Is colonoscopy necessary in cases of infection by Streptococcus bovis biotype II?

The association of colorectal neoplasia (CRN) with Streptococcus bovis biotype I (SBI) infection is well recognized. However, this is not the case for Streptococcus bovis biotype II (SBII). We conducted this study in order to analyze the relationship between SBII and CRN. We analyzed all cases of bacteremia due to SBI (n = 99) and SBII (n = 36) diagnosed in our hospital (during the period 1988-2011) that were followed up with colonoscopy. In addition, we reviewed the literature (during the period 1982-2011) to select all cases of infection of SB that had undergone colonoscopy or other adequate form of colorectal examination. A multivariate analysis was performed to detect CRN risk factors in patients infected with SB. From the 223 cases of SB infection included in the analysis (135 from our institution and 88 from the literature review), 159 were due to SBI and 64 were caused by SBII. As compared with SBI, the SBII cases had a lower frequency of CRN (27 % vs. 67 %, p <0.001), advanced adenomas (8 % vs. 29 %, p <0.01), and carcinomas (6 % vs. 21 %, p <0.01). In a multivariate analysis, and after adjusting for age, sex, type of infection, and biotype, SBII infection was not associated with CRN: odds ratio (OR) = 0.17; 95 % confidence interval (CI) = 0.09 to 0.33. The only factor independently associated with CRN was SBI infection: OR = 5.7; 95 % CI = 3.0 to 10.9. The prevalence of CRN in patients infected with SBII is significantly lower than patients with SBI and does not appear to be higher than the CRN prevalence among the general population.

Sedation with propofol controlled by endoscopists during percutaneous endoscopic gastrostomy.

BACKGROUND: propofol is a hypnotic used with increasing frequency for sedation during endoscopic procedures. Most of the reports published related with its employment by non-anaesthesiologists, refers to basic endoscopy, with little reference to its use in advanced endoscopy. OBJECTIVE: to evaluate the efficacy and safety of propofol sedation administered by endoscopists, while performing percutaneous endoscopic gastrostomy, an advanced technique that is usually performed in high anesthetic level risk patients. MATERIAL AND METHODS: prospective study of a series of endoscopic gastrostomy performed consecutively in our department; the sedation was carried out exclusively with propofol. The staff in the room consisted of two medical gastroenterologists, a nurse and a nursing assistant. Propofol was administered by bolus doses adjusted to patient weight. Arterial oxygen saturation, heart rate and blood pressure were monitored; respiratory activity was monitored visually by observing respiratory excursions of the patient. RESULTS: we included 47 patients, with an average age of 82 years. 87% were ASA III and the rest, ASA IV. The mean dose of propofol was 51 mgr. Complications were recorded: 8 cases of desaturation and two of hypotension, all of them minor and quickly reversible. All procedures were carried out successfully, at a median time of 8 minutes. CONCLUSION: the propofol sedation carried out by non-anaesthesiologist trained staff, seems to appear as a safe and effective procedure while performing percutaneous endoscopic gastrostomy.

Sedación con propofol controlada por endoscopista durante la realización de gastrostomía percutánea endoscópica / Sedation with propofol controlled by endoscopists during percutaneous endoscopic gastrostomy

Introducción: el propofol es un hipnótico usado cada vez conmás frecuencia para la sedación durante procedimientos endoscópicos.La mayor parte de los trabajos publicados en relación consu empleo por personal no anestesista se refiere a exploracionesde endoscopia básica, siendo escasas las referencias a su empleoen endoscopia avanzada.Objetivo: valorar la eficacia y la seguridad de la sedación mediantepropofol administrado por endoscopistas, durante la realizaciónde gastrostomía endoscópica percutánea, técnica avanzaday generalmente aplicada sobre pacientes de riesgo anestésico alto.Material y métodos: estudio prospectivo de una serie degastrostomías endoscópicas realizadas consecutivamente en nuestroservicio; las sedaciones se llevaron a cabo exclusivamente conpropofol. El personal presente en la sala consistió en dos médicosgastroenterólogos, una enfermera y una auxiliar de enfermería. Elpropofol se administró en bolos, ajustando las dosis al peso de lospacientes. Se monitorizaron la saturación arterial de oxígeno, lafrecuencia cardiaca y la tensión arterial. La actividad respiratoriase controló de forma visual mediante la observación de las excursionesrespiratorias de los enfermos.Resultados: se incluyeron 47 pacientes, con una edad mediade 82 años. El 87% fueron ASA III y el resto ASA IV. La dosismedia de propofol fue de 51 mg. Como complicaciones se registraron8 casos de desaturación y dos de hipotensión, todas leves yrápidamente reversibles. Todos los procedimientos se llevaron acabo satisfactoriamente, en un tiempo medio de 8 minutos.Conclusión: la sedación mediante propofol llevada a cabopor personal entrenado no anestesista parece mostrarse como unmétodo seguro y eficaz durante la realización de gastrostomía percutáneaendoscópica(AU)

