Clinical validation of the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II criteria in an open-access unit: a prospective study.

BACKGROUND AND STUDY AIMS: The European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE I) criteria were recently updated (EPAGE II), but no prospective studies have used these criteria in clinical practice. The aim of the current study was to validate the EPAGE II criteria in an open-access endoscopy unit. PATIENTS AND METHODS: A prospective observational study was conducted in an open-access endoscopy unit at a tertiary care referral center. Consecutive outpatients (n = 1004; mean age 58.9 ±â€†13.1 years; 45 % men) were referred for diagnostic colonoscopy between September 2009 and February 2010. The appropriateness of colonoscopy was assessed based on EPAGE II criteria, and the relationship between appropriateness and both referral doctor and detection of significant lesions was examined. The effectiveness of EPAGE II criteria in assessing appropriateness was measured by means of sensitivity, specificity, and positive and negative predictive values for detecting significant lesions. RESULTS: Colonoscopic cecal intubation was achieved in 956 patients (95.2 %). Most referral doctors were gastroenterologists (58.0 %) and the most common indication was colorectal cancer (CRC) screening (35.2 %). EPAGE II criteria were applicable in 968 patients (96.4 %); of these patients, the indication was appropriate in 778 (80.4 %), inappropriate in 102 (10.5 %), and uncertain in 88 (9.1 %). Patients with appropriate or uncertain indications based on EPAGE II criteria had more relevant endoscopic findings than those with inappropriate indications (38.8 % vs. 24.5 %; OR 1.95, 95 %CI 1.22 - 3.13; P < 0.005). Sensitivity and negative predictive value of EPAGE II criteria for detecting significant lesions were 93.1 % (95 %CI 90 % - 96 %) and 75.5 % (95 %CI 67 % - 84 %), respectively, whereas for advanced neoplastic lesions these values were 98.0 % (95 %CI 95 % - 100 %) and 98.0 % (95 % CI 95 % - 100 %), respectively. Adherence to EPAGE II recommendations was an independent predictor of finding a significant lesion (OR 1.93, 95 %CI 1.20 - 3.11; P = 0.007). CONCLUSIONS: EPAGE II is a simple, valid score for detecting inappropriate colonoscopies in clinical practice.

[Contribution of the patent foramen ovale to the etiopathogeny of the irritable bowel syndrome]. / Contribución del foramen oval permeable a la etiopatogenia del síndrome de intestino irritable.

A higher prevalence of cardiac right-to-left shunt through a patent foramen ovale (PFO) has been recently reported in the irritable bowel syndrome (IBS). At the same time, signs of ischemia in medullary cerebral microcirculation and the presence of excess sympathetic activity in peripheral circulation have been identified, both related with change in pain perception and autonomic dysfunction characteristic of IBS. Considering these findings together, the possible etiopathogenic role of PFO in the development of IBS can be proposed, because the paradoxical embolism characteristic of PFO could damage the cerebral and intestinal microcirculation, and that injury would be also amplified by the percentage of venous blood that shunts the pulmonary filter, producing an alteration in the metabolism of serotonin, pro-inflammatory bradykinins or neurotensin, substances with a proven etiopathogenic relationship with IBS.

Contribución del foramen oval permeable a la etiopatogenia del síndrome de intestino irritable / Contribution of the patent foramen ovale to the etiopathogeny of the irritable bowel syndrome

En el síndrome de intestino irritable (SII) ha sido observada recientemente una mayor prevalencia de cortocircuito de derecha a izquierda cardíaco por foramen oval permeable (FOP). Paralelamente se han identificado signos de isquemia en la microcirculación cerebral a nivel bulbar y de exceso de actividad simpática en la circulación periférica, relacionables ambos con la alteración en la percepción del dolor y la disfunción autonómica características del SII. Sumando estos hallazgos, puede plantearse una posible contribución etiopatogénica del FOP al desarrollo de SII, basada en que la embolización paradójica característica del FOP podría alterar la microcirculación (cerebral, intestinal, periférica, etc.) que se vería además potenciada por el porcentaje de sangre venosa que elude el filtro pulmonar produciendo una alteración en el metabolismo de la serotonina, las bradiquininas proinflamatorias y la neurotensina, sustancias de probada relación etiopatogénica con el SII (AU)

