Diagnostic yield and therapeutic impact of rectal retroflexion: a prospective, single-blind study conducted in three centers.

BACKGROUND/AIMS: No clear data have been established and validated regarding whether rectal retroflexion has an important and therapeutic impact. The aim of the present study was to evaluate the diagnostic yield and therapeutic impact of rectal retroflexion compared with straight view examination. METHODS: A prospective single-blind study was conducted. Consecutive patients evaluated between October 2011 and April 2012 were included. RESULTS: A total of 934 patients (542 women, 58%) were included. The mean age was 57.4±14.8 years. Retroflexion was successful in 917 patients (98.2%). Distinct lesions in the anorectal area were detected in 32 patients (3.4%), of which 10 (1%) were identified only on retroflex view and 22 (2.4%) on both straight and retroflex views. Of the 32 identified lesions, 16 (50%) were polyps, nine (28.1%) were angiodysplasias, six (18.8%) were ulcers, and one (3.1%) was a flat lesion. All 10 patients (1%) in whom lesions were detected only by rectal retroflexion showed a therapeutic impact. CONCLUSIONS: Rectal retroflexion has minimal diagnostic yield and therapeutic impact. However, its low rate of major complications and the possibility of detecting lesions undetectable by straight viewing justify its use.

Inflammatory myofibroblastic tumour of the liver. Case report.

Inflammatory myofibroblastic tumour (IMT), also called inflammatory pseudotumour, is an uncommon neoplastic benign lesion histopathologically characterized by fibroblast and myofibroblast proliferation, with inflammatory cell infiltration. Systemic inflammatory response can appear although specific pathogens are rarely found. We present a case of a woman in whom liver abscess was initially suspected The absence of microorganisms in the tissue obtained by needle aspiration biopsy and the lack of antibiotic therapy response indicated hepatic resection that lead to diagnosis of IMT of the liver, which has to be differentiated from abscess and abscessed tumours. The aim of this case report is to analyze the clinical presentation, course, diagnostic methods, therapies, and existing evidence of the possible pathogenic mechanisms leading to this neoplasm.

Clinical course and management of acute hepatitis A infection in adults.

BACKGROUND: Hepatitis A is the most common type of viral hepatitis in Mexico. The change of hepatitis A epidemiology in Mexico from high to intermediate endemicity leads to increasing susceptible adults for severe illness. OBJECTIVE: To describe the clinical characteristics and hospital outcome of adult patients with acute hepatitis A infection, and determine risk factor for mortality. MATERIAL AND METHODS: This is a retrospective observational, multicentre study in Mexico City and in Guatemala City. All inhospital patients were followed until discharge or death. Risk factors for death/acute liver failure were identified. RESULTS: Forty seven patients were analyzed, sixty percent were male, the prodrome phase was from 3 to 30 days. The three most common symptoms were fever, malaise and jaundice, with 87%, 74% and 62% respectively. The incidence of patients who were treated with antibiotics before hospital admission was up to 34%. Unnecessary imaging studies and out of guidelines drugs were used. Presence of encephalopathy, leukocytes > 19,000/mL, blood urea nitrogen > 36 mg/dL, creatinine > 2 mg/dL, albumin < 2.5 mg/dL and total bilirubin > 9.6 mg/dL, are predictors of mortality. Serum creatinine > 2 mg/dL has the best sensibility and specificity for predicting fulminant hepatitis/death. CONCLUSION: Acute hepatitis A infection in adults is associated some unnecessary diagnostic and therapeutic approach. Could be associated with fulminant hepatitis, and a creatinine value > 2 mg/dL is the best predictor for fulminant hepatitis and death.

Bacterial meningitis in cirrhotic patients: case series and description of the prognostic role of acute renal failure.