Background: propofol is a hypnotic used with increasing frequencyfor sedation during endoscopic procedures. Most of thereports published related with its employment by non-anaesthesiologists,refers to basic endoscopy, with little reference to its usein advanced endoscopy.Objective: to evaluate the efficacy and safety of propofol sedationadministered by endoscopists, while performing percutaneousendoscopic gastrostomy, an advanced technique that is usuallyperformed in high anesthetic level risk patients.Material and methods: prospective study of a series of endoscopicgastrostomy performed consecutively in our department;the sedation was carried out exclusively with propofol.The staff in the room consisted of two medical gastroenterologists,a nurse and a nursing assistant. Propofol was administeredby bolus doses adjusted to patient weight. Arterial oxygen saturation,heart rate and blood pressure were monitored; respiratoryactivity was monitored visually by observing respiratory excursionsof the patient.Results: we included 47 patients, with an average age of 82years. 87% were ASA III and the rest, ASA IV. The mean dose ofpropofol was 51 mgr. Complications were recorded: 8 cases ofdesaturation and two of hypotension, all of them minor and quicklyreversible. All procedures were carried out successfully, at a mediantime of 8 minutes.Conclusion: the propofol sedation carried out by non-anaesthesiologisttrained staff, seems to appear as a safe and effectiveprocedure while performing percutaneous endoscopic gastrostomy(AU)

Endoscopic treatment of acute colorectal obstruction with self-expandable metallic stents: experience in a community hospital.

BACKGROUND: The purpose of this study was to evaluate the efficacy and security of treatment with self-expandable metallic stents for acute colonic obstruction. METHODS: Retrospectively, we analyzed our experience in placing colonic stents in patients with acute colonic obstruction. Sixty-two patients with malignant colon obstruction were sent to our hospital endoscopic unit from February 1999 through September 2003. The mean age was 75.21 years. A total of 63 self-expandable metallic stents were implanted. All procedures were done under endoscopic and fluoroscopic guidance. RESULTS: Technical success was obtained in 58 patients (93.54%). Clinical improvement and resolution of the obstruction were confirmed in 56 of these 58 patients (96.55%) within 48-72 h. Sixteen complications were observed in 11 patients (19%). Twelve cases were minor complications: five patients had pain and rectal tenesmus, and there were seven cases of distal migration of the stent. Four patients (6.9%) had severe complications. Three patients underwent surgery to resolve colonic perforations and one patient developed a colovesical fistula 7 months after stent placement. The stent was used as a bridge to the elective surgery in 22 patients (37.93%). The mean time between stent placement and surgery was 7.66 days (range, 2-20). The stent was used as a definitive palliative treatment in 36 patients (62.07%). CONCLUSION: Stenting was a useful treatment of acute malignant colonic obstruction. The use of stents as a "bridge to the elective surgery" allowed the intestinal preparation, general status restoration, and a one-stage operation with resection and primary reanastomosis. We have also used the stents as a definitive palliative treatment, avoiding surgery in those patients with a very widely metastatic disease or who cannot undergo operation because of comorbid underlying conditions.

Endoscopic sphincterotomy for prevention of the recurrence of acute biliary pancreatitis in patients with gallbladder in situ: long-term follow-up of 88 patients.

BACKGROUND: Endoscopic sphincterotomy without cholecystectomy is a therapeutic option in selected patients after acute biliary pancreatitis. We conducted a prospective evaluation of the long-term effects of sphincterotomy in terms of the need for of subsequent cholecystectomy and the recurrence of gallstone pancreatitis. METHODS: We studied 88 patients with acute biliary pancreatitis and an intact gallbladder who, underwent endoscopic sphincterotomy either because they were high-risk candidates for surgery or because they had refused of cholecystectomy. The median follow-up was 51 months (range, 5-86). RESULTS: Only two patients (2.2%) experienced recurrent pancreatitis. Subsequent cholecystectomy was performed in 10 patients because of acute cholecystitis in eight cases and biliary colic in two cases. Sixty-six patients (75%) remained asymptomatic. CONCLUSIONS: Endoscopic sphincterotomy is a safe and acceptable alternative to cholecystectomy for the prevention of recurring attacks of gallstone pancreatitis. As a result of this procedure, 75% of patients remained free of symptoms in the long term.

