Health care and patients' education in a European inflammatory bowel disease inception cohort: an ECCO-EpiCom study.

BACKGROUND AND AIMS: The EpiCom study and inception cohort was initiated in 2010 in 31 centers from 14 Western and 8 Eastern European countries, covering a 10.1million person background population. Our aim was to investigate whether there is a difference between Eastern and Western Europe in health care and education of patients with inflammatory bowel disease (IBD). METHODS: A quality of care (QoC) questionnaire was developed in the EpiCom group consisting of 16 questions covering 5 items: time interval between the onset of symptoms and diagnosis, information, education, empathy and access to health care providers. RESULTS: Of 1,515 patients, 947 (217 east/730 west) answered the QoC questionnaire. Only 23% of all patients had knowledge about IBD before diagnosis. In Eastern Europe, significantly more patients searched out information about IBD themselves (77% vs. 68%, p<0.05), the main source was the Internet (92% vs. 88% p=0.23). In Western Europe, significantly more patients were educated by nurses (19% vs. 1%, p<0.05), while in Eastern Europe, gastroenterologists were easier to contact (80% vs. 68%, p<0.05). CONCLUSION: Health care differed significantly between Eastern and Western Europe in all items, but satisfaction rates were high in both geographic regions. Because of the low awareness and the rising incidence of IBD, general information should be the focus of patient organizations and medical societies. In Western Europe IBD nurses play a very important role in reducing the burden of patient management.

Environmental factors in a population-based inception cohort of inflammatory bowel disease patients in Europe--an ECCO-EpiCom study.

BACKGROUND AND AIMS: The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe possibly due to changes in environmental factors towards a more "westernised" standard of living. The aim of this study was to investigate differences in exposure to environmental factors prior to diagnosis in Eastern and Western European IBD patients. METHODS: The EpiCom cohort is a population-based, prospective inception cohort of 1560 unselected IBD patients from 31 European countries covering a background population of 10.1 million. At the time of diagnosis patients were asked to complete an 87-item questionnaire concerning environmental factors. RESULTS: A total of 1182 patients (76%) answered the questionnaire, 444 (38%) had Crohn's disease (CD), 627 (53%) ulcerative colitis (UC), and 111 (9%) IBD unclassified. No geographic differences regarding smoking status, caffeine intake, use of oral contraceptives, or number of first-degree relatives with IBD were found. Sugar intake was higher in CD and UC patients from Eastern Europe than in Western Europe while fibre intake was lower (p<0.01). Daily consumption of fast food as well as appendectomy before the age of 20 was more frequent in Eastern European than in Western European UC patients (p<0.01). Eastern European CD and UC patients had received more vaccinations and experienced fewer childhood infections than Western European patients (p<0.01). CONCLUSIONS: In this European population-based inception cohort of unselected IBD patients, Eastern and Western European patients differed in environmental factors prior to diagnosis. Eastern European patients exhibited higher occurrences of suspected risk factors for IBD included in the Western lifestyle.

East-West gradient in the incidence of inflammatory bowel disease in Europe: the ECCO-EpiCom inception cohort.

OBJECTIVE: The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe. The reasons for these changes remain unknown. The aim of this study was to investigate whether an East-West gradient in the incidence of IBD in Europe exists. DESIGN: A prospective, uniformly diagnosed, population based inception cohort of IBD patients in 31 centres from 14 Western and eight Eastern European countries covering a total background population of approximately 10.1 million people was created. One-third of the centres had previous experience with inception cohorts. Patients were entered into a low cost, web based epidemiological database, making participation possible regardless of socioeconomic status and prior experience. RESULTS: 1515 patients aged 15 years or older were included, of whom 535 (35%) were diagnosed with Crohn's disease (CD), 813 (54%) with ulcerative colitis (UC) and 167 (11%) with IBD unclassified (IBDU). The overall incidence rate ratios in all Western European centres were 1.9 (95% CI 1.5 to 2.4) for CD and 2.1 (95% CI 1.8 to 2.6) for UC compared with Eastern European centres. The median crude annual incidence rates per 100,000 in 2010 for CD were 6.5 (range 0-10.7) in Western European centres and 3.1 (range 0.4-11.5) in Eastern European centres, for UC 10.8 (range 2.9-31.5) and 4.1 (range 2.4-10.3), respectively, and for IBDU 1.9 (range 0-39.4) and 0 (range 0-1.2), respectively. In Western Europe, 92% of CD, 78% of UC and 74% of IBDU patients had a colonoscopy performed as the diagnostic procedure compared with 90%, 100% and 96%, respectively, in Eastern Europe. 8% of CD and 1% of UC patients in both regions underwent surgery within the first 3 months of the onset of disease. 7% of CD patients and 3% of UC patients from Western Europe received biological treatment as rescue therapy. Of all European CD patients, 20% received only 5-aminosalicylates as induction therapy. CONCLUSIONS: An East-West gradient in IBD incidence exists in Europe. Among this inception cohort--including indolent and aggressive cases--international guidelines for diagnosis and initial treatment are not being followed uniformly by physicians.

Ultrasonography is an accurate technique for the diagnosis of gastrointestinal tumors in patients without localizing symptoms.

