Left Perforated Colonic Tumor with Synchronous Locally Advanced Right Colonic Tumor.

Colorectal cancer is one of the most common malignant neoplasms worldwide. Overall mortality is 33%. Synchronous colorectal cancer refers to more than one malignant tumor detected in different segments of the colon, simultaneously or within 6 months of initial diagnosis. The development of colorectal cancer is a multistep process that originates with a genetic mutation leading to a malignant phenotype and generating a growth advantage. Colorectal cancer presents up to 16% of hypermutations, of which 75% are characterized by microsatellite instability which in turn leads to poorer cell differentiation. Patients with synchronous tumors appear to have a higher proportion of microsatellite instability than patients with single tumors. The clinical case of a 35-year-old man with a perforated left colon tumor and a locally advanced synchronous tumor of the right colon and signs of acute abdomen is presented. The treatment should be based on the location of the synchronous tumors, stage at the time of approach, and the patient's condition. However, when faced with a complication secondary to colonic cancer, adhering to the principles of oncological surgery can be overcome by the nature of the emergency.

Is albumin a predictor of severity and mortality in patients with abdominal sepsis?

BACKGROUND: Patients with a lower level of albumin have a more severe infection, the level of said biomarker is a strong predictor of mortality. OBJECTIVE: To determine the usefulness of the serum albumin level as a predictor of severity and mortality. METHODS: Retrospective, descriptive, cross-sectional study of patients diagnosed with abdominal sepsis. During the period from April 2016-February 2017. The severity was determined by Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), Mannheim and mortality. The sample was divided into those with albumin > 2.9 mg/dl and < 2.8 mg/dl. RESULTS: We included 155 cases, 62 female and 93 male; the main organ causing abdominal sepsis was the appendix 42%. The average albumin for the sample was 3.2 mg/dl (DE ± 0.9). The findings, subjected to statistical verification by means of the Mann-Whitney test, showed statistical significance among the cases with albumin < 2.8 mg/dl with those have ranged Mannheim > 26 points (p = 0.001), APACHE > 15 (p = 0.015) and SOFA > 6 (p = 0.001), No statistical significance was obtained between albumin level < 2.8, and mortality (p = 0.052). CONCLUSION: Albumin can be considered as a predictor of severity, although not as a predictor of mortality.

INTRODUCCIÓN: Los pacientes con unos valores más bajos de albúmina presentan una infección más grave; el nivel de dicho biomarcador es un fuerte predictor de la mortalidad. OBJETIVO: Determinar la utilidad de la concentración sérica de albúmina como predictor de gravedad y mortalidad. MÉTODO: Estudio retrospectivo, descriptivo, transversal, de pacientes con diagnóstico de sepsis abdominal, atendidos durante el periodo de abril de 2016 a febrero de 2017. Se determinaron la gravedad mediante APACHE II, SOFA y Mannheim, y la mortalidad. Se dividió la muestra en pacientes con albúmina > 2.9 y < 2.8 mg/dl. RESULTADOS: Se incluyeron 155 casos (62 mujeres y 93 hombres); el principal órgano causante de sepsis abdominal fue el apéndice (42%). El valor medio de la albúmina para la muestra se situó en 3.2 mg/dl (desviación estándar: ± 0.9). Los hallazgos, sometidos a verificación estadística mediante la prueba U de Mann-Whitney, mostraron una relación con significancia estadística entre los casos con albúmina < 2.8 mg/dl y los casos con puntaje de Mannheim > 26 puntos (p = 0.001), APACHE > 15 (p = 0.015) y SOFA > 6 (p = 0.001). No se obtuvo significancia estadística entre el valor de la albúmina < 2.8 y la mortalidad (p = 0.052). CONCLUSIÓN: La albúmina puede ser considerada como un predictor de gravedad, pero no de mortalidad.

Factores de riesgo asociados al desarrollo de fístula anal / Risk factor associated to the development of anal fistula

Objetivo: Determinar los factores de riesgo asociados para el desarrollo de fístula anal posterior a absceso anal. Sede: Hospital General de México. Diseño: Estudio de casos y controles. Análisis estadístico: Análisis univariado. Pacientes y métodos: Se incluyeron 250 pacientes observados en el periodo de mayo de 2009 a enero de 2012, evaluados en consulta externa de la Unidad de Coloproctología con el diagnóstico de absceso anal y con tres meses o más de seguimiento. Las variables analizadas fueron: edad, ocupación, diabetes mellitus, tabaquismo, consumo de alcohol, antibióticos previos y posteriores al drenaje, tipo de evacuación de acuerdo a la escala de Bristol, anorrecepción, tiempo de evolución del absceso y lugar de drenaje del absceso (consultorio, quirófano o espontáneamente). Resultados: De los 250 pacientes con absceso anal tratados con un drenaje simple, 103 (41.2%) desarrollaron fístula anal. Los resultados del análisis univariado no mostraron significancia estadística para ninguna de estas variables. Conclusión: No identificamos factor de riesgo, estudiados en este trabajo, para poder determinar qué pacientes pueden desarrollar fístula anal posterior a un evento de absceso anal.