A higher prevalence of cardiac right-to-left shunt through a pateA higher prevalence of cardiac right-to-left shunt through a patent foramen ovale (PFO) has been recently reported in the irritable bowel syndrome (IBS). At the same time, signs of ischemia in medullary cerebral microcirculation and the presence of excess sympathetic activity in peripheral circulation have been identified, both related with change in pain perception and autonomic dysfunction characteristic of IBS. Considering these findings together, the possible etiopathogenic role of PFO in the development of IBS can be proposed, because the paradoxical embolism characteristic of PFO could damage the cerebral and intestinal microcirculation, and that injury would be also amplified by the percentage of venous blood that shunts the pulmonary filter, producing an alteration in the metabolism of serotonin, pro-inflammatory bradykinins or neurotensin, substances with a proven etiopathogenic relationship with IBS (AU)

Reliability of the Spanish version of a brief questionnaire on patient satisfaction with gastrointestinal endoscopy.

BACKGROUND: There has not been a validated questionnaire available in Spanish to evaluate patient satisfaction with gastrointestinal endoscopy. Our aim was to evaluate the external validity and internal consistency of the Spanish version of a questionnaire on patient satisfaction with gastrointestinal endoscopy elaborated by the American Society for Gastrointestinal Endoscopy. DESIGN: Prospective questionnaire validation study. PATIENTS AND METHODS: A total of 485 consecutive patients referred to two different hospitals for endoscopy were interviewed by telephone. Internal consistency was studied using Cronbach's alfa test and corrected item-total correlations (CITC). External validity was determined using a mailed questionnaire completed by 185 patients-correlations between telephone and postal responses were calculated, as well as the correlation with the total score obtained. RESULTS: Cronbach's alfa was 0.82 and mean CITC was 0.59. Weighted kappa values for the same questionnaire items performed by telephone or mail varied between 0.51 and 0.81. Total score correlation was 0.78. Internal consistency and external validity were not affected by differences in the administration of the questionnaire (mail or by telephone), different interviewers, type of endoscopy, or source of patients. CONCLUSIONS: The Spanish version of the ASGE questionnaire on satisfaction with endoscopy is valid, reliable, and reproducible.

Validación de un cuestionario breve sobre satisfacción del paciente en endoscopia digestiva / Reliability of the Spanish version of a brief questionnaire on patient satisfaction with gastrointestinal endoscopy

Objetivos: no se dispone en castellano de un cuestionario validadopara la valoración de la satisfacción del paciente en endoscopiadigestiva. Evaluar la validez externa y la consistencia internade la versión en castellano del cuestionario recomendado por laAmerican Society for Gastrointestinal Endoscopy sobre satisfacciónen endoscopia.Diseño experimental: estudio de validación de un cuestionario,recogida de datos prospectiva.Pacientes y métodos: cuatrocientos ochenta y cinco pacientesconsecutivos remitidos para endoscopia a dos hospitales diferentesfueron entrevistados telefónicamente. La validez interna seestudió mediante alfa de Cronbach y correlación total inter-ítemmedia. Para estimar la validez externa se remitió un cuestionarioanónimo a 185 pacientes y se calcularon las correlaciones entrelas respuestas dadas telefónicamente y por correo, así como la correlaciónen la puntuación global obtenida mediante la suma delos valores para las siete cuestiones del cuerpo principal del cuestionario.Resultados: la alfa de Cronbach fue de 0,82 y la CTITM de0,59. La kappa ponderada entre las mismas cuetiones en loscuestionarios administrados telefónica o anónimamente variaronentre 0,51 y 0,81. La correlación en la puntuación total fue de0,78. La validez interna y externa no se vio afectada por diferenciasen la administración del cuestionario (correo o telefónico), losdiferentes entrevistadores, el tipo de endoscopia o la procedenciade los pacientes.Conclusiones: la versión en castellano del cuestionario recomendadopor la ASGE sobre satisfacción en endoscopia es válida,fiable y reproducible