INTRODUCTION AND OBJECTIVES: This study compared the accuracy of ultrasonography in the diagnosis of gastrointestinal tumors in patients with several degrees of clinical suspicion. MATERIAL AND METHODS: We recruited patients that were suspect for gastrointestinal neoplasia but with no evidence of localizing symptoms (group A), and patients that were suspect for colon cancer (group B) or for gastric cancer (group C). Accuracy in the diagnosis was compared for: gastric cancer in groups A and C, and for colon cancer in groups A and B. The comparison was made by using the contingency coefficient, which quantifies coincidence of endoscopic and ultrasonographic diagnoses. RESULTS: Seventy-nine patients were included in group A (48 males), wherein 12 colon and 5 gastric neoplasms were detected. Group B was comprised of 153 patients (78 males) and included 66 patients with colorectal cancer (CCR). Group C contained 58 patients (35 males), 31 of whom were diagnosed with gastric cancer. The accuracy of sonography for diagnosing colon cancer was 95.5% for group A and 87.5% for group B. The contingency coefficient for endoscopy vs. ultrasonography was greater for group A: 0.658 than for group B: 0.549. The diagnostic accuracy for gastric cancer was 97.4% for group A and 86.2% for group C. The contingency coefficient between endoscopic and ultrasonographic diagnoses was also greater in group A (0.618) than in group C (0.588). CONCLUSIONS: The accuracy of ultrasonography in diagnosing colon and gastric cancer is not lower in patients without localizing symptoms.

La ecografía es una técnica sensible en el diagnóstico de las neoplasias gastrointestinales en pacientes sin síntomas localizadores / Ultrasonography is an accurate technique for the diagnosis of gastrointestinal tumors in patients without localizing symptoms

Introducción y objetivos: en todos los estudios publicadoshasta la fecha se ha evaluado la precisión de la ecografía en eldiagnóstico del cáncer de colon y del cáncer gástrico en pacientesen los que esta era la sospecha diagnóstica o ya con un diagnósticoestablecido de esta patología. Nosotros, en este estudio, comparamosla sensibilidad de la ecografía en pacientes con diferentesgrados de sospecha clínica.Material y método: reclutamos pacientes con sospecha deneoplasia digestiva, sin evidencia de síntomas localizadores (grupoA), pacientes con sospecha de cáncer de colon (grupo B) y pacientescon sospecha de cáncer gástrico (grupo C). Comparamosla precisión de la ecografía en el diagnóstico del cáncer gástricoen los grupos A y C, y la precisión en el diagnóstico del cáncer decolon en los grupos A y B. El parámetro usado en la comparaciónes el coeficiente de contigencia que cuantifica la coincidencia dediagnóstico endoscópico y ecográfico.Resultados: se han incluido 79 pacientes en el grupo A (48varones y 31 mujeres, con una edad media de 69,3 años), en losque se han diagnosticado 12 neoplasias colónicas y 5 gástricas. Elgrupo B se compone de 153 pacientes (78 varones y 75 mujeres,con una edad media de 66,5 años) e incluye 66 pacientes conCCR. Finalmente, el grupo C está formado por 58 pacientes (35varones y 23 mujeres, con una edad media de 67,4 años), siendodiagnosticados de cáncer gástrico 31 pacientes. La precisión de laecografía en el diagnóstico del cáncer de colon fue del 95,5% enel grupo A y del 87,5% en el grupo B. El coeficiente de contingenciaentre los diagnósticos endoscópico y ecográfico tambiénfue superior en el grupo A: 0,658 frente a 0,549. La precisión dela ecografía en el diagnóstico del cáncer gástrico fue del 97,4% enel grupo A y del 86,2% en el grupo C...(AU)

Introduction and objectives: this study compared the accuracyof ultrasonography in the diagnosis of gastrointestinal tumorsin patients with several degrees of clinical suspicion.Material and methods: we recruited patients that were suspectfor gastrointestinal neoplasia but with no evidence of localizingsymptoms (group A), and patients that were suspect for coloncancer (group B) or for gastric cancer (group C). Accuracy in thediagnosis was compared for: gastric cancer in groups A and C,and for colon cancer in groups A and B. The comparison wasmade by using the contingency coefficient, which quantifies coincidenceof endoscopic and ultrasonographic diagnoses.Results: seventy-nine patients were included in group A (48males), wherein 12 colon and 5 gastric neoplasms were detected.Group B was comprised of 153 patients (78 males) and included66 patients with colorectal cancer (CCR). Group C contained 58patients (35 males), 31 of whom were diagnosed with gastric cancer.The accuracy of sonography for diagnosing colon cancer was95.5% for group A and 87.5% for group B. The contingency coefficientfor endoscopy vs. ultrasonography was greater for groupA: 0.658 than for group B: 0.549. The diagnostic accuracy forgastric cancer was 97.4% for group A and 86.2% for group C.The contingency coefficient between endoscopic and ultrasonographicdiagnoses was also greater in group A (0.618) than ingroup C (0.588).Conclusions: the accuracy of ultrasonography in diagnosingcolon and gastric cancer is not lower in patients without localizingsymptoms(AU)

[Usefulness of ultrasonography in diagnosing patients suspect for digestive tract neoplasms]. / Utilidad de la ecografía en el diagnóstico de los pacientes con sospecha de neoplasias del tubo digestivo.

