Cápsula endoscópica y hemorragia digestiva de origen oscuro: ¿importa la forma de presentación? / Capsule endoscopy and obscure gastrointestinal bleeding: does the form of presentation matter?

INTRODUCCIÓN: La hemorragia digestiva de origen oscuro (HDOO) es aquella en la que no se consigue identificar su origen tras la evaluación mediante endoscopia digestiva alta y baja. En esos casos se sospecha un origen en intestino delgado. La HDOO puede ser oculta o manifiesta. El objetivo de este estudio es analizar las características clínico-analíticas, los hallazgos de la cápsula endoscópica e investigar qué factores se relacionan con la detección de lesiones en ambas formas de presentación. MÉTODOS: Estudio retrospectivo sobre las cápsulas endoscópicas realizadas entre noviembre de 2009 y noviembre de 2012 para el estudio de HDOO. RESULTADOS: Se analizaron 284 exploraciones de 272 pacientes. Inicialmente, 12 fueron no valorables y se repitieron, analizando finalmente las cápsulas evaluables (272). Ciento catorce (41,9%) fueron normales. Los pacientes con HDOO manifiesta tenían significativamente mayor edad (70,2 vs. 67,5 años; p = 0,04), consumían más AINE (24,2% vs. 11,9%; p = 0,01), tenían menores niveles de hemoglobina (9,3 vs. 10,4; p < 0,001) y requirieron más transfusiones (64,5% vs. 32,2%; p < 0,001) respecto a los pacientes con HDOO oculta. La detección de lesiones del tipo afta-úlcera y pólipo-masa no mostró diferencias significativas entre ambas formas de presentación. Las lesiones vasculares se detectaron con mayor frecuencia en la forma de HDOO manifiesta respecto a la forma oculta (40,3% vs. 25,7%, respectivamente), (p < 0,05). Considerando el total de diagnósticos realizados por la cápsula, no se observaron diferencias en la capacidad diagnóstica entre la forma manifiesta (57%) y la forma oculta (54%), (p = 0,6). El análisis multivariado mostró cómo el consumo de fármacos: AINE (OR 2,75; p = 0,01), antiagregantes y anticoagulantes (OR 2,64; p = 0,03), así como datos analíticos: hemoglobina (OR 3,23; p < 0,001) e INR (OR 1,8; p = 0,02) predijeron de forma estadísticamente significativa la detección de lesiones con la cápsula endoscópica en la forma de HDOO manifiesta. En la forma de presentación oculta, el análisis multivariado mostró que la edad (OR 1,9; p = 0,04) y el consumo de AINE (OR 2,1; p = 0,01) estaban estadísticamente relacionados con la detección de lesiones en la cápsula. CONCLUSIONES: La cápsula endoscópica es fundamental en la valoración de la HDOO. Aunque la capacidad diagnóstica fue similar entre ambas formas de presentación, las lesiones vasculares se detectaron con mayor frecuencia en el subtipo manifiesta. Teniendo en cuenta la forma de presentación de la HDOO (manifiesta vs. oculta) y algunas características clínico-analíticas de los pacientes (edad, consumo de fármacos, hemoglobina) se podría optimizar la capacidad diagnóstica de la cápsula