[Resident physician training in the digestive system. The point of view of the residents]. / Formación MIR en aparato digestivo. El punto de vista de los residentes.

AIM: To evaluate various aspects of current training of Spanish residents in gastroenterology. METHOD: An anonymous postal questionnaire was sent to fourth-year resident physicians in Spanish hospitals with accredited gastroenterology residency programs. RESULTS: Forty residents in the fourth year (53% offered positions), four from the second year and one from the first year (20 men, 25 women) answered the survey. Mean age was 29.7 years (26-42 years). Fifty-one percent of the departments did not have ultrasonography facilities apart from those in the radiology department. Endoscopic retrograde cholangiopancreatography (ERCP) was available in all the departments but in 55% of these, residents did not receive training in this technique. Forty-one percent of residents did not know the objectives of the various training periods. Eighty-four percent evaluated the pressure of clinical work as "intense" or "very intense" with 67% reporting that it disturbed their training "seriously" or "very seriously" and 71% that it disturbed their personal lives. Supervision in ultrasonography, endoscopy and clinical work were mainly evaluated as "good" or "very good". Supervision was rated lower in outpatient departments and while on duty. Forty-two percent of residents rated the supervision of the personal tutor as "average". Seventy-six percent were "fairly" or "very interested" in the introduction of "areas of specific training". CONCLUSIONS: The quality of residents' training in general and of gastroenterology training in particular is high. There are, however, several aspects which could be improved.

[Endoscopic drainage with polyethylene endoprosthesis of malignant obstructive jaundice]. / Drenaje endoscópico mediante prótesis de polietileno de la ictericia obstructiva maligna.

AIM: To evaluate the efficacy and complications of endoscopic drainage of malignant obstructive jaundice with plastic endoprosthesis as well as to identify possible factors related with occlusion. PATIENTS AND METHODS: One-hundred and forty patients with malignant obstructive jaundice were retrospectively evaluated. The site of obstruction was proximal in 35 patients (25.0%), distal in 64 (45.7) and ampullary in 41 (29.3). Amsterdam or pigtail polyethylene prostheses of variable caliber and length were used. Drainage was preoperative in 41 patients and palliative in 99. Seventy-seven patients who underwent with palliative drainage were followed up long-term. RESULTS: Drainage was satisfactory in 132 patients (94.2%). Early morbidity was 10.7% (14/140) and early mortality related with the technique was 5% (7/140). Time free of obstruction was 4.6 +/- 1.0 months and in 47/77 (60%) the prostheses were still working at the end of follow-up. The actuarial rate of obstruction at 6 months was 42%, the majority (61%) occurring in the first 3 months. The median survival was 5.9 +/- 1.3 months. Of all the factors analyzed, greater permeability was found only in the ampullary tumors (p < 0.01) and in prostheses of caliber equal or superior to 10 French (p < 0.01). CONCLUSIONS: Endoscopic biliary drainage using plastic prostheses is satisfactory in the majority of patients with malignant jaundice. It has a low complication rate and provides acceptable palliation: the majority of patients do not require prostheses to be replaced and, when they becomes clogged, substitution usually solves the problem. Ampullary tumors and prostheses of higher caliber (> or = 10F) have been associated with greater permeability.

[The predictive factors of a good response to the transfusion of erythrocyte concentrates in patients with controlled digestive hemorrhage]. / Factores predictivos de buena respuesta a la transfusión de concentrados de hematíes en pacientes con hemorragia digestiva controlada.