Background: there has not been a validated questionnaireavailable in Spanish to evaluate patient satisfaction with gastrointestinalendoscopy. Our aim was to evaluate the external validityand internal consistency of the Spanish version of a questionnaireon patient satisfaction with gastrointestinal endoscopy elaboratedby the American Society for Gastrointestinal Endoscopy.Design: prospective questionnaire validation study.Patients and methods: a total of 485 consecutive patients referredto two different hospitals for endoscopy were interviewed bytelephone. Internal consistency was studied using Cronbach’s alfatest and corrected item-total correlations (CITC). External validitywas determined using a mailed questionnaire completed by 185 patients–correlations between telephone and postal responses werecalculated, as well as the correlation with the total score obtained.Results: Cronbach´s alfa was 0.82 and mean CITC was 0.59.Weighted kappa values for the same questionnaire items performedby telephone or mail varied between 0.51 and 0.81. Totalscore correlation was 0.78. Internal consistency and external validitywere not affected by differences in the administration of thequestionnaire (mail or by telephone), different interviewers, typeof endoscopy, or source of patients.Conclusions: the Spanish version of the ASGE questionnaireon satisfaction with endoscopy is valid, reliable, and reproducible

[Utility of routine use of reversion after sedation in outpatient colonoscopy]. / Utilidad en la práctica clínica habitual de la reversión tras sedación en colonoscopia ambulatoria.

INTRODUCTION: Randomized clinical trials have demonstrated the effectiveness of flumazenil in reducing recovery time in the endoscopy unit after conscious sedation with midazolam and meperidine. However, its effectiveness in routine clinical practice has not been proved and therefore its use is debated. AIM: To determine the effectiveness of reversion with flumazenil after conscious sedation with midazolam and pethidine in outpatient colonoscopy and to evaluate its cost-effectiveness. MATERIAL AND METHOD: Two hundred consecutive outpatients scheduled for colonoscopy with conscious sedation with midazolam and pethidine in 2 endoscopy units were prospectively included. According to routine clinical practice in each unit, 100 patients were reverted with flumazenil and 100 were not. Medical and demographic data, indications for endoscopy, doses of the medications used and endoscopic findings were collected. Three weeks after the colonoscopy each patient was interviewed by telephone to determine discomfort and complications associated with the endoscopy and/or with the use of sedation. The cost-effectiveness of the use of flumazenil was analyzed. RESULTS: There were no differences between the two groups in age (52.9 +/- 15.5 vs 52.7 +/- 18.3, p = NS), indications for colonoscopy, findings, percentage of full colonoscopies (93 vs 95%; p = NS) or in the doses of sedatives used. The recovery time in each endoscopy unit was similar (19.2 +/- 11.7 vs 15.5 +/- 10.1 minutes, p = NS). In the reversion group there were fewer patients with prolonged stays, defined as those > 20 minutes (23 vs 11%, p < 0.001). The number of patients who remembered discomfort during the colonoscopy was significantly greater in the reversion group (23 vs 13%; p < 0.05). There were no differences in the number of patients who reported discomfort in the days following the endoscopy. The best cost-effectiveness ratio was obtained for a mean stay of 25 min. CONCLUSION: Routine use of reversion does not decrease the mean stay in the endoscopy unit but does decrease the number of prolonged stays. Unpleasant memories of the colonoscopy were more frequent in reverted patients. The effectiveness of the routine use of reversion with flumazenil after conscious sedation with midazolam and pethidine depends on the ratio between the number of daily colonoscopies and the capacity of the recovery room.

