Bone mineral density and bone turnover in non-cirrhotic patients with chronic hepatitis C and sustained virological response to antiviral therapy with peginterferon-alfa and ribavirin.

UNLABELLED: Patients with chronic hepatitis C have low bone mineral density and increased bone resorption related to serum transaminase levels. Elevated serum soluble tumor necrosis factor (sTNFR-55) receptor levels may play a role in the bone mass loss in these patients. Bone mass is improved and bone turnover normalized in patients who respond to antiviral therapy with interferon and ribavirin. INTRODUCTION: Low bone mineral density (BMD) has been described in patients with chronic hepatitis C (HCV). The study objective was to evaluate the effect of antiviral therapy on BMD and bone metabolism in non-cirrhotic HCV patients with sustained virological response. METHODS: We conducted a prospective study in 36 consecutive outpatients from the general community with non-cirrhotic HCV and an early and sustained virological response to peginterferon-alfa and ribavirin therapy. Determinations of BMD (dual X-ray absorptiometry at lumbar spine and femoral neck) and biochemical measurements of bone metabolism and sTNFR-55 were made at baseline, after 24 and 48 weeks of antiviral therapy, and at 48 weeks after the end of treatment. RESULTS: Patients had a significantly reduced BMD, which significantly increased during the follow-up. Serum levels of sTNFR-55 and bone turnover markers were increased at baseline and significantly reduced at all subsequent time points. We found an inverse correlation between BMD and both serum aminotransferase levels and urine deoxypyridinoline (D-pyr) and a positive correlation between serum aminotransferases and both urine D-Pyr and serum sTNFR-55. CONCLUSIONS: Patients with chronic hepatitis C have low bone mass associated with increased bone resorption, and some relationship can be expected between serum aminotransferase levels and the degree of bone mass loss. Bone mass may be improved and bone turnover normalized in patients who respond to antiviral therapy. Elevated serum sTRFR-55 levels may play a role in the bone mass loss of these patients.

Biliary sphincterotomy dilation for the extraction of difficult common bile duct stones

Background and aim: endoscopic retrograde cholangiopancreatography(ERCP) with biliary sphincterotomy (BS) is the usualmethod for extracting common bile duct stones. However, followingBS and by means of extraction balloons and Dormia baskets acomplete bile duct clearance cannot be achieved in all cases. Wepresent a study on the impact that hydrostatic balloon dilation of aprevious BS (BSD) may have in the extraction rate of choledocholithiasis.Patients and methods: a prospective study which included 91consecutive patients diagnosed with choledocholithiasis who underwentERCP. For stone removal, extraction balloons and Dormia basketswere used, and when necessary BSD was employed.Results: complete bile duct clearance was achieved in 86/91(94.5%) patients. BSD was used in 30 (33%) cases. In these cases,extraction was complete in 29/30 (97%); 23 (76%) patients in theBSD group had anatomic difficulties or bleeding disorders. Themost frequently used hydrostatic balloon diameter was 15 mm(60%). There were 7 (7.6%) complications: two self-limited hemorrhageepisodes in the BSD group and one episode of cholangitis,one of pancreatitis, and three of bleeding in the group inwhich BSD was not used.Conclusions: BSD is a very valuable tool for extracting commonbile duct stones. In our experience, there has been an increasein the extraction rate from 73% (Rev Esp Enferm Dig2002; 94: 340-50) to 94.5% (p = 0.0001, OR 0.1, CI 0.05-0.45), with no increase in complications(AU)

[Palliative management of malignant gastric outlet obstruction with endoscopically inserted self-expanding metal stents].