BACKGROUND: The Positive Predictive Value (PPV) of signs and symptoms for the diagnosis of colon and gastric cancer is low. Furthermore, many patients are referred to us to discard a digestive tract neoplasm with no symptoms suggestive of its whereabouts, in whom clinical PPV is even lower. This study evaluates the usefulness of ultrasonography as a first approach to diagnosis. MATERIAL AND METHODS: Seventy-nine patients were recruited into the study (48 males with an average age of 69.3 years). Ultrasonography was performed on all patients prior to endoscopy. Parameters studied included diagnostic accuracy for colon and gastric cancer, ultrasonographic diagnoses, and number of endoscopies that can be avoided. Predictive factors for neoplasm location were also studied. RESULTS: Five gastric cancers (6.3%), 12 colon cancers (15,1%), 3 pancreatic cancers (3.8%), 2 uterine neoplasms (2.5%), and 2 hypernephromas (2.5%) were diagnosed. The figures for sensitivity, specificity, PPV, Negative Predictive Value (NPV) and global accuracy of ultrasonography were 80%, 98.6%, 80%, 98.6%, and 97.4%, respectively, for gastric cancer, while these figures were 100%, 94.5%, 80%, 100%, and 95.5%, respectively, for colon cancer. Ultrasonography enabled to avoid 10% of endoscopic explorations. The only parameter that helps locate a neoplasm is the presence of anemia, which is more frequently associated with a diagnosis of colon cancer: 30.4 versus 4.3% (p = 0.033). CONCLUSIONS: In patients without specific symptoms who were sent to us for discarding digestive tract neoplasm, "extra-digestive" neoplasms were frequently diagnosed. If we further take into account the high diagnostic accuracy of ultrasonography, then this procedure could be a very good first approach towards such diagnosis.

Utilidad de la ecografía en el diagnóstico de los pacientes con sospecha de neoplasias del tubo digestivo / No disponible

Introducción: el valor predictivo positivo de síntomas y signosen el diagnóstico del cáncer de colon y gástrico es bajo. Además,muchos pacientes son remitidos para descartar una neoplasiadigestiva, sin síntomas que sugieran su localización, siendo elVPP de la clínica aún menor. En este trabajo evaluamos la utilidadde la ecografía como primera aproximación diagnóstica.Material y método: se han reclutado 79 pacientes (48 varones,edad media 69,3 años). En todos ellos se realiza una ecografíaantes de la endoscopia. Se evalúa la precisión en el diagnósticodel cáncer de colon y gástrico, los diagnósticos ecográficos y elnúmero de endoscopias que se evitarían. También se buscan factorespredictivos de la localización de la neoplasia.Resultados: se han diagnosticado 5 neoplasias gástricas(6,3%) y 12 de colon (19%), 3 cáncer de páncreas (3,8%), 2 neoplasiasuterinas (2,5%) y 2 hipernefromas (2,5%). Las cifras desensibilidad, especificidad, VPP, VPN y precisión de la ecografíafueron 80%, 98,6%; 80%; 98,6%; y 97,4% respectivamente enel diagnóstico del cáncer gástrico, y del 100%, 94,5%; 80%;100% y 95,5% respectivamente en el diagnóstico del cáncer decolon. La ecografía permitió evitar el 10% de las endoscopias. Elúnico dato que orienta la localización de la neoplasia es la presenciade anemia, que se asocia con mayor frecuencia al diagnósticode cáncer de colon: 30,4 versus 4,3% (p = 0,033).Conclusiones: en los pacientes remitidos para descartar unaneoplasia digestiva, con síntomas inespecíficos, se diagnostica confrecuencia de patología neoplásica ajena al tubo digestivo. Si consideramos,además, la elevada precisión diagnóstica de la ecografía,esta podría ser una muy buena primera aproximación diagnóstica

Background: the Positive Predictive Value (PPV) of signs andsymptoms for the diagnosis of colon and gastric cancer is low. Furthermore,many patients are referred to us to discard a digestive tractneoplasm with no symptoms suggestive of its whereabouts, in whomclinical PPV is even lower. This study evaluates the usefulness of ultrasonographyas a first approach to diagnosis.Material and methods: seventy-nine patients were recruitedinto the study (48 males with an average age of 69.3 years). Ultrasonographywas performed on all patients prior to endoscopy. Parametersstudied included diagnostic accuracy for colon and gastriccancer, ultrasonographic diagnoses, and number of endoscopies thatcan be avoided. Predictive factors for neoplasm location were alsostudied.Results: five gastric cancers (6.3%), 12 colon cancers (15,1%), 3pancreatic cancers (3.8%), 2 uterine neoplasms (2.5%), and 2 hypernephromas(2.5%) were diagnosed. The figures for sensitivity, specificity,PPV, Negative Predictive Value (NPV) and global accuracy ofultrasonography were 80%, 98.6%, 80%, 98.6%, and 97.4%, respectively,for gastric cancer, while these figures were 100%,94.5%, 80%, 100%, and 95.5%, respectively, for colon cancer. Ultrasonographyenabled to avoid 10% of endoscopic explorations.The only parameter that helps locate a neoplasm is the presence ofanemia, which is more frequently associated with a diagnosis ofcolon cancer: 30.4 versus 4.3% (p = 0.033).Conclusions: in patients without specific symptoms who weresent to us for discarding digestive tract neoplasm, “extra-digestive”neoplasms were frequently diagnosed. If we further take into accountthe high diagnostic accuracy of ultrasonography, then this procedurecould be a very good first approach towards such diagnosis

Dolor abdominal como forma de presentación rara del carcinoma hepatocelular: utilidad de la ecografía en el diagnóstico / No disponible

No disponible

[Usefulness of digestive ultrasonography in the assessment of ulcerative colitis extent]. / Utilidad de la ecografía en la valoración de la extensión de la colitis ulcerosa.