AIM: To analyze the mortality risk factors in cirrhotic patients with bacterial meningitis (BM). BACKGROUND: Cirrhotic patients are susceptible to infections. Despite its high mortality rate, BM has not been extensively studied in this group of patients. STUDY: BM patients diagnosed with cirrhosis, between 1987 and 2008, were studied. BM was defined as the presence of signs or symptoms of meningitis and a cerebrospinal fluid (CSF) leukocyte count >100/mm3 or the presence of bacteria in CSF. RESULTS: We identified 4955 infections among 7591 cirrhotic patients; 12 (0.2%) had BM. The mean age at diagnosis was 60±16 years. Abnormal mental status (83%), fever (67%), and neck stiffness (67%) were the most frequent clinical presentations. The sensitivity of CSF culture was 75% (Streptococcus pneumoniae, 2; Staphylococcus aureus, 2; Listeria monocytogenes, 1; Group B Streptococcus, 1; Streptococcus agalactiae, 1; Streptococcus bovis, 1; and Escherichia coli, 1), and its correlation with blood culture was 78%. Five patients died. On admission, the serum creatinine level was 1.63±0.93 mg/dL. A serum creatinine level ≥1.3 mg/dL was associated with increased mortality (P=0.028). The model for end-stage liver disease score, gastrointestinal bleeding, bilirubin level >3.5 mg/dL, hepatic encephalopathy, diabetes mellitus, and results of cytology and biochemistry tests of CSF were not associated with mortality. CONCLUSIONS: BM in cirrhotic patients is associated with a high mortality rate. The clinical and microbiologic features of BM in cirrhotic patients differ from those in the general population. A serum creatinine level ≥1.3 mg/dL on admission is associated with a higher risk of mortality.

Endoscopic treatment with argon plasma coagulation in postradiation proctopathy.

INTRODUCTION: Postradiation proctopathy (PP) is a major complication in patients who receive radiotherapy for cancer. Medical treatments of this entity are unsatisfactory. Argon plasma coagulation (APC) had been shown to be successful with low complications. The aim was to describe our experience with APC in the management of PP. METHODS: We conducted a retrospective analysis of electronic- and paper-based records of patients with PP managed with APC. RESULTS: Nineteen patients with PP were included, nine were women. Median age was 64 years, and follow-up was 29 months. The most frequent cause of radiotherapy for cancer was cervicouterine and prostate ENDOSCOPIC FINDINGS: Moderate disease was observed in nine patients; mild and severe diseases were observed in five patients each. At endoscopy, telangiectasias were present in 15, ulcers in five, and active bleeding in two patients. Median of APC sessions was two (one to seven). Mean dose of APC was 30 W (30-40 W) and 1.7 l (1.5-2.0 l). Median time for relief of symptoms was 3 months. All patients were asymptomatic at the end of treatment, and bleeding was controlled at the end of treatment in all patients. Recurrence of bleeding presented in one patient at 4 months. No complications were related to the APC treatment. CONCLUSIONS: According to our data, APC is successful in treatment of PP, with few sessions and low morbidity and null mortality.

Growth factors as treatment for inflammatory bowel disease: a concise review of the evidence toward their potential clinical utility.

In the process of inflammation and repair of the intestinal mucosa in inflammatory bowel disease (IBD), there occurs a complex and an unknown interplay of innate and adaptive immune mechanisms. This interaction of factors may explain why IBD is characterized by a relapsing and remitting clinical course. Different components of innate immunity, hormones and interleukins in IBD have been suggested to be impaired. The growth hormone, epidermal growth factor, keratinocyte growth factor and colony-stimulating factors have emerged as potential tools for the modulation of intestinal inflammation and repair. Despite promising results of initial studies, the evidence that justify treatment of patients in clinical practice is not enough as some of the trials are nonrandomized or included a small number of patients. In this concise review, we provide a summary of the most recent and relevant evidence regarding the potential therapeutic effects of growth factors in IBD.

Marcadores serológicos en enfermedadinflamatoria intestinal: diferenciaspoblacionales y limitaciones de suaplicación / Serological markers in inflammatory bowel

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Factors that influence outcome in non-invasive and invasive treatment in polycystic liver disease patients.