AIM AND BACKGROUND: the insertion of self-expanding metal stents to palliate malignant gastric outlet obstruction is a minimally invasive procedure that is being increasingly used. We discuss experience with this technique in a level-II hospital in the Spanish National Health System. PATIENTS AND METHODS: a retrospective five-year study (2003-2007) was conducted in 23 patients who underwent 27 procedures aimed at resolving malignant gastric outlet obstruction (mean, 0.45 procedures per month) using endoscopically inserted noncovered stents (Wallstent and Wallflex). RESULTS: insertion was technically feasible in all 27 (100%) attempts, with satisfactory clinical results in 25 cases (92.5%). Endoscopy alone was used 10 times (37%), and both endoscopy and fluoroscopy on 17 (63%) occasions. After stent insertion, one patient was intervened for treatment, and a patient with an unsuccessful prosthesis received a palliative surgical bypass. Four stents became obstructed by tumoral ingrowth, and patency was reestablished by inserting a new stent. Obstructive jaundice caused by stents covering the papilla of Vater occurred in three cases. There were no other complications or mortality due to the procedure. Mean survival was 104 days (range 28-400, SD +/- 94). CONCLUSIONS: in our experience endoscopic insertion of self-expanding metal stents appears to be a safe and efficient palliative method for malignant gastric outlet obstruction, and can be performed successfully in a center with our characteristics.

Long-term follow-up of patients with small-bowel angiodysplasia on capsule endoscopy. Determinants of a higher clinical impact and rebleeding rate.

BACKGROUND: the clinical impact of small-bowel angiodysplasia has not been defined. We present a prospective study to determine the features of individuals with a higher risk of rebleeding or a worse clinical outcome. PATIENTS AND METHODS: thirty patients with angiodysplasia found on CE were included and followed for 12 months. Angiodysplasia were classified by their size as small ( 10 mm). We also studied angiodysplasia lesion numbers in each patient. Rebleeding was defined as a hemoglobin drop of more than 2 g/dl in the absence of melena or hematochezia in the case of occult GI bleeding, or with any or both manifestations. RESULTS: a therapeutic procedure was carried out in 13 patients (43.4%). Individuals with large angiodysplasia had higher transfusion requirements, a higher proportion of therapeutic procedure performed after CE, lower hemoglobin concentration, and a lower rebleeding rate. Patients with ten or more angiodysplasia lesions had also higher transfusion requirements and lower hemoglobin levels, but we found no differences in the number of therapeutic procedures or rebleeding rate between both groups. On follow up rebleeding was detected in 5 patients (16.7%), all of them with small angiodysplasias. Rebleeding was more frequent in patients who did not receive further interventions (23.53 vs. 7.69%; p = 0.037). CONCLUSIONS: angiodysplasia size >or= 10 mm determines a worse clinical impact and more possibilities of receiving a therapeutic procedure. Our findings support that patients with large lesions would benefit from therapeutic interventions with a reduction in rebleeding rate.

Tratamiento paliativo de la obstrucción tumoral del vaciamiento gástrico con prótesis metálicas autoexpandibles insertadas endoscópicamente / No disponible

Antecedentes y objetivo: la inserción de prótesis metálicas autoexpandiblespara paliar la obstrucción tumoral del vaciamiento gástricoes un procedimiento mínimamente invasivo, que cada vez seutiliza con más frecuencia. Presentamos la experiencia de esta técnicaen un hospital de nivel II del Sistema Nacional de Salud.Pacientes y métodos: estudio retrospectivo de un periodo decinco años (2003-2007), en los que se trató de resolver la obstruccióntumoral del vaciamiento gástrico en 27 ocasiones a 23 pacientes(media de 0,45 procedimientos por mes), mediante la inserciónendoscópica de prótesis no recubiertas (Wallstent® y Wallflex®).Resultados: la inserción fue técnicamente posible en el 100%de los 27 intentos. Se obtuvo un buen resultado clínico en 25 ocasiones(92,5%). Se utilizó sólo endoscopia 10 (37%) veces y en lasotras 17 (63%) también fluoroscopia. Tras la inserción de la prótesisse intervino a un paciente con intención curativa y a otro, enel que la prótesis no funcionó, para realizar una derivación paliativa.Cuatro prótesis se obstruyeron por crecimiento tumoral, recanalizándosemediante la inserción de nuevas prótesis. En tres ocasionesse produjo ictericia obstructiva en prótesis que cubrían lapapila de Vater. No hubo otras complicaciones. Tampoco mortalidadderivada del procedimiento. La media de supervivencia fuede 104 días (rango 28-400, DE ± 94).Conclusiones: en nuestra experiencia, la inserción endoscópicade prótesis metálicas autoexpandibles parece un método seguroy eficaz en el tratamiento paliativo de la obstrucción tumoraldel vaciamiento gástrico y puede llevarse a cabo con éxito en uncentro de nuestras características

