Usefulness of magnetic resonance enterography in the clinical decision-making process for patients with inflammatory bowel disease / Utilidad de la enterografía por resonancia magnética en la toma de decisiones clínicas en pacientes con enfermedad inflamatoria intestinal

OBJECTIVE: To evaluate the impact of magnetic resonance enterography (MRE) diagnosis on clinical decision-making regarding treatment choice and maintenance of treatment over time in patients with inflammatory bowel disease (IBD). METHODS: A cohort of patients who underwent MRE for IBD assessment between 2011 and 2014 was analyzed. From clinical records, we retrospectively retrieved their demographic data and clinical data on their IBD at the time of MRE, the results of MRE and the patient's clinical course. Medical management decisions made during the three months following MRE and at the 15-month follow-up were assessed. RESULTS: In total, 474 MREs were reviewed. In the first three-month period, MRE results led to changes in the medical management of 266 patients (56.1%). Of those, maintenance therapy was altered in 140 patients (68.3%) (90.7% step-up and 9.3% top-down strategy), 65 (24.4%) were prescribed a course of steroids and 61 (22.9%) underwent surgery. MRE confirmed a CD diagnosis in 14/41 patients (34.1%) previously diagnosed with indeterminate colitis or ulcerative colitis and in 4/18 patients (22.2%) with suspected IBD. At the 15-month follow-up, treatment remained unchanged in 289 patients (65.8%). CONCLUSIONS: These results suggest that MRE is a diagnostic tool that provides valid information for the clinical-decision making process for patients with CD

OBJETIVO: Evaluar el impacto del diagnóstico de la enterografía por resonancia magnética (ERM) en la toma de decisiones clínicas con respecto a la elección del tratamiento y el mantenimiento del mismo a lo largo del tiempo en pacientes con enfermedad inflamatoria intestinal (EII). MÉTODOS: Se analizó una cohorte de pacientes que se sometieron a ERM para la evaluación de EII entre 2011 y 2014. De los registros clínicos recuperamos retrospectivamente sus datos demográficos y datos clínicos sobre su EII en el momento de la ERM, los resultados de la ERM y la evolución clínica del paciente. Se evaluaron las decisiones de manejo médico tomadas durante los 3 meses posteriores a la ERM y a los 15 meses de seguimiento. RESULTADOS: Se revisaron 474 ERM. En el primer período de 3 meses, los resultados de la ERM llevaron a cambios en el manejo médico en 266 pacientes (56,1%). De ellos, se modificó el tratamiento de mantenimiento en 140 (68,3%) pacientes (se escaló en el 90,7% y top-down en el 9,3%), 65 (24,4%) recibieron un curso de esteroides y 61 (22,9%) se sometieron a cirugía. La ERM confirmó un diagnóstico de enfermedad de Crohn (EC) en 14/41 pacientes (34,1%) diagnosticados previamente con colitis indeterminada o colitis ulcerosa y en 4/18 pacientes (22,2%) con sospecha de EII. A los 15 meses de seguimiento, el tratamiento se mantuvo sin cambios en 289 (65,8%) pacientes. CONCLUSIONES: Estos resultados sugieren que la ERM es una herramienta de diagnóstico que proporciona información válida para el proceso de toma de decisiones clínicas para pacientes con EC

Encuesta de adherencia al tratamiento en enfermedad inflamatoria intestinal. Estudio ENADEII / Survey of adherence to treatment in inflammatory bowel disease. ENADEII study