Objective: To determine the risk factors associated to the development of anal after an anal abscess. Setting: General Hospital of Mexico (third level health care center). Design: Case-controls study. Statistical analysis: Univariate analysis. Patients and methods: The study comprised 250 patients observed in the period of May 2009 to January 2012 assessed in the outpatient clinic of the Coloproctology Unit, with a diagnosis of anal abscess and three months or more of follow-up. Analyzed varaibles were: age, ocupation, diabetes mellitus, smoking, alcohol consumption, previous antibiotics and after the drainage, type of evacuation according to the Bristol scale, anal reception, time of abscess evolution, and site where drainage of the abscess was performed (outpatient clinic, surgery room, or spontaneously). Results: Of the 250 patients with an anal abscess treated with a simple drainage, 103 (41.2%) developed an anal. Results of the univariate analysis did not reveal any statistical significance for any of the studied variables. Conclusion: We did not identify any risk factor in this paper to be able to determine which patients can develop an anal after an anal abscess event.

A one-year economic evaluation of six alternative strategies in the management of uninvestigated upper gastrointestinal symptoms in Canadian primary care.

BACKGROUND: The cost-effectiveness of initial strategies in managing Canadian patients with uninvestigated upper gastrointestinalsymptoms remains controversial. OBJECTIVE: To assess the cost-effectiveness of six management approaches to uninvestigated upper gastrointestinal symptoms in the Canadian setting. METHODS: The present study analyzed data from four randomized trials assessing homogeneous and complementary populations of Canadian patients with uninvestigated upper gastrointestinal symptoms with comparable outcomes. Symptom-free months, qualityadjusted life-years (QALYs) and direct costs in Canadian dollars of two management approaches based on the Canadian Dyspepsia Working Group (CanDys) Clinical Management Tool, and four additional strategies (two empirical antisecretory agents, and two prompt endoscopy) were examined and compared. Prevalence data, probabilities, utilities and costs were included in a Markov model, while sensitivity analysis used Monte Carlo simulations. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were determined. RESULTS: Empirical omeprazole cost $226 per QALY ($49 per symptom-free month) per patient. CanDys omeprazole and endoscopy approaches were more effective than empirical omeprazole, but more costly. Alternatives using H2-receptor antagonists were less effective than those using a proton pump inhibitor. No significant differences were found for most incremental cost-effectiveness ratios. As willingness to pay (WTP) thresholds rose from $226 to $24,000 per QALY, empirical antisecretory approaches were less likely to be the most costeffective choice, with CanDys omeprazole progressively becoming a more likely option. For WTP values ranging from $24,000 to $70,000 per QALY, the most clinically relevant range, CanDys omeprazole was the most cost-effective strategy (32% to 46% of the time), with prompt endoscopy-proton pump inhibitor favoured at higher WTP values. CONCLUSIONS: Although no strategy was the indisputable cost effective option, CanDys omeprazole may be the strategy of choiceover a clinically relevant range of WTP assumptions in the initial management of Canadian patients with uninvestigated dyspepsia.

Validation of a short questionnaire in English and French for use in patients with persistent upper gastrointestinal symptoms despite proton pump inhibitor therapy: the PASS (Proton pump inhibitor Acid Suppression Symptom) test.

BACKGROUND: The management of persistent symptoms during acid suppression therapy in patients with gastroesophageal reflux disease or dyspepsia might be improved if patient-physician communication regarding the presence and character of these persistent symptoms were facilitated. AIM: To validate a short, simple questionnaire (the Proton pump inhibitor [PPI] Acid Suppression Symptom [PASS] test), in English and French, to identify patients with persistent acid-related symptoms during PPI therapy and document their response to a change in therapy. METHODS: Patients with persistent acid-related symptoms on PPI therapy were interviewed to produce a draft, five-item questionnaire; content validity was evaluated by focus groups comprising English- and French-speaking patients. Psychometric validity was subsequently evaluated in a multicentre, family practice-based study of English- and French-speaking patients with persistent acid-related upper gastrointestinal symptoms despite PPI therapy. The PASS test, Global Overall Symptom scale, Gastrointestinal Symptom Rating Scale (GSRS), Quality of Life in Reflux and Dyspepsia questionnaire and Reflux Disease Questionnaire were completed at baseline and repeated after one week while patients continued their original PPI therapy. All patients then received esomeprazole 40 mg once daily for four weeks, after which all questionnaires and an evaluation of overall treatment effect were completed. RESULTS: Content validity was established in 20 English- and 16 French-speaking patients. Psychometric validation in 158 English- and 113 French-speaking patients revealed good-to-excellent test-retest reliability coefficients: 0.76 for English; 0.68 for French. For construct validity, the PASS test showed moderate-to-high correlation with the GSRS scale (0.51 for English; 0.43 for French). After four weeks of therapy, the PASS test score fell to zero in 30% of English- and 33% of French-speaking patients, while the Global Overall Symptom score fell to one (no symptoms) in 32% of patients (English- and French-speaking); the PASS test demonstrated good responsiveness in comparison with the GSRS, Reflux Disease Questionnaire and Quality of Life in Reflux and Dyspepsia questionnaire. CONCLUSION: The five-item PASS test is a valid tool for the evaluation of persistent acid-related symptoms in patients receiving PPI therapy. It demonstrates good content validity, test-retest reliability, responsiveness and construct validity in both English and French forms. The PASS test is a simple, clinically applicable tool for the identification of patients with persistent acid-related symptoms during therapy and the assessment of their responses to a change in therapy.