INTRODUCTION: Obscure gastrointestinal bleeding (OGIB) is defined as bleeding from the gastrointestinal tract with no obvious cause after assessment with upper and lower gastrointestinal endoscopy. In these cases, the source is suspected to be in the small bowel. Obscure bleeding can be occult or overt. The aim of this study was to analyze the clinical and analytical characteristics and findings on capsule endoscopy in patients with OGIB and to determine the factors related to the detection of lesions in both forms of presentation. METHODS: We performed a retrospective study of capsule endoscopies carried out between November 2009 and November 2012 for OGIB. RESULTS: We analyzed 284 capsule endoscopies in 272 patients. Initially, 12 procedures could not be evaluated and were repeated. A total of 272 procedures were finally included in the analysis. The results of 114 (41.9%) capsule endoscopies were normal. Compared with patients with occult OGIB, those with overt OGIB were significantly older (70.2 vs. 67.5 years; p = 0.04), consumed more NSAID (24.2% vs. 11.9%; p = 0.01), had higher hemoglobin levels (9.3 vs. 10.4; p < 0,001) and more frequently required transfusion (64.5% vs 32.2%; p < 0.001). No differences were found between the two forms of presentation in the detection of canker sores-ulcers and polyps-masses. Vascular lesions were more frequently detected in overt than in occult OGIB (40.3% vs. 25.7%, respectively), (p < 0.05). When the total number of diagnoses carried out by capsule endoscopy was analyzed, no differences were found in diagnostic yield between overt OGIB (57%) and occult OGIB (54%), (p = 0.6). In overt OGIB, multivariate analysis showed that the variables that significantly predicted the detection of lesions on capsule endoscopy were consumption of medication NSAID (OR 2.75; p = 0.01), antiplatelets and anticoagulants (OR 2.64; p = 0.03) and analytical data hemoglobin (OR 3.23; p < 0.001) and INR (OR 1.8; p = 0.02). In occult OGIB, multivariate analysis showed that the factors significantly related to the detection of lesions on endoscopy were age (OR 1.9; p = 0.04) and NSAID consumption (OR 2.1; p = 0.01). CONCLUSIONS: Capsule endoscopy is essential in the assessment of OGIB. Although the diagnostic yield was similar in both forms of presentation, vascular lesions were more frequently detected in overt OGIB. The diagnostic yield of capsule endoscopy could be optimized by taking into account the form of presentation (overt vs. occult) and certain clinical and analytic data (age, drug consumption, hemoglobin) (AU)

[Capsule endoscopy and obscure gastrointestinal bleeding: does the form of presentation matter?]. / Cápsula endoscópica y hemorragia digestiva de origen oscuro: ¿importa la forma de presentación?

INTRODUCTION: Obscure gastrointestinal bleeding (OGIB) is defined as bleeding from the gastrointestinal tract with no obvious cause after assessment with upper and lower gastrointestinal endoscopy. In these cases, the source is suspected to be in the small bowel. Obscure bleeding can be occult or overt. The aim of this study was to analyze the clinical and analytical characteristics and findings on capsule endoscopy in patients with OGIB and to determine the factors related to the detection of lesions in both forms of presentation. METHODS: We performed a retrospective study of capsule endoscopies carried out between November 2009 and November 2012 for OGIB. RESULTS: We analyzed 284 capsule endoscopies in 272 patients. Initially, 12 procedures could not be evaluated and were repeated. A total of 272 procedures were finally included in the analysis. The results of 114 (41.9%) capsule endoscopies were normal. Compared with patients with occult OGIB, those with overt OGIB were significantly older (70.2 vs. 67.5 years; p = 0.04), consumed more NSAID (24.2% vs. 11.9%; p = 0.01), had higher hemoglobin levels (9.3 vs. 10.4; p < 0,001) and more frequently required transfusion (64.5% vs 32.2%; p < 0.001). No differences were found between the two forms of presentation in the detection of canker sores-ulcers and polyps-masses. Vascular lesions were more frequently detected in overt than in occult OGIB (40.3% vs. 25.7%, respectively), (p < 0.05). When the total number of diagnoses carried out by capsule endoscopy was analyzed, no differences were found in diagnostic yield between overt OGIB (57%) and occult OGIB (54%), (p = 0.6). In overt OGIB, multivariate analysis showed that the variables that significantly predicted the detection of lesions on capsule endoscopy were consumption of medication NSAID (OR 2.75; p = 0.01), antiplatelets and anticoagulants (OR 2.64; p = 0.03) and analytical data hemoglobin (OR 3.23; p < 0.001) and INR (OR 1.8; p = 0.02). In occult OGIB, multivariate analysis showed that the factors significantly related to the detection of lesions on endoscopy were age (OR 1.9; p = 0.04) and NSAID consumption (OR 2.1; p = 0.01). CONCLUSIONS: Capsule endoscopy is essential in the assessment of OGIB. Although the diagnostic yield was similar in both forms of presentation, vascular lesions were more frequently detected in overt OGIB. The diagnostic yield of capsule endoscopy could be optimized by taking into account the form of presentation (overt vs. occult) and certain clinical and analytic data (age, drug consumption, hemoglobin).