La tasa de no adherencia al tratamiento médico en la enfermedad inflamatoria intestinal (EII) está en torno al 50%, empeorando así los resultados de los tratamientos, la morbilidad y el coste. OBJETIVOS: Determinar mediante una encuesta online entre gastroenterólogos con especial dedicación a la EII el conocimiento sobre la adherencia al tratamiento de sus pacientes y los métodos utilizados para mejorarla. MÉTODOS: Desde la secretaría técnica de GETECCU se envió un correo a los socios con un enlace a la encuesta a través de un sistema online. RESULTADOS: Se invitó a 760 socios. Se obtuvieron 184 encuestas (28,5%). El 68% de los encuestados tenía publicaciones sobre EII indexadas, solo el 13% eran sobre adherencia. A pesar de que casi el 99% consideraban la adherencia como muy importante/importante, el 25% de los médicos no la medía. Pese a que el 100% consideraba que mejorar la adherencia implicaría un mejor pronóstico, el 47% no utilizaba sistemas para mejorarla. Los factores asociados con la medición y mejora de la adherencia fueron: hospital universitario (81,4%), que el paciente recibiera tratamiento combinado con tiopurínicos y biológicos (44,6%), médico de sexo femenino (63,1%), dedicar ≥ 6 h semanalmente a la EII (71,6%), que el médico tenga publicaciones indexadas sobre EII (68,5%) y sobre adherencia en EII (12,5%) y que el médico considere la adherencia importante o muy importante (98,9%). CONCLUSIONES: Aunque el conocimiento sobre la relevancia de la adherencia al tratamiento médico en EII está generalizado, entre los gastroenterólogos con dedicación especial a la EII que fueron encuestados casi la mitad no utiliza ningún sistema objetivo para cuantificarla. Se debe hacer un esfuerzo para cuantificar y mejorar la adherencia al tratamiento de estos pacientes

The rate of non-adherence to medical treatment in inflammatory bowel disease (IBD) is around 50%, with the consequent negative impact on treatment results, morbidity and cost. OBJECTIVES: To determine through an online survey among gastroenterologists with special dedication to IBD, their knowledge about the adherence to treatment of their patients and the methods used to improve it. METHODS: An email was sent to gastroenterologists from the technical office of the Crohn's disease and ulcerative colitis Spanish working group (GETECCU), with a link to the online survey. RESULTS: 760 physicians were invited. One hundred eighty-four surveys were obtained (28.5%). A total of 68% of respondents had indexed IBD publications, 13% of which were on adherence. Although almost 99% considered adherence as very important/important, 25% of physicians did not assess it. Even though 100% considered that improving adherence would imply a better prognosis, 47% did not use any system to improve it. The factors associated with the assessment and improvement of adherence were: university hospital (81.4%), combined treatment with thiopurines and biological drugs (44.6%), physician gender (female) (63.1%), dedicating ≥ 6 hours weekly to IBD (71.6%), previous published indexed papers on IBD (68.5%) and on adherence in IBD (12.5%), and considering adherence as important/very important (98.9%). CONCLUSIONS: Although knowledge about the relevance of adherence to medical treatment in IBD is widespread, among the gastroenterologists with special dedication to IBD who were surveyed, almost half do not use any objective system to quantify it. An effort must be made to quantify and improve adherence to the treatment of these patients

Usefulness of magnetic resonance enterography in the clinical decision-making process for patients with inflammatory bowel disease.

OBJECTIVE: To evaluate the impact of magnetic resonance enterography (MRE) diagnosis on clinical decision-making regarding treatment choice and maintenance of treatment over time in patients with inflammatory bowel disease (IBD). METHODS: A cohort of patients who underwent MRE for IBD assessment between 2011 and 2014 was analyzed. From clinical records, we retrospectively retrieved their demographic data and clinical data on their IBD at the time of MRE, the results of MRE and the patient's clinical course. Medical management decisions made during the three months following MRE and at the 15-month follow-up were assessed. RESULTS: In total, 474 MREs were reviewed. In the first three-month period, MRE results led to changes in the medical management of 266 patients (56.1%). Of those, maintenance therapy was altered in 140 patients (68.3%) (90.7% step-up and 9.3% top-down strategy), 65 (24.4%) were prescribed a course of steroids and 61 (22.9%) underwent surgery. MRE confirmed a CD diagnosis in 14/41 patients (34.1%) previously diagnosed with indeterminate colitis or ulcerative colitis and in 4/18 patients (22.2%) with suspected IBD. At the 15-month follow-up, treatment remained unchanged in 289 patients (65.8%). CONCLUSIONS: These results suggest that MRE is a diagnostic tool that provides valid information for the clinical-decision making process for patients with CD.