INTRODUCTION: Not all patients respond the same to the transfusion of erythrocyte concentrates (EC) after achieving the control of gastrointestinal bleeding. AIM: The aim of the present study was to analyze the predictive factors of good response to EC transfusion in patients with controlled gastrointestinal hemorrhage and determine the stability of transfusion performance. PATIENTS AND METHODS: A prospective study was carried out in 61 patients with controlled gastrointestinal bleeding. The epidemiologic data were compared and prior to transfusion different analytical and hemodynamic variables were compared basally. On completion of the transfusion analytical controls were performed at 4 and 24 hours. The response was considered as optimum when pretransfusional basal hemoglobin (Hb) increased at least 1 g and the hematocrit (HCT) rose 3 points for each EC administered. RESULTS: The response to transfusion was optimum in 29 patients and bad in 32. The women responded significantly better than the men (p < 0.05), as did patients with lower weight (p < 0.05) and body surface (p < 0.05). The mean age of the responding patients was greater (p = 0.06) and the height, to the contrary, lower (p = 0.09). No significant differences were observed in the presence or not of associated disease, type of lesion causing the hemorrhage, or number of EC transfused. Likewise, no differences were found with regard to the pretransfusional values of TAM, TAS, FC, PVC, Hb, HCT, VCM, HCM, urea and creatinine. The only variables with independent predictive value of good response were female sex and low body surface. The difference between the Hb and HCT values at 4 and 24 h after transfusion did not achieve statistical significance. CONCLUSIONS: 1. The hemodynamic state and the degree of basal anemia do not condition response to EC transfusion in controlled gastrointestinal bleeding. 2. The response to the administration of EC is better in women and subjects of lower body surface. 3. Postransfusional analytical control at 4 hours allows early evaluation of the effects of the transfusion in patients at risk of recurrent hemorrhage.

[Delayed reposition of gastrostomy tube using Savary's dilators]. / Reposición diferida de sonda de gastrostomía utilizando dilatadores de Savary.

The delay in substituting a gastrostomy tube after removal leads to the gastrocutaneous tract closure and to the impossibility of putting other nourishment tube without needing another complete endoscopic procedure. We have used the technique described by Tsang through the one which and using Savary's dilators, the stenosed gastrocutaneous tract after accidental removal of the tube, is dilated permitting to put in a simple way a new one. We accomplished the procedure in three patients that attended by removal of the probe and severe stenosis of the stoma. In all they and under endoscopic control we put a new tube in a way rapid and without complications.

[Transpapillary endoscopic drainage of pancreatic pseudocyst]. / Drenaje endoscópico transpapilar de un pseudoquiste pancreático.

Drainage of pancreatic pseudocysts can be achieved by means of endoscopy. In this paper we report a case of a pancreatic pseudocyst of ten centimeters in diameter, that was successfully managed by insertion of a nasocystic drainage through the papilla of Vater. The procedure was simple and complications were absent. Transpapillary drainage of pancreatic pseudocysts is an effective procedure.

[Chronic gastritis and Helicobacter pylori in patients with non-ulcerous dyspepsia. Role and significance of age]. / Gastritis crónica y Helicobacter pylori en pacientes con dispepsia no ulcerosa. Papel e importancia de la edad.

Patients with recurrent upper abdominal complaints and without peptic ulcer or definite evidence of organic disease have been labelled as suffering from nonulcer dyspepsia and included in the study. A total of 125 patients were studied and upper gastrointestinal endoscopy performed. Histology, urease rapid test and ELISA serology were done in order to detect Helicobacter pylori infection. Age groups were done. The most frequent endoscopic and histological finding was chronic gastritis in all age groups of patients. In patients under 30 years old, the highest rate of normal endoscopy was found. Chronic gastritis was associated with Helicobacter pylori infection in 89.8% of all patients. The highest rate of chronic gastritis non associated with Helicobacter pylori infection was found in the age group of patients younger than 30 years old. Other factors as biliary reflux, gastroduodenal dismotility, decreased pain tolerance or stress have been proposed to be the etiology of chronic gastritis in young patients.

[Usefulness of the breath test with urea-13C in the diagnosis of Helicobacter pylori infection]. / Utilidad del test del aliento con urea-13C en el diagnóstico de la infección por Helicobacter pylori.

BACKGROUND: Many diagnostic methods of variable diagnostic profitability are available to detect infection by Helicobacter pylori. The aim of this study was to evaluate the usefulness of the European method of the breath test with urea-13C and compare the results with common histologic methods, the rapid urease test and serology. METHODS: Thirty-six patients who attended the Endoscopy Unit for recurrent symptomatology of the upper digestive tract were included in the study. A patient was considered to present infection by Helicobacter pylori on positivity of 2 of the usual methods: histology, rapid urease test and serology. RESULTS: The breath test with urea-13C was positive in 25 patients (13CO2 > 5 per 1,000) and negative in 10 patients with 100% specificity and 96% sensitivity. The specificity of the rapid urease test, histology and serologic tests were 90, 90 and 80%, respectively with 92, 88, and 88% sensitivity, respectively. CONCLUSIONS: The European method of the breath test with urea-13C is simple, non invasive and achieves the greatest profitability in the determination of Helicobacter pylori.