Aim and background: the insertion of self-expanding metalstents to palliate malignant gastric outlet obstruction is a minimallyinvasive procedure that is being increasingly used. We discussexperience with this technique in a level-II hospital in the SpanishNational Health System.Patients and methods: a retrospective five-year study(2003-2007) was conducted in 23 patients who underwent 27procedures aimed at resolving malignant gastric outlet obstruction(mean, 0.45 procedures per month) using endoscopically insertednoncovered stents (Wallstent® and Wallflex®).Results: insertion was technically feasible in all 27 (100%) attempts,with satisfactory clinical results in 25 cases (92.5%). Endoscopyalone was used 10 times (37%), and both endoscopy andfluoroscopy on 17 (63%) occasions. After stent insertion, one patientwas intervened for treatment, and a patient with an unsuccessfulprosthesis received a palliative surgical bypass. Four stentsbecame obstructed by tumoral ingrowth, and patency was reestablishedby inserting a new stent. Obstructive jaundice caused bystents covering the papilla of Vater occurred in three cases. Therewere no other complications or mortality due to the procedure.Mean survival was 104 days (range 28-400, SD ± 94).Conclusions: In our experience endoscopic insertion of selfexpandingmetal stents appears to be a safe and efficient palliativemethod for malignant gastric outlet obstruction, and can be performedsuccessfully in a center with our characteristics

Long-term follow-up of patients with small bowel angiodysplasia on capsule endoscopy. Determinants of a higher clinical impact and rebleeding rate

Introducción: no se ha definido con exactitud el impacto clínicode las angiodisplasias del intestino delgado. Presentamos un estudioprospectivo para determinar las características de los individuos conmayor riesgo de recidiva hemorrágica o peor evolución clínica.Pacientes y métodos: en este estudio se incluyeron treintapacientes con angiodisplasias, halladas con la cápsula endoscópica,que fueron seguidos durante 12 meses. Las lesiones se clasificaronpor su tamaño en pequeñas (≤ 10 mm) o grandes (> 10mm). Estudiamos también el número de angiodisplasias en cadapaciente. La recidiva hemorrágica se definió como una caída enlas cifras de hemoglobina de 2 g/dl, en ausencia de melenas o hematoqueciapara la hemorragia de origen oscuro o en presenciade cualquiera de estas manifestaciones.Resultados: se realizaron procedimientos terapéuticos en 13pacientes (43,4%). Los pacientes con angiodisplasias grandes tuvieronmayores requerimientos transfusionales, un mayor númerode procedimientos diagnósticos realizados tras la cápsula endoscópica,cifras inferiores de hemoglobina y menor tasa de recidivahemorrágica. Los pacientes con diez o más angiodisplasias recibierontambién más transfusiones y presentaron cifras inferioresde hemoglobina, pero no hubo diferencias en los procedimientosterapéuticos o recidiva hemorrágica entre ambos grupos. En el seguimiento,la recidiva hemorrágica se detectó en 5 pacientes(16,7%), todos con angiodisplasias pequeñas. Esta fue más frecuenteen pacientes que no recibieron tratamiento (23,53 vs.7,69%; p = 0,037).Conclusiones: el tamaño >= 10 mm de las angiodisplasias determinaun mayor impacto clínico y más posibilidades de recibirtratamiento. Nuestros hallazgos indican que pacientes con lesionesde mayor tamaño se beneficiarían de procedimientos terapéuticoscon una reducción de la tasa de recidiva hemorrágica