Environmental risk factors in inflammatory bowel diseases. Investigating the hygiene hypothesis: a Spanish case-control study.

OBJECTIVE: Environmental factors have been implicated in the etiology of inflammatory bowel disease (IBD), but evidence for the hygiene hypothesis is unclear. We investigated the relationship between early-life infection-related exposures and risk of IBD. PATIENTS AND METHODS: A hospital-based case-control study was carried out. A total of 124 cases of Crohn's disease (CD) and 146 of ulcerative colitis (UC) were compared with 235 and 278 well-matched control subjects, respectively. A multi-item questionnaire on familial history of IBD, childhood circumstances and familial socioeconomic status was carried out. RESULTS: In a multivariate model, living in urban areas (odds ratio (OR) 4.58 (95% CI 2.17-10)), high educational level (OR 1.83 (95% CI 14-2.95)) and social status (OR 1.68 (95% CI 1.2-2.35)) were risk factors for CD, whereas childhood respiratory infections (OR 0.35 (95% CI 0.23-0.52)) and gastroenteritis (OR 0.55 (95% CI 0.36-0.85)) were protective factors. Living in urban areas (OR 4.6 (95% CI 2.29-9.9)), a high educational level (OR 10.3 (95% CI 2.54-42.1)) and social status (OR 2.042 (95% CI 1.31-3.17)) were also risk factors for UC, whereas respiratory infections (OR 0.42 (95% CI 0.29-0.6)) and gastroenteritis (OR: 0.6 (95% CI 0.42-0.86)) were protective factors. Appendectomy (OR 0.173 (95% CI 0.06-0.52)) and current smoking (OR 0.75 (95% CI 0.59-0.96)) were also protective for UC. CONCLUSION: These results further support the hypothesis that better living conditions during childhood are associated with an increased risk for IBD, and reinforce the negative association between smoking and appendectomy and the risk of UC.

Colitis ulcerosa asociada a enfermedad de Vogt-Koyanagi-Harada / Ulcerative colitis associated with Vogt-Koyanagi-Harada disease

A continuación se presenta el caso de una paciente diagnosticada a los 14 años de enfermedad de Vogt-Koyanagi-Harada (VKH) en la que posteriormente se desarrolló paraparesia por mielopatía secundaria a esta enfermedad. Asimismo, se detectaron en la resonancia magnética craneal lesiones en la sustancia blanca periventricular, hiperintensas en secuencias ponderadas en T2, indicativas de desmielinización. Doce años después, la paciente se realizó un estudio debido a un cuadro de dolor abdominal asociado a diarrea con productos patológicos siendo diagnosticada de colitis ulcerosa (CU).La asociación de estas 2 enfermedades se ha comunicado con anterioridad de forma anecdótica.Las manifestaciones neurológicas de la paciente complicaron el tratamiento terapéutico de la CU, ya que, aunque publicaciones recientes avalan el tratamiento con anti-TNF (antitumor necrosis factor‘antifactor de necrosis tumoral’) en la uveítis propia de enfermedad de VKH, la falta de experiencia en casos asociados a focalidad neurológica y el desconocimiento de la verdadera patogénesis de las lesiones parenquimatosas indicativas de desmielinización desaconsejaron el uso de estos fármacos en este caso (AU)

We report the case of a female patient who was diagnosed with Vogt-Koyanagi-Harada disease at the age of 14 years and who developed myelopathy, resulting in paraparesis. A cerebral magnetic resonance imaging scan revealed the presence of T2-hyperintense lesions in the periventricular white matter, suggesting demyelinization. Twelve years later, ulcerative colitis was diagnosed during workup for abdominal pain associated with bloody diarrhea.The association of these two diseases has previously been reported anecdotically.The management of the ulcerative colitis was complicated by the patient's neurological manifestations. Even though recent reports support the use of anti-TNF drugs in the management of Vogt-Koyanagi-Harada-associated uveitis, because of the lack of experience in patients with neurological symptoms, and the presence of apparently demyelinating lesions in our patient, we did not use these drugs in this case (AU)