Survey of adherence to treatment in inflammatory bowel disease. ENADEII study. / Encuesta de adherencia al tratamiento en enfermedad inflamatoria intestinal. Estudio ENADEII.

The rate of non-adherence to medical treatment in inflammatory bowel disease (IBD) is around 50%, with the consequent negative impact on treatment results, morbidity and cost. OBJECTIVES: To determine through an online survey among gastroenterologists with special dedication to IBD, their knowledge about the adherence to treatment of their patients and the methods used to improve it. METHODS: An email was sent to gastroenterologists from the technical office of the Crohn's disease and ulcerative colitis Spanish working group (GETECCU), with a link to the online survey. RESULTS: 760 physicians were invited. One hundred eighty-four surveys were obtained (28.5%). A total of 68% of respondents had indexed IBD publications, 13% of which were on adherence. Although almost 99% considered adherence as very important/important, 25% of physicians did not assess it. Even though 100% considered that improving adherence would imply a better prognosis, 47% did not use any system to improve it. The factors associated with the assessment and improvement of adherence were: university hospital (81.4%), combined treatment with thiopurines and biological drugs (44.6%), physician gender (female) (63.1%), dedicating≥6hours weekly to IBD (71.6%), previous published indexed papers on IBD (68.5%) and on adherence in IBD (12.5%), and considering adherence as important/very important (98.9%). CONCLUSIONS: Although knowledge about the relevance of adherence to medical treatment in IBD is widespread, among the gastroenterologists with special dedication to IBD who were surveyed, almost half do not use any objective system to quantify it. An effort must be made to quantify and improve adherence to the treatment of these patients.

Risk factors associated with colorectal flat adenoma detection.

OBJECTIVES: Colorectal flat adenomas have been associated with a higher risk of colorectal malignancy. We describe demographic characteristics and endoscopic findings in patients with colorectal flat adenomas. METHODS: In total, 1934 consecutive patients undergoing colonoscopy were prospectively included. Polyp shape was classified according to the Japanese classification. Chromoendoscopy was applied whenever a flat lesion was suspected. Indications for colonoscopy, demographic data, and characteristics of neoplastic lesions were recorded. Patients were classified as follows: group 1, no adenomas (n=1250); group 2, only protruding adenomas (n=427); group 3, protruding and flat adenomas (n=118); and group 4, only flat adenomas (n=139). RESULTS: Approximately one in every 10 patients (13.2%) had flat adenomas. Among them, concomitant protruding adenomas were identified in approximately half of the cases. In multivariate analysis, age older than 50 years [odds ratio (OR)=1.62; 95% confidence interval (CI)=1.08-2.43, P=0.02], protruding adenomas (OR=2.17; 95% CI=1.65-2.87, P<0.001), follow-up colonoscopy for polyps or cancer (OR=2.22; 95% CI=1.59-3.10, P<0.001), screening colonoscopy (OR=1.60, 95% CI=1.15-2.22, P=0.005), and specifically trained endoscopist (OR=2.02, 95% CI=1.53-2.68, P<0.001) were associated independently with flat adenoma detection. CONCLUSION: Flat adenomas have specific demographic factors that might help to improve detection. Particularly, age older than 50 years, colorectal neoplasia surveillance, and the presence of protruding adenomas should alert endoscopists to the possible presence of these lesions. Trained endoscopists may offer a greater chance of detecting these lesions.