Background: the clinical impact of small-bowel angiodysplasiahas not been defined. We present a prospective study to determinethe features of individuals with a higher risk of rebleeding ora worse clinical outcome.Patients and methods: thirty patients with angiodysplasiafound on CE were included and followed for 12 months. Angiodysplasiawere classified by their size as small (≤ 10 mm) orlarge (> 10 mm). We also studied angiodysplasia lesion numbersin each patient. Rebleeding was defined as a hemoglobin drop ofmore than 2 g/dl in the absence of melena or hematochezia inthe case of occult GI bleeding, or with any or both manifestations.Results: a therapeutic procedure was carried out in 13 patients(43.4%). Individuals with large angiodysplasia had highertransfusion requirements, a higher proportion of therapeutic procedureperformed after CE, lower hemoglobin concentration, anda lower rebleeding rate. Patients with ten or more angiodysplasialesions had also higher transfusion requirements and lower hemoglobinlevels, but we found no differences in the number of therapeuticprocedures or rebleeding rate between both groups. Onfollow up rebleeding was detected in 5 patients (16.7%), all ofthem with small angiodysplasias. Rebleeding was more frequent inpatients who did not receive further interventions (23.53 vs.7.69%; p = 0.037).Conclusions: angiodysplasia size >= 10 mm determines aworse clinical impact and more possibilities of receiving a therapeuticprocedure. Our findings support that patients with large lesionswould benefit from therapeutic interventions with a reductionin rebleeding rate

Outcomes of bile duct drainage by means of ERCP in geriatric patients / Resultados del drenaje de la vía biliar por CPRE en pacientes con edad geriátrica.

BACKGROUND AND OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) is usually the procedure of choice for relieving bile duct obstruction. a large number of patients undergoing this intervention are geriatric population (aged 75 years of age and older). Our aim was to assess the efficacy of ERCP in this group of patients as compared to younger ones. PATIENTS AND METHODS: A retrospective study. All patients in whom a therapeutic biliary endoscopy had been performed over a four-year period of time (2002-2005) were included. RESULTS: 178 geriatric patients and 159 younger ones underwent ERCP. No differences were found in successful biliary drainage (97.7 vs. 98.7%), complication number (11.8 vs. 14.4%), or mortality rate (1.1 vs. 0.6%). On the other hand, more common bile duct stones were found in geriatric patients (57.3 vs. 39.6%, p = 0.004), and also more self-expanding metal stents were employed to drain malignant obstructive jaundice (47 vs. 8%, p = 0.0035). In the youngest group, more ERCPs were repeated in the same patients (4 vs. 10%, p = 0.001). CONCLUSIONS: The geriatric population showed similar success and morbidity and mortality rates when compared to younger patients in draining their bile duct by means of ERCP. Common bile duct stones were more frequently found in geriatric patients. No patients needing an ERCP should be excluded only because of their age.

Resultados del drenaje de la vía biliar por CPRE en pacientes con edad geriátrica / Outcomes of bile duct drainage by means of ERCP in geriatric patients

Antecedentes y objetivo: la colangiopancreatografía retrógradaendoscópica (CPRE) es habitualmente la técnica de elecciónpara desobstruir la vía biliar. Una gran parte de los pacientes a losque se realiza esta intervención están en edad geriátrica (mayoresde 75 años). Nuestro objetivo ha sido valorar la eficacia de laCPRE en este grupo de pacientes, comparado con los de menoredad.Pacientes y métodos: estudio retrospectivo en el que se hanincluido los pacientes a quienes se realizó terapéutica biliar endoscópicamediante CPRE en un periodo de cuatro años (2002-2005).Resultados: se realizó CPRE a 178 pacientes en edad geriátricay a 159 de menor edad. No hubo diferencias en el éxito deldrenaje biliar (97,7-98,7%), en el número de complicaciones(11,8-14,4%), ni en la mortalidad (1,1-0,6%). Por el contrario, enel grupo geriátrico hubo más coledocolitiasis (57,3-39,6%, p =0,004) y se utilizaron más prótesis metálicas autoexpandiblespara drenar la ictericia obstructiva tumoral (47-8%, p = 0,0035).En el grupo de menor edad se repitieron más CPRE a los mismospacientes (4-10%, p = 0,001).Conclusiones: el éxito y la morbimortalidad para drenar lavía biliar mediante CPRE son similares en los pacientes con edadgeriátrica y en los de edad inferior. La coledocolitiasis es más frecuenteen los pacientes mayores. No se debe excluir a ningún pacienteque precise de una CPRE sólo por la edad

