El futuro de la radiología digestiva / No disponible

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[Idiopathic thrombocytopenic purpura as an extraintestinal manifestation of Crohn's disease]. / Púrpura trombocitopénica idiopática como manifestación extraintestinal de la enfermedad de Crohn.

Idiopathic thrombocytopenic purpura is an infrequent extraintestinal manifestation of inflammatory bowel disease. It is particularly rare in association with Crohn's disease. In these cases it presents certain peculiarities with respect to its normal clinical features, occurring more frequently when Crohn's disease is mainly colonic and usually appearing after the diagnosis of Crohn's disease has been made. Moreover, it usually complicates the clinical course of both diseases. We present a case of idiopathic thrombocytopenic purpura in a 14-year-old girl in whom the two diseases first presented simultaneously. The clinical course was poor and both diseases were refractory to habitual treatment.

Anisakiasis gastro-alérgica: hipersensibilidad inmediata debida a parasitación por anisakis simplex / Gastroallergic anisakiasis: immediate hypersensitivity due to Anisakis simplex infestation

En España, hasta 1995 los casos de anisakiasis eran anecdóticos. Sin embargo, en 1995, los alergologos españoles, de la mano del grupo del Dr. Fernández de Corres, llegan al Anisakis simplex (AS) por casos de reacciones alérgicas tras consumo de pescado "presumiblemente" bien cocinado y con pruebas cutáneas e IgE específica a AS positivas. La base de la alergia al AS parecía estar en la termoestabilidad de antígenos del AS. Tras observar algunos casos de anafilaxia con parasitación por AS, se inició un estudio prospectivo en 1997 en el Hospital Universitario "La Paz" de Madrid. Se introdujeron pacientes que acudían a urgencias con síntomas alérgicos o gastrointestinales tras ingestión de productos de mar, aceptando pacientes que hubieran tomado el alimento hasta 48 horas antes. Si el cuadro digestivo persistía se realizaba endoscopia. En 18 meses se evaluaron 120 pacientes que consultaron por síntomas alérgicos y de los cuales en 96 se implicó verdaderamente al AS. En esos 18 meses, y sobre la base de los síntomas de alergia, se detectaron 24 pacientes a los que se extrajo uno o más parásitos de su estómago (más parásitos hallados en sólo 18 meses que desde 1991 en España). El boquerón en vinagre y en algunos casos la merluza fresca, presumiblemente bien cocinada, fueron la fuente de la mayoría de las parasitaciones. Los autores denominaron a esta entidad anisakiasis gastro-alérgica diferenciándola de la anisakiasis gástrica, dado que los síntomas de hipersensibilidad tras el contacto con el parásito eran más intensos y severos que los gástricos. Parecía que en su mayoría era el parásito vivo la fuente antigénica y más aún, que necesitaba fijarse a la submucosa para producir la reacción de hipersensibilidad. El paso siguiente en estos pacientes con anisakiasis gastro-alérgica fue la provocación con parásitos congelados no infectivos. Se confirmó su tolerancia en varios pacientes y a partir de entonces al resto se les permitió comer pescado congelado sin suceder ningún problema. En ese punto, la alergia a proteínas termoestables del AS parecía menos frecuente de lo presupuesto y se intuía que la repuesta IgE mediada en la mayoría de los pacientes sensibilizados correspondía a contactos (parasitaciones en forma luminal o asintomáticas) con el parásito vivo. El antecedente dietético, la clínica, la respuesta a los test cutáneos y la medición seriada de IgE específica a AS son importantes claves para el diagnóstico. Puede que existan casos de verdadera alergia a AS, pero en vistas de este estudio prospectivo deben ser infrecuentes (AU)

Gastroallergic anisakiasis: borderline between food allergy and parasitic disease-clinical and allergologic evaluation of 20 patients with confirmed acute parasitism by Anisakis simplex.