Uso de Internet entre los pacientes con enfermedades digestivas en un hospital general / Internet use among patients with gastrointestinal diseases in a general hospital

Introducción Internet ha supuesto un cambio radical en el acceso a la información médica. No se ha estudiado el acceso a webs médicas en los pacientes con enfermedades digestivas en nuestro medio. Objetivo Determinar el nivel de acceso y el uso de Internet como fuente de información médica de los pacientes con enfermedades digestivas en nuestro entorno. Material y métodos Se encuestaron 699 pacientes consecutivos, ingresados y de consultas externas intra y extrahospitalarias de Digestivo. Resultados Respondieron 671 pacientes (55% mujeres), rango de edad 18 a 88 años, media de 54 + 16. Usaban Internet el 36%. No hubo diferencias por sexos, pero sí por edad (86% los mayores de 30 años vs 6% los mayores de 70, p<0,005). Buscaron más información los pacientes del hospital que los extrahospitalarios (77 vs 54%, p<0,005). Los pacientes con enfermedad inflamatoria utilizaron más Internet que el resto (57 vs 33%, p>0,005, OR 2,710 IC 1,628-4,511). La información le pareció menos fiable que la del médico al 77% de los hombres y al 70% de las mujeres. Al 86% le gustaría usar el correo electrónico con su médico. El 89% consideraban Internet útil para resolver dudas, el 89% querían direcciones de salud y el 90% información periódica sobre su enfermedad. Los pacientes no universitarios demandaban más información periódica (p = 0,01) y sobre cómo buscar información médica (p = 0,03). Conclusiones Una tercera parte de los pacientes con enfermedades digestivas utilizan Internet para informarse acerca de su enfermedad. Los pacientes quieren mayor información de su médico sobre recursos de salud en Internet (AU)

Introduction The internet has provoked a radical change in access to medical information. Access to medical websites among patients with gastrointestinal diseases has not been studied in our environment. Objective To determine the level of access and use of internet as a source of medical information in patients with gastrointestinal diseases in our environment. Material and methods We surveyed 699 consecutive patients, who were admitted to hospital or who were from intra- and extrahospital outpatient gastroenterology clinics. Results Responses were obtained from 671 patients (55% women), aged from 18 to 88 years, (mean 54 +16). Thirty-six percent used the internet. There were no differences between men and women, but differences were found by age (86% >30 years vs 6%>70, p<0.005). More inpatients sought information than outpatients (77% vs 54%, p<0.005). Patients with inflammatory disease used the internet more than the remaining patients (57% vs 33%, p>0.005, OR 2.710 CI 1.628-4.511). Seventy-seven percent of men and 70% of women believed the information was less reliable than that provided by the physician. Eighty-six percent of patients would like e-mail contact with their physician. Eighty-nine percent thought the internet was useful to resolve doubts, 89% wanted the addresses of health sites and 90% wanted to receive periodic information on their disease. Patients without a university education wanted more periodic information (p = 0.01) and more information on how to search for medical information (p = 0.03).Conclusions One-third of patients with gastrointestinal diseases use the internet to obtain information on their disease. Patients require more information from their physician on internet health resources (AU)

[Internet use among patients with gastrointestinal diseases in a general hospital]. / Uso de Internet entre los pacientes con enfermedades digestivas en un hospital general.

INTRODUCTION: The internet has provoked a radical change in access to medical information. Access to medical websites among patients with gastrointestinal diseases has not been studied in our environment. OBJECTIVE: To determine the level of access and use of internet as a source of medical information in patients with gastrointestinal diseases in our environment. MATERIAL AND METHODS: We surveyed 699 consecutive patients, who were admitted to hospital or who were from intra- and extrahospital outpatient gastroenterology clinics. RESULTS: Responses were obtained from 671 patients (55% women), aged from 18 to 88 years, (mean 54 +16). Thirty-six percent used the internet. There were no differences between men and women, but differences were found by age (86% >30 years vs 6%>70, p<0.005). More inpatients sought information than outpatients (77% vs 54%, p<0.005). Patients with inflammatory disease used the internet more than the remaining patients (57% vs 33%, p>0.005, OR 2.710 CI 1.628-4.511). Seventy-seven percent of men and 70% of women believed the information was less reliable than that provided by the physician. Eighty-six percent of patients would like e-mail contact with their physician. Eighty-nine percent thought the internet was useful to resolve doubts, 89% wanted the addresses of health sites and 90% wanted to receive periodic information on their disease. Patients without a university education wanted more periodic information (p = 0.01) and more information on how to search for medical information (p = 0.03). CONCLUSIONS: One-third of patients with gastrointestinal diseases use the internet to obtain information on their disease. Patients require more information from their physician on internet health resources.