INTRODUCTION: A full examination of the colon should be avoided upon finding severe endoscopic lesions in patients with ulcerative colitis. However, knowledge of the precise extent of disease is quite important for disease prognosis and the making of therapeutic decisions. Therefore, any validation of a non-invasive technique to assess the extent of ulcerative colitis gains a lot of interest and importance. MATERIAL AND METHOD: The study included patients that were previously diagnosed of having ulcerative colitis or were beginning to suffer from the disease. A prospective and blind evaluation was carried out to determine the precision of digestive ultrasonography in assessment of ulcerative colitis extent. All ultrasonography was carried out by the same person and was always performed prior to carrying out a full endoscopic study, which is used as the gold standard. The hydrocolonic ultrasonograpy technique was not used in any of the cases. RESULTS: A total of 20 patients -13 males (65%) and 7 females (35%), with an average age of 51.7 years (aged between 24-82 years)- were included in the study. Endoscopic studies revealed severe disease in 5 cases (25%), moderate disease in 12 patients (60%), and mild lesions in the 3 remaining cases (15%). A colonic ultrasonogram was considered satisfactory in 18 cases (90%), and the extent of disease as established by ultrasonography was in all cases consistent with that established through colonoscopy: 3 patients (16.6%) had ulcerative proctitis, 9 patients (50%) had left-sided ulcerative colitis, and 6 (33.3%) had extensive colitis. CONCLUSIONS: Digestive ultrasonography allows to study the colon in most patients, especially when inflammatory activity is present, and provides a greater accuracy in assessing ulcerative colitis extent, which is independent of its activity level.

Utilidad de la ecografía en la valoración de la extensión de la colitis ulcerosa / Usefulness of digestive ultrasonography in assessment of ulcerative colitis extent

Introducción: el hallazgo de lesiones endoscópicas severasen un paciente con colitis ulcerosa desaconseja la realización deuna exploración completa del colon. No obstante el conocimientode la extensión precisa de la enfermedad tiene gran importanciaen las decisiones terapéuticas a tomar y también en el pronósticode la enfermedad. Por todo ello, la validación de una técnica noinvasiva para el estudio de extensión de la colitis ulcerosa cobragran interés e importancia.Material y método: se incluyen en el estudio pacientes condiagnóstico previo de colitis ulcerosa o en el debut de la enfermedady, de forma prospectiva y ciega se evalúa la precisión de laecografía digestiva en la valoración de la extensión de la colitis ulcerosa.Las exploraciones ecográficas son realizadas todas ellaspor el mismo explorador y siempre con anterioridad al estudio endoscópicocompleto, que se usa como patrón oro. No se empleala técnica hidrocolónica en ningún caso.Resultados: han sido incluidos en el estudio 20 pacientes, 13varones (65%) y 7 mujeres (35%), con una edad media de 51,7años (rango de 24 a 82 años). Los estudios endoscópicos mostraronuna afectación severa en 5 casos (25%), moderada en 12 pacientes(60%) y lesiones leves en los 3 casos restantes (15%). Elestudio ecográfico del colon fue considerado satisfactorio en 18casos (90%) y la extensión de la enfermedad establecida en el estudioecográfico coincide en todos los casos con la determinadapor la colonoscopia: 3 pacientes (16,6%) presentaban una proctitisulcerosa, 9 (50%) una colitis izquierda y 6 (33,3%) una colitisextensa.Conclusiones: la ecografía digestiva permite el estudio delmarco colónico en la mayoría de los pacientes, especialmente siexiste actividad inflamatoria, permitiendo establecer con gran precisiónla extensión de la colitis ulcerosa, independientemente delgrado de actividad de la misma

Introduction: a full examination of the colon should be avoidedupon finding severe endoscopic lesions in patients with ulcerativecolitis. However, knowledge of the precise extent of disease isquite important for disease prognosis and the making of therapeuticdecisions. Therefore, any validation of a non-invasive techniqueto assess the extent of ulcerative colitis gains a lot of interestand importance.Material and method: the study included patients that werepreviously diagnosed of having ulcerative colitis or were beginningto suffer from the disease. A prospective and blind evaluation wascarried out to determine the precision of digestive ultrasonographyin assessment of ulcerative colitis extent. All ultrasonographywas carried out by the same person and was always performedprior to carrying out a full endoscopic study, which is used as thegold standard. The hydrocolonic ultrasonograpy technique wasnot used in any of the cases.Results: a total of 20 patients –13 males (65%) and 7 females(35%), with an average age of 51.7 years (aged between 24-82years)– were included in the study. Endoscopic studies revealed severedisease in 5 cases (25%), moderate disease in 12 patients(60%), and mild lesions in the 3 remaining cases (15%). A colonicultrasonogram was considered satisfactory in 18 cases (90%), andthe extent of disease as established by ultrasonography was in allcases consistent with that established through colonoscopy: 3 patients(16.6%) had ulcerative proctitis, 9 patients (50%) had leftsidedulcerative colitis, and 6 (33.3%) had extensive colitis.Conclusions: digestive ultrasonography allows to study thecolon in most patients, especially when inflammatory activity ispresent, and provides a greater accuracy in assessing ulcerativecolitis extent, which is independent of its activity level