BACKGROUND: Human subjects can be parasitized by Anisakis simplex by eating raw or undercooked fish. Gastric anisakiasis is probably the most frequent clinical entity presenting with severe epigastric pain, vomiting, and diarrhea. In gastroallergic anisakiasis hypersensitivity symptoms predominate. OBJECTIVE: We sought to describe clinical features, laboratory data, and gastroscopic findings in gastroallergic anisakiasis. METHODS: We selected 40 patients presenting to the emergency department with an acute allergic reaction, and if we suspected acute parasitism by A simplex, a fiberoptic gastroscopy was performed. In 20 patients we could detect one or more nematodes; these patients are referred to as group A. Those in whom no worm could be found are referred to as group B (n = 20). A detailed history, clinical features, gastroscopic findings, laboratory data, and skin prick test responses were compared. RESULTS: Long-time intervals of up to 26 hours between fish intake and onset of hypersensitivity symptoms were found (group A, 5.4 +/- 6.3 hours; group B, 5.3 +/- 2.6 hours). Patients in groups A and B did not differ with respect to allergic symptoms (urticaria, angioedema, erythema, bronchospasm, and anaphylaxis) or the mainly light abdominal symptoms (upper abdominal pain, nausea, vomiting, and diarrhea). No significant differences were found with respect to age, time interval between fish intake and onset of symptoms, white cell and eosinophil counts, specific IgE levels against A simplex, or total IgE levels. CONCLUSIONS: The peculiar sometimes long-time interval between fish intake and onset of allergic symptoms render the diagnosis difficult. An early gastroscopy can confirm the diagnosis and prevent complications. We suggest that gastroallergic anisakiasis be considered a distinct clinical entity in which the predominant symptoms are hypersensitivity symptoms and in which the correct diagnosis is not only important in the management of the acute reaction but also in the prevention of further allergic episodes.

Usefulness of early serial measurement of specific and total immunoglobulin E in the diagnosis of gastro-allergic anisakiasis.

BACKGROUND: Sensitization to Anisakis simplex (A. simplex) has been documented to produce severe allergic reactions following ingestion of mainly raw or under-cooked parasitized fish. False positive skin prick tests (SPT) or specific IgE against this nematode and cross-reactivity restricts diagnosis. Gastric anisakiasis and gastro-allergic anisakiasis occur if fish is parasitized by live A. simplex OBJECTIVE: To investigate if serial serological analysis could be useful in the diagnosis of acute parasitation by this nematode. METHODS: We included 41 patients who experienced an allergic reaction and/or abdominal symptoms after ingestion of raw or undercooked fish and displayed specific IgE against A. simplex. Total and specific IgE were determined two times: in the 24-h period after onset of clinical symptoms and after 1 month. SPTs were performed against A. simplex and implicated fish. A fibre optic gastroscopy was performed in 22 patients. RESULTS: Median total IgE was 80.0 (Interquartile range [IQR] 41.5-186.5) kU/L in the first evaluation and 247.0 (IQR 96.5-649.5) kU/L after 1 month. Median specific IgE against A. simplex was 11.4 (IQR 7.1-33.5) kU/L in the first 24 h and 36.8 (IQR 19.5-79.5) kU/L after 1 month. A rise of total IgE was observed in 35 of 41 patients (P<0.00001) and a rise in specific IgE against A. simplex in 37 of 41 patients (P<0.00001). Mean percentage increment was 392% (215-571%; 95% confidence interval [CI]) for total IgE and 339% (177-502%; 95% CI) for specific IgE. In nine of 22 gastroscopic examinations at least one larva, identified as A. simplex, could be detected by our microbiology service. In this group (n = 9) a rise of total and specific IgE was detected in eight patients (89%) (P = 0.02). CONCLUSIONS: We consider a rise of total and specific IgE in the first month after an allergic reaction as a useful tool in the diagnosis of gastro-allergic anisakiasis (together with patient's history), even if the parasite cannot be seen with fibre optic gastroscopy. The important rise of total and specific IgE against A. simplex can be considered as a reaction induced by the live parasitizing larva in the context of a polyclonal immunological stimulation.

[The usefulness of hydrogastric ultrasonography in the detection of neoplastic lesions of the gastric wall]. / Utilidad de la ecografía hidrogástrica en la detección de lesiones neoformativas de la pared gástrica.