Masa intraabdominal de difícil diagnóstico: tumor fibroso peritoneal solitario / Intraabdominal mass with difficult diagnosis: Solitary fibrous tumor

El tumor fibroso solitario es un tumor raro de origen mesenquimal, de localización preferentemente en la pleura y las meninges, y menos frecuentemente se diagnostica como masa asintomática peritoneal hepática, en el páncreas o renal. Los hallazgos clínicos y radiológicos no son específicos, aunque nos permiten sospechar una evolución maligna por invasión o metástasis. Sin embargo, la citología preoperatoria suele ser de resultado dudoso o equívoco. Por tanto, el diagnóstico definitivo se logra tras la resección quirúrgica y el estudio mediante inmunohistoquímica con marcadores tales como CD34, vimentina y desmina. Presentamos un caso de tumor fibroso solitario de difícil diagnóstico, incluso tras una extensa serie de pruebas de imagen (AU)

Solitary fibrous tumor (SFT) is a rare neoplasm of mesenchymal origin. The most commonly reported locations are the pleura and meninges. Less frequently, SFT manifests as an asymptomatic mass in the pancreas, liver, peritoneum or kidney. Clinical and radiological findings have failed to provide any specific diagnostic pattern but allow malignant development to be suspected due to infiltration or metastasis. In addition, preoperative cytology often yields inconclusive or misleading results. Therefore the definitive diagnosis is achieved after both surgical resection and immunohistochemical analysis, with markers such as CD34, vimentin and desmin. We present a case of SFT, which was difficult to diagnose, even after an extensive battery of tests based on imaging techniques (AU)

[Intraabdominal mass with difficult diagnosis: Solitary fibrous tumor]. / Masa intraabdominal de difícil diagnóstico: tumor fibroso peritoneal solitario.

Solitary fibrous tumor (SFT) is a rare neoplasm of mesenchymal origin. The most commonly reported locations are the pleura and meninges. Less frequently, SFT manifests as an asymptomatic mass in the pancreas, liver, peritoneum or kidney. Clinical and radiological findings have failed to provide any specific diagnostic pattern but allow malignant development to be suspected due to infiltration or metastasis. In addition, preoperative cytology often yields inconclusive or misleading results. Therefore the definitive diagnosis is achieved after both surgical resection and immunohistochemical analysis, with markers such as CD34, vimentin and desmin. We present a case of SFT, which was difficult to diagnose, even after an extensive battery of tests based on imaging techniques.

The challenge of colorectal cancer prevention in Spain.

Colorectal cancer (CRC) is the leading cause of all new cancer cases and the second major cause for all cancer deaths in Spain. CRC survival has improved over the past few decades and is now higher than the 5-years European average, but this is associated with improved treatment than to early detection. A number of screening pilot programs have been completed in various regions, likely leading to national implementation in the future. Treatment guidelines have been developed and implemented to set standards and reduce practice variability. Newer treatments are available, including laparoscopic surgery, adjuvant chemotherapy and the use of targeted treatments. Specific programs are in place for rural patients, as well as programs to reduce waiting times. Overall, Spain is aware of the issues raised by CRC oncology management and has acted to improve patient outcomes, adding screening to its arsenal will further impact survival rates.

[Spontaneous bacterial peritonitis due to methicillin-resistant Staphylococcus aureus in patients with cirrhosis]. / Peritonitis bacteriana por Staphylococcus aureus resistente a meticilina en pacientes cirróticos.