Rentabilidad de la ecografía abdominal en el diagnóstico del cáncer de colon / The value of abdominal ultrasound in the diagnosis of colon cancer

Introducción: el cáncer de colon es una de las principalescausas de muerte por cáncer. Su diagnóstico exige la exploración de la totalidad del marco colónico mediante técnicas radiológicas o endoscópicas. Muchos pacientes son remitidos para la realización de colonoscopia con sospecha de cáncer de colon y esta sospecha no se confirma tras la exploración endoscópica. El objetivodel estudio es la evaluación de la fiabilidad de la ecografía abdominal en el diagnóstico de estos tumores.Material y método: se seleccionaron pacientes que fueronremitidos a la unidad de endoscopias para la práctica de una colonoscopia con sospecha de cáncer de colon. A todos ellos se les realizó una ecografía abdominal previa a la endoscopia. Considerando como patrón oro la exploración endoscópica, se evaluó la sensibilidad, especificidad, valor predictivo positivo (VPP) y negativo (VPN) de la ecografía. Asimismo, se evaluaron una serie de parámetrosclínicos y analíticos, realizándose un análisis univariante y multivariante, tratando de establecer factores asociados al padecimiento de un cáncer de colon. El análisis estadístico se realizó mediante el paquete estadístico SPSS 12.0 para Windows. Resultados: se incluyeron definitivamente 145 pacientes (56,6% varones) con una edad media de 66,72 (22-89). Se diagnosticóun cáncer en 42 casos (28,9%). La ecografía abdominalpresenta una sensibilidad del 79,06%, una especificidad del 92,15%, un VPP y un VPN del 80,9% y del 91,2% respectivamente en el diagnóstico del cáncer de colon. Excluyendo del análisis las lesiones de la ampolla rectal, que no puede ser valorada adecuadamente mediante la ecografía, las cifras de sensibilidad, especificidad, VPP y VPN ascienden a un 91,8, 92,1, 80,9 y 96,9% respectivamente. El análisis univariante mostró como una edad superior a 65 años y la presencia de microcitosis se asociaron a un mayor riesgo de padecer cáncer de colon, mientras que tras el análisis multivariante sólo la presencia de microcitosis resultó ser un factor independiente predictivo de cáncer. Conclusiones: la ecografía abdominal presenta una elevada sensibilidad, especificidad, VPP y VPN en el diagnóstico de cáncerde colon. La combinación de una ecografía y una rectoscopia permite descartar con gran seguridad la presencia de un carcinoma colorrectal. En los pacientes con microcitosis y posiblemente en los mayores de 65 años, si la sospecha clínica es importante, unaecografía negativa puede no ser suficiente para descartar una neoplasia colorrectal

Introduction: colon cancer is one of the main causes of cancer death. Diagnosis requires the examination of the entire large bowel by means of radiological or endoscopic techniques. Many patients suspect of colon cancer are referred for colonoscopy but nevertheless this suspicion is not confirmed after endoscopic examination. The objective of this study is the evaluation of the reliability of abdominal ultrasound in the diagnosis of these tumors. Material and method: we selected patients suspect of colon cancer referred to the endoscopy unit for a colonoscopy. An abdominal ultrasound was carried out on all patients prior to the endoscopy. Considering the endoscopic examination as a gold standard, the sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the ultrasonography were evaluated. Likewise, a series of analytical and clinical parameters were evaluated, in an attempt to establish associated factors of a colon cancer. The statistical analysis was carried out by means of the statistical package SPSS 12.0 for Windows. Results: 145 patients were included in the study (56.6% males) with an average 66.72 years of age (22-89). A cancer was diagnosed in 42 cases (28.9%). In the diagnosis of colon cancer, abdominal ultrasound presents a sensitivity of 79.06%, a specificity of 92.15%, a PPV and a NPV of 80.9% and of 91.2%, respectively. Excluding from the analysis lesions of the rectal ampulla, which cannot be adequately evaluated by means of ultrasound, the figures for sensitivity, specificity, PPV and NPV increase to 91.8, 92.1, 80.9 and 96.9% respectively. The univariate analysis showed that an age over 65 years and the presence of microcytosis are associated to a greater risk of colon cancer while after multivariate analysis only the presence of microcytosis resulted to be an independent predictive factor of cancer. Conclusions: abdominal ultrasound presents high sensitivity, specificity, PPV and NPV in the diagnosis of colon cancer. The combination of an ultrasonography and a rectoscopy permits us to rule out the presence of a colorectal carcinoma. In patients with microcytosis of 65 years and over, if there is strong clinical suspicion, a negative ultrasound may not be sufficient to rule out a colorectal neoplasia

Usefulness of endoscopic ultrasonography in the preoperative diagnosis of submucosal digestive tumours.