Background and objective: endoscopic retrograde cholangiopancreatography(ERCP) is usually the procedure of choice forrelieving bile duct obstruction. A large number of patients undergoingthis intervention are geriatric population (aged 75 years ofage and older). Our aim was to assess the efficacy of ERCP in thisgroup of patients as compared to younger ones.Patients and methods: a retrospective study. All patients inwhom a therapeutic biliary endoscopy had been performed over afour-year period of time (2002-2005) were included.Results: 178 geriatric patients and 159 younger ones underwentERCP. No differences were found in successful biliarydrainage (97.7 vs. 98.7%), complication number (11.8 vs.14.4%), or mortality rate (1.1 vs. 0.6%). On the other hand,more common bile duct stones were found in geriatric patients(57.3 vs. 39.6%, p = 0.004), and also more self-expanding metalstents were employed to drain malignant obstructive jaundice (47vs. 8%, p = 0.0035). In the youngest group, more ERCPs wererepeated in the same patients (4 vs. 10%, p = 0.001).Conclusions: the geriatric population showed similar successand morbidity & mortality rates when compared to younger patientsin draining their bile duct by means of ERCP. Common bileduct stones were more frequently found in geriatric patients. Nopatients needing an ERCP should be excluded only because oftheir age

El aceite de oliva es un excelente lubricante para el dilatador tipo Witzel / Olive oil is a good lubricating agent for the Witzel dilator

No disponible

La restricción de sal a los cirróticos españoles es demasiado rigurosa / Sodium restriction for Spanish cirrhotics is too severe

No disponible

Hemorragia digestiva de origen incierto / Obscure gastrointestinal bleeding

No disponible

[Treatment of malignant colorectal obstruction by means of endoscopic insertion of self-expandable metallic stents]. / Tratamiento de la obstrucción neoplástica del colon meciante la inserción endoscópica de prótesis metálicas autoexpandibles.

BACKGROUND AND AIM: Self-expandable metallic stents are being used increasingly to treat the obstruction of different segments of the digestive tract and biliary tree. We present our centre experience on the initial resolution of malignant colorectal obstruction by means of this type of stents. PATIENTS AND METHODS: During a 18-month period, 13 patients patients suffering from malignant obstruction at the level of rectum, sigmoid or descending colon tried to be initially treated by means of endoscopic insertion of stents (non covered enteral Wallstents). Ten procedures were performed with both endoscopy and fluroscopy and three with only endoscopy. RESULTS: In 12 of the 13 patients (92,3%) the obstruction was solved by means of correct stent insertion. All the exclusively endoscopic procedures (without fluoroscopy) were successful. Six (50 %) patients with tumours at the rectosigmoid underwent later scheduled surgery. In the remaining six ones (a patient with an ovarian carcinoma and five with colonic adenocarcinoma) the stents were considered to be a palliative definitive treatment. Stent migration was observed in two of these patients and both were extracted endoscopically. Only one patient needed to have another stent inserted. A tumoural colo-vesical fistula developed in another patient in the palliative group, inside the previous inserted stent, and was treated by coaxial insertion of an esophageal Ultraflex. There were no other complications or mortality related to the endoscopic procedures. CONCLUSIONS: Self-expandable metallic stents might be considered, in general, as the initial treatment for the malignant obstruction at the level of rectum, sigmoid and descending colon