A substantial epidemiologic change in the etiology of spontaneous bacterial peritonitis (SBP) has been observed in recent years. Gram-positive, as well as multiresistant bacteria, have emerged as an important cause of SBP mainly among hospitalized patients. In this setting, SBP caused by methicillin-resistant Staphylococcus aureus (MRSA) could become a major clinical problem in the near future. We present two cases of SBP due to MRSA without clinical response to vancomycin, even though in vitro sensitivity was observed in both cases. We review the current literature on the incidence and clinical significance of SBP due to MRSA infection in cirrhotic patients, as well as its prevention and treatment.

Peritonitis bacteriana por Staphylococcus aureus resistente a meticilina en pacientes cirróticos / Spontaneous bacterial peritonitis due to methicillin-resistant Staphylococcus aureus in patients with cirrhosis

En los últimos años, se ha producido un importante cambio epidemiológico en la etiología de la peritonitis bacteriana espontánea (PBE). Se ha registrado, especialmente en el ámbito intrahospitalario, un notable incremento en la proporción de casos originados tanto por bacterias grampositivas como por microorganismos resistentes a antibióticos. En este contexto, se ha señalado que la PBE causada por Staphylococcus aureus resistente a meticilina (SARM) podría constituir una problema relevante en un futuro próximo. Se presentan 2 casos de PBE por SARM, sin respuesta clínica al tratamiento con vancomicina en ninguno de ellos, a pesar de detectarse sensibilidad in vitro a dicho antibiótico. Se revisa la literatura médica acerca de la incidencia y la relevancia clínica de la PBE por SARM en pacientes cirróticos, y se discute la evidencia acerca de las posibilidades de prevención y tratamiento de dicho proceso

A substantial epidemiologic change in the etiology of spontaneous bacterial peritonitis (SBP) has been observed in recent years. Gram-positive, as well as multiresistant bacteria, have emerged as an important cause of SBP mainly among hospitalized patients. In this setting, SBP caused by methicillin-resistant Staphylococcus aureus (MRSA) could become a major clinical problem in the near future. We present two cases of SBP due to MRSA without clinical response to vancomycin, even though in vitro sensitivity was observed in both cases. We review the current literature on the incidence and clinical significance of SBP due to MRSA infection in cirrhotic patients, as well as its prevention and treatment

The use of preoperative endoscopic tattooing in laparoscopic colorectal cancer surgery for endoscopically advanced tumors: a prospective comparative clinical study.

BACKGROUND: Endoscopic India ink marking techniques are often used for the intraoperative location of colonic polyps and early stage neoplasms. The aim of this study was to compare how effective this technique is compared with conventional localization methods, as well as its influence on the results of colorectal laparoscopy (LSCRC) for endoscopically advanced tumors. METHODS: From January 2003 to January 2005, 47 patients with colorectal carcinomas were included in the study. In one group, lesions were localized preoperatively by endoscopic India ink tattooing (n = 21; tattooed group, TG), while conventional methods were used in the others (n = 26; non-tattooed group, NTG). Patients' perioperative clinical and pathoanatomical data were prospectively collected. RESULTS: Both groups were comparable in age, sex distribution, American Society of Anesthesiologists (ASA) score, body mass index (BMI), technique performed, tumor size and proportion of patients who had previous abdominal surgery. Three patients presented ink spillage without clinical repercussions. Visualization of the correct resection site was higher in the TG (100% vs. 80.8%, P = 0.03). Operative time (147.3 +/- 46.2 vs. 187.0 +/- 52.7 minutes, P = 0.02) and blood loss (99.3 +/- 82.8 vs. 163.6 +/- 96.6 cc, P = 0.03) were lower in the TG. There were no differences between groups regarding peristalsis, introduction of oral intake, hospital stay or intra- and postoperative complication rates. No differences were observed amongst pathoanatomical data studied. CONCLUSIONS: Preoperative endoscopic tattooing is a safe and effective technique for intraoperative localization of advanced colorectal neoplasms, improving the operative results of LSCRC.

Efectos de los AINE sobre la mucosa gastrointestinal / The effects of NSAIDS on the gastrointestinal mucosa

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