INTRODUCTION: The preoperative diagnosis of submucosal lesions in the gut may be complicated. Conventional endoscopy does not allow to clearly establishing a diagnosis, and does not adequately assess lesion size. Furthermore, endoscopic biopsy is usually not diagnostic. Cytology as performed by means of fine-needle puncture does not have enough sensitivity and specificity to be considered the gold standard in the diagnosis of these lesions. We will now assess the usefulness of endoscopic ultrasonography in the study of submucosal digestive tumors. MATERIALS AND METHODS: We have prospectively collected ultrasonographic studies from all the patients with submucosal tumors who were treated surgically. We assessed the sensitivity and specificity of this technique in the diagnosis of malignancy in said lesions, alongside factors that predict malignant behavior with the highest reliability. We also valued the reliability of ultrasound endoscopy in the assessment of lesion size and the wall layer where lesions are located. The results of histological studies were considered the gold standard. RESULTS: The average size of lesions as measured by ultrasound endoscopy was 37.42 mm, with no significant differences in surgical piece: 38.98 (p = 0.143). However, conventional endoscopy underestimates the size of lesions. Endoscopic ultrasonography was able to adequately establish the origin layer of lesions in all cases. Sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound endoscopy in the diagnosis of malignancy were 89.5, 90.9, 89.5, and 90.9%, respectively. In the univariate analysis, the ultrasonographic characteristics associated with a diagnosis of malignancy included presence of ulceration (p = 0.043), size above 4 cm (p = 0.049), irregular edges of lesion (p = 0.0001), a heterogeneous ultrasonographic pattern (p = 0.002), and the presence of cystic areas above 2 mm (p = 0.012). In the multivariate analysis, the last three factors were considered independent predictive factors for malignancy. CONCLUSIONS: Endoscopic ultrasonography has a great sensitivity and specificity in the diagnosis of malignancy regarding submucosal lesions. The irregularity of lesion borders, a heterogeneous ultrasonographic pattern, and the presence of cystic areas above 2 mm in size were considered independent predictive factors for malignancy.

Utilidad de la ecoendoscopia en el diagnóstico preoperatorio de malignidad de los tumores submucosos digestivos / Usefulness of endoscopic ultrasonographic in the preoperative diagnosis of submucosal digestive tumours

Introducción: el diagnóstico preoperatorio de las lesionessubmucosas del tubo digestivo puede ser complicado. La endoscopiaconvencional no permite establecer claramente un diagnósticoy no valora adecuadamente el tamaño de las lesiones. Además, labiopsia endoscópica no suele ser diagnóstica. La citología obtenidapor medio de la punción con aguja fina tampoco presenta lasuficiente sensibilidad y especificidad como para ser consideradacomo el patrón oro en el diagnóstico de estas lesiones. Evaluamosa continuación la utilidad de la ultrasonografía endoscópica en elestudio de los tumores submucosos digestivos.Material y métodos: hemos recogido de forma prospectivalos estudios ultrasonográficos de todos los pacientes con tumoressubmucosos tratados quirúrgicamente en nuestro centro. Se haevaluado la sensibilidad y especificidad de esta técnica en el diagnósticode malignidad de estas lesiones, así como los factores quecon mayor fiabilidad predicen el comportamiento maligno. Tambiénse valoró la fiabilidad de la ecoendoscopia en la valoracióndel tamaño y en identificar la capa de la pared en que se localizanlas lesiones. Los resultados del estudio anatomopatológico fueronconsiderados el patrón oro en el diagnóstico.Resultados: el tamaño medio de las lesiones medido por ecoendoscopiano presenta diferencias significativas con el de la piezaquirúrgica. Sin embargo, la endoscopia convencional infravalorael tamaño de las lesiones. La ultrasonografía endoscópica establecióadecuadamente la capa de origen de las lesiones en todos loscasos. La sensibilidad, especificidad, valor predictivo positivo y valorpredictivo negativo de la ecoendoscopia en el diagnóstico demalignidad eran del 89,5, 90,9, 89,5 y 90,9% respectivamente.En el análisis univariante las características endoscópicas y ultrasonográficasque se asociaban a un diagnóstico de malignidad eranla presencia de ulceración (p = 0,043), un tamaño mayor de 40mm (p = 0,049), la irregularidad de los bordes de la lesión (p =0,0001), un patrón ultrasonográfico heterogéneo (p = 0,002) y lapresencia de áreas quísticas mayores de 2 mm (p = 0,012). En elanálisis multivariante, todos excepto el tamaño y la presencia deulceración se consideraron factores independientes predictivos demalignidad.Conclusiones: la ultrasonografía endoscópica presenta unagran sensibilidad y especificidad en el diagnóstico de malignidadde las lesiones submucosas. La irregularidad de los bordes de la lesión,un patrón ultrasonográfico heterogéneo y la presencia deáreas quísticas mayores de 2 mm se consideraron factores independientespredictivos de malignidad