Utilidad en la práctica clínica habitual de la reversión tras sedación en colonoscopia ambulatoria / Utility of routine use of reversion after sedation in outpatient colonoscopy

Introducción: La reversión con flumazenilo ha demostrado, en ensayos clínicos aleatorizados, su eficacia para disminuir el tiempo de estancia de los pacientes en la sala de recuperación tras sedación con midazolam y meperidina. Sin embargo, su efectividad en la práctica clínica diaria no ha sido demostrada, por lo que su uso es muy debatido. Objetivo: Determinar la efectividad de la reversión con flumazenilo tras la sedación consciente con midazolam y petidina en colonoscopia ambulatoria y valorar su relación coste-efectividad. Material y método: Se estudió prospectivamente a 200 pacientes ambulatorios remitidos para colonoscopia y sedados con midazolam y meperidina, procedentes de 2 unidades de endoscopia. Siguiendo la práctica habitual de cada una de las unidades, 100 pacientes fueron revertidos con flumazenilo y 100 no. Se recogieron los datos demográficos y médicos, las indicaciones de la colonoscopia, la dosis de fármacos utilizada y los hallazgos de la endoscopia. Tres semanas después se realizó una encuesta telefónica para determinar las molestias y complicaciones asociadas a la endoscopia o la sedación. Se estudió la relación coste-efectividad. Resultados: No hubo diferencias entre ambos grupos en la edad (52,9 ± 15,5 frente a 52,7 ± 18,3 años; p = NS), en las indicaciones de la colonoscopia, en los hallazgos de la prueba, en el porcentaje de colonoscopias completas (el 93 frente al 95%; p = NS) ni en las dosis de midazolam y meperidina utilizadas. La estancia media en la unidad tras la exploración fue similar (19,2 ± 11,7 frente a 15,5 ± 10,1 min; p = NS). En el grupo de reversión había menos pacientes con estancias prolongadas –estancias de más de 20 min– (el 23 frente al 11%; p < 0,001). El número de pacientes que recordaban molestias durante la exploración era significativamente mayor en el grupo de reversión (el 23 frente al 13%; p < 0,05). No existían diferencias en el número de pacientes con molestias en días posteriores. La mejor relación coste-efectividad se conseguía cuando se buscaba una estancia media de 25 min. Conclusión: La reversión no disminuyó la estancia media en la unidad de endoscopia, pero bajó el número de estancias prolongadas. Los pacientes revertidos experimentan mayores recuerdos desagradables de la exploración. La efectividad del uso de la reversión con flumazenilo tras la sedación con midazolam y meperidina depende de la relación entre el número de exploraciones diarias de la unidad de endoscopia y la capacidad de su unidad de recuperación

Introduction: Randomized clinical trials have demonstrated the effectiveness of flumazenil in reducing recovery time in the endoscopy unit after conscious sedation with midazolam and meperidine. However, its effectiveness in routine clinical practice has not been proved and therefore its use is debated. Aim: To determine the effectiveness of reversion with flumazenil after conscious sedation with midazolam and pethidine in outpatient colonoscopy and to evaluate its cost-effectiveness. Material and method: Two hundred consecutive outpatients scheduled for colonoscopy with conscious sedation with midazolam and pethidine in 2 endoscopy units were prospectively included. According to routine clinical practice in each unit, 100 patients were reverted with flumazenil and 100 were not. Medical and demographic data, indications for endoscopy, doses of the medications used and endoscopic findings were collected. Three weeks after the colonoscopy each patient was interviewed by telephone to determine discomfort and complications associated with the endoscopy and/or with the use of sedation. The cost-effectiveness of the use of flumazenil was analyzed Results: There were no differences between the two groups in age (52.9 ± 15.5 vs 52.7 ± 18.3, p = NS), indications for colonoscopy, findings, percentage of full colonoscopies (93 vs 95%; p = NS) or in the doses of sedatives used. The recovery time in each endoscopy unit was similar (19.2 ± 11.7 vs 15.5 ± 10.1 minutes, p = NS). In the reversion group there were fewer patients with prolonged stays, defined as those > 20 minutes (23 vs 11%, p < 0.001). The number of patients who remembered discomfort during the colonoscopy was significantly greater in the reversion group (23 vs 13%; p < 0.05). There were no differences in the number of patients who reported discomfort in the days following the endoscopy. The best cost-effectiveness ratio was obtained for a mean stay of 25 min. Conclusion: Routine use of reversion does not decrease the mean stay in the endoscopy unit but does decrease the number of prolonged stays. Unpleasant memories of the colonoscopy were more frequent in reverted patients. The effectiveness of the routine use of reversion with flumazenil after conscious sedation with midazolam and pethidine depends on the ratio between the number of daily colonoscopies and the capacity of the recovery room