AIM: To evaluate the factors that influence outcome of both non-invasive and invasive treatment of polycystic liver disease. METHODS: Analysis of clinical files of patients with complete follow-up from July 1986 to June 2006. RESULTS: Forty-one patients (male, 7; female, 34), 47.8 +/- 11.9 years age, and 5.7 +/- 6.7 years follow-up, were studied. Alkaline phosphatase (AP) elevation (15% of patients) was associated with the requirement of invasive treatment (IT, P = 0.005). IT rate was higher in symptomatic than non-symptomatic patients (65.4% vs 14.3%, P = 0.002), and in women taking hormonal replacement therapy (HRT) (P = 0.001). Cysts complications (CC) were more frequent (22%) in the symptomatic patients group (P = 0.023). Patients with body mass index (BMI) > 25 (59%) had a trend to complications after IT (P = 0.075). Abdominal pain was the most common symptom (56%) and indication for IT (78%). Nineteen patients (46%) required a first IT: 12 open fenestration (OF), 4 laparoscopic fenestration (LF) and 3 fenestration with hepatic resection (FHR). Three required a second IT, and one required a third procedure. Complications due to first IT were found in 32% (OF 16.7%, LF 25%, FHR 66.7%), and in the second IT in 66.7% (OF 100%). Follow-up mortality rate was 0. CONCLUSION: Presence of symptoms, elevated AP, and CC are associated with IT requirement. HRT is associated with presence of symptoms and IT requirement. Patients with BMI > 25 have a trend be susceptible to IT complications. The proportions of complications are higher in FHR and second IT groups. RS is more frequent after OF.

New treatment options in the management of IBD - focus on colony stimulating factors.

Inflammatory bowel disease (IBD) is characterized by inflammation of the gastrointestinal tract, typically with a relapsing and remitting clinical course. The intestinal inflammation in IBD is controlled by a complex interplay of innate and adaptive immune mechanisms. Innate immunity comprises a set of distinct elements, which includes circulating cells such as neutrophils, monocytes, and resident intestinal immune cells (dendritic and Paneth cells), as well as intestinal epithelium and cellular products, including antimicrobial peptides such as defensins and cathelicidins. Different components of innate immunity in IBD have been suggested to be defective or impaired. The human granulocyte-macrophage colony-stimulating factor (GM-CSF) and the human granulocyte colony-stimulating factor (G-CSF) have emerged as potential tools for the modulation of intestinal inflammation and repair. The greatest evidence supporting the use of colony-stimulating factors in intestinal inflammation comes from studies conducted in active Crohn's disease (CD) patients treated with sargramostim and filgrastim, but evidence for its recommendation as treatment remains weak, as the majority of studies are open label, nonrandomized, and with a small number of patients.

Basic and clinical aspects of osteoporosis in inflammatory bowel disease.

Low bone mineral density and the increased risk of fracture in gastrointestinal diseases have a multifactorial pathogenesis. Inflammatory bowel disease (IBD) has been associated with an increased risk of osteoporosis and osteopenia and epidemiologic studies have reported an increased prevalence of low bone mass in patients with IBD. Certainly, genetics play an important role, along with other factors such as systemic inflammation, malnutrition, hypogonadism, glucocorticoid therapy in IBD and other lifestyle factors. At a molecular level the proinflammatory cytokines that contribute to the intestinal immune response in IBD are known to enhance bone resorption. There are genes influencing osteoblast function and it is likely that LRP5 may be involved in the skeletal development. Also the identification of vitamin D receptors (VDRs) and some of its polymorphisms have led to consider the possible relationships between them and some autoimmune diseases and may be involved in the pathogenesis through the exertion of its immunomodulatory effects during inflammation. Trying to explain the physiopathology we have found that there is increasing evidence for the integration between systemic inflammation and bone loss likely mediated via receptor for activated nuclear factor kappa-B (RANK), RANK-ligand, and osteoprotegerin, proteins that can affect both osteoclastogenesis and T-cell activation. Although glucocorticoids can reduce mucosal and systemic inflammation, they have intrinsic qualities that negatively impact on bone mass. It is still controversial if all IBD patients should be screened, especially in patients with preexisting risk factors for bone disease. Available methods to measure BMD include single energy x-ray absorptiometry, DXA, quantitative computed tomography (QCT), radiographic absorptiometry, and ultrasound. DXA is the establish method to determine BMD, and routinely is measured in the hip and the lumbar spine. There are several treatments options that have proven their effectiveness, while new emergent therapies such as calcitonin and teriparatide among others remain to be assessed.

Wallenberg's Syndrome: An Unusual Case of Dysphagia.

A 56-year-old man presented with sudden-onset oropharyngeal dysphagia and vomiting of central etiology. Neurological evaluation showed uvula deviation to the left, paresis of the mid-right portion of the soft palate, lateralization of gaze to the right side, and dysphonia. Magnetic resonance imaging (MRI) showed an infarction in the left lateral medullary region, therefore the diagnosis of Wallenberg's syndrome was established. The neurological issues along with the dysphagia gradually improved and the patient was discharged.