel Trenaunay Weber syndrome

Presentamos el caso de un niño de 12 años, diagnosticado de Síndrome de Klippel Trenaunay Weber, con nevus angiomatosos y dilataciones varicosas en pierna derecha y que refería rectorragia ocasional. En colonoscopia se detectaron lesiones angiodisplásicas planas de color violáceo en recto y porción distal de sigma, similares a las cutáneas. Creemos de interés este caso debido a la rareza de la afección del tubo digestivo en esta entidad y la importancia de considerar la exploración endoscópica en las revisiones de estos pacientes (AU)

Prognosis of hepatocellular carcinoma in relation to treatment: a multivariate analysis of 178 patients from a single European institution.

BACKGROUND: Because the prognosis of patients with hepatocellular carcinoma is not fully understood, particularly regarding therapy, we have evaluated it in a series of patients with a homogeneous diagnostic and therapeutic work-up. METHODS: From 1985 to 1996, 42 variables were recorded prospectively in 178 constructive patients who had a diagnosis of hepatocellular carcinoma. Treatment consisted of liver transplantation ( n = 22), partial hepatectomy (n = 11), arterial, chemoembolization ( n = 52), systemic or regional chemotherapy (n = 51), and other therapies (n = 5); 37 patients received no specific therapy. Statistical analysis was performed according to a Cox model. RESULTS: There were no differences between the survival of patients receiving chemotherapy, other therapies, or no treatment (control group n = 93). survival rates a 1,3, and 5 years were 81%, 74%, and 74% for liver transplantation, 72%, 58%, and 58% for hepatectomy, 55%, 26%, and 13% for chemoembolization, and 13%, 3%, and 0% for the control group. Cirrhosis, systemic syndrome, bilobar involvement, Child's stage C disease, and treatment were independent predictors of survival. CONCLUSIONS: This series shows that certain easily accessible parameters may help establish individual prognosis and stratify patients in clinical trials and indicates that chemoembolization, partial resection, and liver transplantation can prolong life expectancy of patients with hepatocellular carcinoma.

[Barrett's esophagus]. / Esófago de Barrett.

Barrett's esophagus (BE), a complication of gastroesophageal reflux disease, is the replacement of squamous tissue with specialized intestinal metaplasia. Other noxious factor, as biliary acids, may contribute to the induction of BE. It is a premalignant condition, and adenocarcinoma arises in some cases. An endoscopic surveillance with multiple biopsies is mandatory to detect different grades of dysplasia or intramucosal cancer and allow effective therapy. Since its prevalence is high, current surveillance protocols become expensive and patient's compliance is difficult. The main medical goals are: 1) To stratify individuals without dysplasia as either lower or higher risk, to screen less often those at lower risk. 2) To obtain complete remission or eliminate the risk of cancer and the need for surveillance. Current treatments have not demonstrate complete regression of metaplasia. Recently, new endoscopic approaches to therapy have been developed. Although they remain experimental and larger series are required, initial results are encouraging.

[Studying of gastric emptying for solids and liquids by means of using stable isotopes]. / Estudio del vaciamiento gástrico de sólidos y líquidos mediante el empleo de isótopos estables.

The study of gastric emptying is usually performed by scintigraphy. Over the last years alternative non radioactive methods have been developed based on the stable isotopes technology. Such techniques use 13C-octanoic acid to measure gastric emptying of solids and sodium 13C-acetate to measure liquids emptying. The enrichment of 13C in breath air along the time reflects the velocity of gastric emptying. Kinetic parameters can be obtained from this enrichment to quantify gastric emptying. Samples can be obtained outside the processing laboratory. Due to the characteristics of the method, it is adequate and safe to evaluate pathologies related to gastric emptying and the efficiency of the therapy.

Embolization of nonvariceal portosystemic collaterals in transjugular intrahepatic portosystemic shunts.

Percutaneous embolization of large portosystemic collaterals was performed in three patients following placement of a transjugular intrahepatic portosystemic shunt in order to improve hepatopetal portal flow. Improved hepatic portal perfusion was achieved in these cases, thereby theoretically reducing the risk of chronic hepatic encephalopathy.

[Dementia caused by bacterial overgrowth in a patient with Billroth II gastrectomy]. / Demencia por sobrecrecimiento bacteriano en paciente portador de gastrectomía Billroth II.

We report the case of a patient in the Psychiatric Department who complained of progressive impairment of cerebral functions consistent with dementia, diarrhea and fecal incontinence in the last few months. His medical history included a Billroth II gastrectomy for gastric ulcer. Biochemical tests detected cobalamin deficiency, without megaloblastic anemia, and an abnormal Schilling test that was not due to intrinsic factor deficiency. Once other causes of cobalamin deficiency were ruled out, we considered it as a deficiency disease due to blind loop syndrome. Treatment with parenteral vitamin B complex and long term oral antibiotic therapy allowed the complete and permanent resolution of neurologic and digestive symptoms. We consider this case to be interesting because it shows the existence of curable dementias and the usefulness of taking into account bacterial overgrowth, usually underestimated, as an entity that can produce a variety of disorders.

Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: effect on clinical, renal, humoral, and hemodynamic parameters.

Seventeen cirrhotics with refractory ascites were treated with transjugular intrahepatic portosystemic shunt (TIPS) and followed for 15.5 +/- 3.4 months. Five patients died, four within 3 months after TIPS (hepatocellular failure) and one after 22 months (cholangiocarcinoma). Six patients received transplants 1 to 10 months after the procedure. Actuarial survival at 6, 12, and 24 months was 75%, 75%, and 63%, respectively. Portosystemic venous pressure gradient decreased by 46% at 1 month and by 38% at 7 to 12 months. Eight patients presented 18 stenoses 1 to 18 months after TIPS. Twelve stenoses required balloon dilatation. Tense ascites was present before TIPS in 100% of the patients, whereas it was mild or absent in 56% at 1 month, in 66% at 3 to 6 months, in 57% at 7 to 12 months, and in 100% at 24 months after TIPS. Requirements for diuretics and paracentesis decreased after TIPS (P < .001, both). One month after TIPS, urinary and fractional sodium excretion increased (P < .001, both), plasma renin activity, plasma aldosterone (P < .005, both), and plasma norepinephrine (P < .05) decreased and cardiac output (P < .01) increased, systemic vascular resistances (P < .005) decreased, and arterial pressure did not change. Acute hepatic encephalopathy was frequent early after TIPS but was responsive to treatment and caused no long-term disability. In conclusion, TIPS is useful in the treatment of refractory ascites through lowering portal pressure and improving renal sodium excretion. This effect could be attributable to an increase in effective blood volume causing deactivation of vasopressor systems.