[Meckel's diverticulum in adults. A 3-decade experience]. / Divertículo de Meckel en el adulto. Experiencia de tres décadas.

OBJECTIVE: To review the prevalence, clinic manifestations and characteristics of the adult Meckel's diverticulum in the Hospital Español de México. BACKGROUND: The Meckel's diverticulum is the most frequent congenital malformation of the gastrointestinal tract. However, only in seldom occasions produces manifestations in adults. METHODS: Retrospective review of 31 years. RESULTS: Meckel's diverticulum was found in only 13 cases. The most common clinical manifestation was pain in the right lower abdominal quadrant; there was not a single case of bleeding. A correct pre surgical diagnosis was done in only one patients. Post surgical course was satisfactory in all patients. CONCLUSION: In adults, the Meckel's diverticulum complications are uncommon, being the most frequent clinical manifestation the pain in the right lower abdominal quadrant and intestinal obstruction.

Epilepsia abdominal en el adulto / Abdominal epilepsy in an adult patient

La epilepsia abdominal es una causa rara de dolor abdominal. Reportamos un paciente adulto con dolor abdominal epigástrico, intermitente, paroxístico, acompañado de náuseas, vomítos inquietud y angustia. A la exploración física sin alteraciones. En el laboratorio sólo leucocitosis con neurotrofilia. Estudios radiológicos, ultrasonido y tomografía abdominales, arteriografía mesentérica y laparotomía exploradora sin anormalidades. El electroencefalograma (EEG) mostró actividad lenta theta bilateral durante la hiperventilación. Se inició tratamiento con carbamazepina, permaneciendo asintomático durante nueve meses. Posteriormente tuvo una recaída por tomar irregularmente el medicamento. En ese momento los niveles séricos de carbamazapina eran bajos. En el EEG se encontraron brotes de ondas agudas difusas paroxísticas. Al llevar nuevamente los niveles séricos de carbamazepina dentro de rangos terapéuticos desapareció el dolor. Ha permanecido asintomático durante los siguientes doce meses, tomando regularmente su tratamiento

[Abdominal epilepsy in the adult]. / Epilepsia abdominal en el adulto.

Abdominal epilepsy is a rare cause of abdominal pain. We report an adult patient with intermittent, paroxysmal epigastric abdominal pain, accompanied by nausea, vomiting, restlessness and anxiety. Physical examination was normal. Blood analysis disclosed only leucocytosis with neutrophilia. X ray examinations, ultrasound and CT abdominal scan, mesenteric arteriography and exploratory laparotomy did not show evidence of pathology. The electroencephalogram (EEG) showed bilateral theta slow activity during hyperventilation. We started treatment with carbamazepine and the patient remained asymptomatic for nine months. However he had a relapse because he did'nt take his medication regularly. At that time the serum levels of carbamazepine were low. The EEG showed bursts of diffuse paroxysmal acute waves. Once therapeutic serum levels of carbamazepine were achieved the pain disappeared. He has remained asymptomatic during the last twelve months, while taking his treatment regularly.