Introduction: the preoperative diagnosis of submucosal lesionsin the gut may be complicated. Conventional endoscopydoes not allow to clearly establishing a diagnosis, and does not adequatelyassess lesion size. Furthermore, endoscopic biopsy isusually not diagnostic. Cytology as performed by means of fineneedlepuncture does not have enough sensitivity and specificityto be considered the gold standard in the diagnosis of these lesions.We will now assess the usefulness of endoscopic ultrasonographyin the study of submucosal digestive tumors.Materials and methods: we have prospectively collected ultrasonographicstudies from all the patients with submucosal tumorswho were treated surgically. We assessed the sensitivity andspecificity of this technique in the diagnosis of malignancy in saidlesions, alongside factors that predict malignant behavior with thehighest reliability. We also valued the reliability of ultrasound endoscopyin the assessment of lesion size and the wall layer wherelesions are located. The results of histological studies were consideredthe gold standard.Results: the average size of lesions as measured by ultrasoundendoscopy was 37.42 mm, with no significant differences in surgicalpiece: 38.98 (p = 0.143). However, conventional endoscopyunderestimates the size of lesions. Endoscopic ultrasonographywas able to adequately establish the origin layer oflesions in all cases. Sensitivity, specificity, positive predictive value,and negative predictive value of ultrasound endoscopy in thediagnosis of malignancy were 89.5, 90.9, 89.5, and 90.9%, respectively.In the univariate analysis, the ultrasonographic characteristicsassociated with a diagnosis of malignancy included presenceof ulceration (p = 0.043), size above 4 cm (p = 0.049),irregular edges of lesion (p = 0.0001), a heterogeneous ultrasonographicpattern (p = 0.002), and the presence of cystic areasabove 2 mm (p = 0.012). In the multivariate analysis, the lastthree factors were considered independent predictive factors formalignancy.Conclusions: endoscopic ultrasonography has a great sensitivityand specificity in the diagnosis of malignancy regarding submucosallesions. The irregularity of lesion borders, a heterogeneousultrasonographic pattern, and the presence of cystic areasabove 2 mm in size were considered independent predictive factorsfor malignancy

Endoscopic resection of gastrointestinal submucosal tumors assisted by endoscopic ultrasonography.

BACKGROUND: The resection and histologic examination of the lesions is generally considered the treatment of choice in order to achieve diagnosis in gastrointestinal submucosal tumors. Moreover, the degree of malignancy of the tumor depends on certain features that can only be studied on the entire resected piece. METHODS: We revised the cases of patients who underwent endoscopic resection of gastrointestinal submucosal tumors in the period from 1997 through 2002. RESULTS: Fifty submucosal lesions were resected in 45 patients (64.4% men). Patient mean age was 55.31 years. Of the lesions, 52% were gastric tumors and 88% were located in the second layer. Mean size was 12.34 mm, and 54% were smaller than 10 mm. Resection with submucosal injection of saline solution and diluted adrenaline was performed on 46% of the lesions, and standard resection using polypectomy snare on 48%. Ligation was used in three cases. Resection was successful in 98% and major complications were observed in 4% (two cases of bleeding, endoscopically resolved). CONCLUSIONS: The endoscopic resection of submucosal tumors is a safe and efficient technique: It has few associated complications and allows diagnosis in all the cases and cure of the lesion in the great majority of cases.

The value of abdominal ultrasound in the diagnosis of colon cancer.

INTRODUCTION: Colon cancer is one of the main causes of cancer death. Diagnosis requires the examination of the entire large bowel by means of radiological or endoscopic techniques. Many patients suspect of colon cancer are referred for colonoscopy but nevertheless this suspicion is not confirmed after endoscopic examination. The objective of this study is the evaluation of the reliability of abdominal ultrasound in the diagnosis of these tumors. MATERIAL AND METHOD: We selected patients suspect of colon cancer referred to the endoscopy unit for a colonoscopy. An abdominal ultrasound was carried out on all patients prior to the endoscopy. Considering the endoscopic examination as a gold standard, the sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the ultrasonography were evaluated. Likewise, a series of analytical and clinical parameters were evaluated, in an attempt to establish associated factors of a colon cancer. The statistical analysis was carried out by means of the statistical package SPSS 12.0 for Windows. RESULTS: 145 patients were included in the study (56.6% males) with an average 66.72 years of age (22-89). A cancer was diagnosed in 42 cases (28.9%). In the diagnosis of colon cancer, abdominal ultrasound presents a sensitivity of 79.06%, a specificity of 92.15%, a PPV and a NPV of 80.9% and of 91.2%, respectively. Excluding from the analysis lesions of the rectal ampulla, which cannot be adequately evaluated by means of ultrasound, the figures for sensitivity, specificity, PPV and NPV increase to 91.8, 92.1, 80.9 and 96.9% respectively. The univariate analysis showed that an age over 65 years and the presence of microcytosis are associated to a greater risk of colon cancer while after multivariate analysis only the presence of microcytosis resulted to be an independent predictive factor of cancer. CONCLUSIONS: Abdominal ultrasound presents high sensitivity, specificity, PPV and NPV in the diagnosis of colon cancer. The combination of an ultrasonography and a rectoscopy permits us to rule out the presence of a colorectal carcinoma. In patients with microcytosis of 65 years and over, if there is strong clinical suspicion, a negative ultrasound may not be sufficient to rule out a colorectal neoplasia.