A randomized trial comparing omeprazole, ranitidine, cisapride, or placebo in helicobacter pylori negative, primary care patients with dyspepsia: the CADET-HN Study.

BACKGROUND: The management of Helicobacter pylori negative patients with dyspepsia in primary care has not been studied in placebo-controlled studies. METHODS: H. pylori negative patients with dyspepsia symptoms of at least moderate severity (> or =4 on a seven-point Likert scale) were recruited from 35 centers. Patients were randomized to a 4-wk treatment of omeprazole 20 mg od, ranitidine 150 mg bid, cisapride 20 mg bid, or placebo, followed by on-demand therapy for an additional 5 months. Treatment success was defined as no or minimal symptoms (score < or = 2 out of 7), and was assessed after 4 wk and at 6 months. RESULTS: Five hundred and twelve patients were randomized and included in the intention-to-treat (ITT) analysis. At 4 wk, success rates (95% CI) were: omeprazole 51% (69/135; 43-60%), ranitidine 36% (50/139, 28-44%), cisapride 31% (32/105, 22-39%), and placebo 23% (31/133, 16-31%). Omeprazole was significantly better than all other treatments (p < 0.05). The proportion of patients who were responders at 4 wk and at 6 months was significantly greater for those receiving omeprazole 31% (42/135, 23-39%) compared with cisapride 13% (14/105, 7-20%), and placebo 14% (18/133, 8-20%) (p= 0.001), but not ranitidine 21% (29/139, 14-27%) (p= 0.053). The mean number of on-demand study tablets consumed and rescue antacid used was comparable across groups. Economic analysis showed a trade-off between superior efficacy and increased cost between omeprazole and ranitidine. CONCLUSION: Treatment with omeprazole provides superior symptom relief compared to ranitidine, cisapride, and placebo in the treatment of H. pylori negative primary care dyspepsia patients.

Treating Helicobacter pylori infection in primary care patients with uninvestigated dyspepsia: the Canadian adult dyspepsia empiric treatment-Helicobacter pylori positive (CADET-Hp) randomised controlled trial.

OBJECTIVE: To determine whether a "test for Helicobacter pylori and treat" strategy improves symptoms in patients with uninvestigated dyspepsia in primary care. DESIGN: Randomised placebo controlled trial. SETTING: 36 family practices in Canada. PARTICIPANTS: 294 patients positive for H pylori ((13)C- urea breath test) with symptoms of dyspepsia of at least moderate severity in the preceding month. INTERVENTION: PARTICIPANTS were randomised to twice daily treatment for 7 days with omeprazole 20 mg, metronidazole 500 mg, and clarithromycin 250 mg or omeprazole 20 mg, placebo metronidazole, and placebo clarithromycin. Patients were then managed by their family physicians according to their usual care. MAIN OUTCOME MEASURES: Treatment success defined as no symptoms or minimal symptoms of dyspepsia at the end of one year. Societal healthcare costs collected prospectively for a secondary evaluation of actual mean costs. RESULTS: In the intention to treat population (n=294), eradication treatment was significantly more effective than placebo in achieving treatment success (50% v 36%; P=0.02; absolute risk reduction=14%; number needed to treat=7, 95% confidence interval 4 to 63). Eradication treatment cured H pylori infection in 80% of evaluable patients. Treatment success at one year was greater in patients negative for H pylori than in those positive for H pylori (54% v 39%; P=0.02). Eradication treatment reduced mean annual cost by $C53 (-86 to 180) per patient. CONCLUSIONS: A "test for H pylori with (13)C-urea breath test and eradicate" strategy shows significant symptomatic benefit at 12 months in the management of primary care patients with uninvestigated dyspepsia.