Forty patients endoscopically diagnosed of different gastric neoplastic lesions were explored by hydrogastric ultrasonography to evaluate the usefulness of this method in the detection of such lesions and to analyze the characteristics of the ultrasonographic images and their correlation with the anatomopathologic findings. The sensitivity of the detection of the lesions was 87.5% being close to 100% in those located in the antrum, showing the body and fundus more difficulties due to gas and the costal ribcage. A clear correlation was observed between the ultrasonographic images and the anatomographic findings. It was concluded that this may be a complementary technique to gastroscopy in the diagnosis of sumucosal lesions and extrinsic compressions of the gastric wall. The infiltration of the wall may be delimited in neoplastic lesions and thus may contribute to correct T stratification of the tumor, although this should be confirmed in further studies.

Gastric anisakiasis: an underestimated cause of acute urticaria and angio-oedema?

Acute urticaria and angio-oedema are common in primary care and in the emergency unit. Food allergy is one possible cause. We describe gastric anisakiasis, in which symptoms are often not obviously related to eating raw fish. A study was made of patients presenting at the emergency department who had allergic symptoms such as urticaria or angio-oedema and had recently eaten raw or undercooked fish. They were divided into two groups. Patients in group A (n = 13) also had abdominal symptoms and were diagnosed as having gastric anisakiasis by fibre-optic gastroscopy where third-stage larvae of Anisakis simplex were visualized and extracted. Skin prick tests and specific IgE to A. simplex were positive. Patients in group B (n = 13) had only allergic symptoms after eating raw fish. Eleven of 13 patients had positive skin prick tests and specific IgE to A. simplex. Three of 15 control subjects had positive skin prick tests and specific IgE to A. simplex. Allergic symptoms appeared from 2 to 20 h (mean 5.0) after ingestion in group A and from 20 min to 23 h (mean 4.3 h) in group B. Gastric symptoms in group A disappeared rapidly after extraction of the larvae. Allergic symptoms disappeared in most cases within the first 24 h. We suggest that the allergic symptoms in group A as well as in group B were mainly due to parasitization by A. simplex in sensitized patients. Gastric anisakiasis may be a widely underdiagnosed clinical entity.

[Upper digestive hemorrhage in the operated stomach (Billroth I and II): clinical course and prognosis]. / Hemorragia digestiva alta en el estómago operado (Billroth I y II): curso y pronóstico.

AIM: To determine course and prognosis of upper gastrointestinal bleeding in gastrectomized patients. MATERIALS AND METHODS: We have conducted a retrospective study on 34 patients (one female, mean age 38.2 +/- 12.14 years) admitted with upper gastrointestinal bleeding between November 1989 and August 1991. All patients had been previously gastrectomized because of benign gastric pathology. Eight had a Billroth I type gastrectomy, and 26 a Billroth II. RESULTS: The causes of gastrointestinal bleeding were recurrent ulcer in 20 patients and alkaline reflux gastritis in 13 patients, both located at the surgical anastomosis; in one case it was not possible to determine the lesion responsible of the bleeding. Initial symptoms were maelena in 16 patients (47%), hematemesis in 12 patients (35.2%) and hematemesis and maelena in 6 (17.6%). Only one patient developed hemodynamic changes (systolic arterial tension < 10 mm Hg and pulse > 100 pm). After admission 3 patients rebled (8.8%) and the mortality reached 8.8%. Although rebleeding and mortality rates were higher than the rates for peptic ulcer in non gastrectomized patients, mortality and rebleeding occurred in patients with severe diseases (chronic hepatopathy), whose evolution conditioned in 2 of 3 patients the course of the upper gastrointestinal bleeding. CONCLUSIONS: The evolution of bleeding was not influenced by the causal lesion or the gastric resective procedure. We conclude that the course and prognosis of upper gastrointestinal bleeding in gastrectomized patients is not severe; hemostatic surgical procedures are indicated in only a minority of patients.

[Extraintestinal manifestations of chronic inflammatory intestinal disease]. / Manifestaciones extraintestinales de la enfermedad inflamatoria crónica intestinal.

Intestinal Inflammatory Chronic Disease includes a series of pathological entities of unknown etiology, basically characterized by inflammatory lesions in the digestive tube. Importance of this disease, which frequency has grown in the last few years, lies in the fact that not only affects the intestine but also other organs, originating systemic manifestations which, occasionally, modify the evolution and therapy of these patients. Because of this fact, we try, in this work, to provide a general overview of the extra-intestinal pathology associated with Crohn's disease and ulcerative colitis.