Resección endoscópica asistida por ecoendoscopia de tumores carcinoides del aparato digestivo / No disponible

Introducción: los carcinoides son los tumores neuroendocrinos más frecuentes, representado el tracto digestivo una de sus localizaciones más habituales. La mayoría de las lesiones se localizan en áreas poco accesibles para la endoscopia convencional (intestino delgado y apéndice); los carcinoides localizados en el tracto gastroduodenal y en el intestino grueso pueden ser estudiados endoscópicamente; en estos casos, si se confirma una enfermedad localizada, el tratamiento local mediante resección endoscópica puede ser el tratamiento de elección. Dado que la ecoendoscopia se ha mostrado como la técnica de elección en el estudio de los tumores de crecimiento submucoso, la selección de los pacientes candidatos a una resección local segura y efectiva ha de basarse en esta técnica. Pacientes y método: se han seleccionado los pacientes con tumores carcinoides digestivos tratados endoscópicamente entre 1997 y 2002. Se consideraron subsidiarios de resección endoscópica aquellos pacientes con tumores menores de 10 mm, que respetan la muscular propia y con un estudio de extensión negativo. Los objetivos finales del estudio fueron la evaluación de la eficacia (resección completa) y seguridad (complicaciones) de la técnica. El seguimiento consistió en biopsias de la escara al mes y los 12 meses de la resección. Resultados: en el periodo referido hemos resecado endoscópicamente 24 tumores en 21 pacientes (edad media de 51,7 años; 71,5% varones). Las lesiones eran en su mayoría hallazgos incidentales en exploraciones indicadas por otros motivos. La resección se indicó en la mayoría de los casos por sospecha ecoendoscópica de tumor carcinoide. La ecoendoscopia además permitió establecer con claridad la capa de origen de la lesión y el tamaño de la misma. La extirpación se llevó a cabo en 13 casos (54,2%) mediante la técnica convencional de polipectomía con asa, en 9 casos (37,5%) asistida con inyección submucosa de suero salino y/o adrenalina y en 2 casos (8,3%) tras ligar la lesión con bandas elásticas. En todos los casos la resección fue completa, sin recidivas durante el seguimiento. En un único caso se produjo una complicación mayor: una hemorragia postpolipectomía que se controló endoscópicamente. Conclusiones: la resección endoscópica de los tumores carcinoides, en pacientes bien seleccionados, es una técnica segura y eficaz permitiendo una resección completa en todos los casos con escasas complicaciones. La ecoendoscopia es la técnica de elección para seleccionar los pacientes candidatos a resección endoscópica (AU)

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Obscure gastrointestinal bleeding: a complication of radiation enteritis diagnosed by wireless capsule endoscopy.

Obscure gastrointestinal bleeding is a common disorder and may account for as many as 5% of all gastrointestinal hemorrhages. It is often caused by lesions in the small intestine, which were very complicated to examine prior to the advent of wireless capsule endoscopy. Here we present the case of a 31-year-old woman with obscure gastrointestinal bleeding as a complication of radiation enteritis, which was diagnosed only after she underwent an examination with wireless capsule endoscopy. This technique has proven to be far superior to other radiographic and endoscopic methods in diagnosing obscure gastrointestinal bleeding and pathologies of the small intestine in general.

Recurrent Dieulafoy's disease with surgical management: diagnosis by endoscopic ultrasonography.

Dieulafoy's disease is an uncommon but potentially significant cause of gastrointestinal bleeding caused by a large-caliber arterial vessel in the submucosa, which causes erosion and debilitation of the surrounding mucosa and may lead to massive gastrointestinal bleeding. Since endoscopy may prove insufficient, echoendoscopy may help in the diagnosis of this condition. Echoendoscopy may also help improve endoscopic management using mechanical techniques (hemoclips or band ligation) or a combination of thermal techniques and injection sclerotherapy, since this allows an accurate localization of the submucosal vessel. We present a case illustrating this approach by endoscopic ultrasonography, and describe the morphological substrate of this condition.

Jejunal leiomyosarcoma, a rare cause of obscure gastrointestinal bleeding diagnosed by wireless capsule endoscopy.

Obscure gastrointestinal bleeding is a relatively frequent disorder and may account for as many as 5% of all cases of gastrointestinal bleeding. The etiology of these hemorrhages may be attributed to lesions in the small intestine, which may not show up in radiologic studies, located in areas inaccessible to conventional endoscopy. The case of a 50-year-old patient admitted to the hospital on two occasions for gastrointestinal bleeding requiring blood transfusions is reported. On the first occasion, the bleeding was thought to be caused by a duodenal ulcer because no other lesions prone to bleeding were found. At the next admission for recurrent bleeding, the ulcer was found to have healed and thus was ruled out as the cause. Wireless capsule endoscopy detected an ulcerated tumor invading the submucosa of the jejunum. The pathologic diagnosis was low-grade leiomyosarcoma. Wireless capsule endoscopy has proved to be far superior to other radiologic and endoscopic techniques for the diagnosis of obscure gastrointestinal bleeding and pathologies of the small intestine in general.