Los servicios de digestivo en el Sistema Nacional de Salud del siglo XXI. Estándares de organización y funcionamiento para un servicio centrado en el paciente / No disponible

La Sociedad Española de Patología Digestiva ha elaborado un documento de consenso sobre los estándares y recomendaciones que considera fundamentales en la organización de las unidades de digestivo para desarrollar sus actividades con eficiencia y calidad. Se han definido cuatro grupos de procesos clave: la atención al paciente adulto agudamente enfermo, la endoscopia digestiva ambulatoria, la consulta e interconsulta en patología digestiva y la asistencia integral del paciente con patología digestiva crónica compleja. Como procesos de soporte se han identificado la estructura y el funcionamiento de las unidades de digestivo y, como procesos estratégicos, la formación e investigación. Se han elaborado, asimismo, los estándares para algunas unidades funcionales y monográficas de digestivo: Unidad de Endoscopia Digestiva, Unidad de Hepatología y Unidad Multidisciplinar de Enfermedad Inflamatoria Intestinal, así como para determinados procedimientos: colangiopancreatografía retrógrada endoscópica, colonoscopia y gastroscopia. Los estándares serán ampliados a otras unidades y procedimientos en la medida en que se vayan desarrollando. Los estándares elaborados deben ser revisados en el plazo máximo de cinco años

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Digestive units in the National Health System of the 21st century. Organizational and management standards for a patient-centered service.

The Spanish Society of Digestive Pathology has set a consensus document on the standards and recommendations for gastroenterology units (GU). These standards are considered as relevant in the organization and management of the unit to develop their activities with efficiency and quality. Four key groups of processes have been identified: a) care for the acutely ill adult patient; b) outpatient digestive endoscopy; c) in-hospital support to other services and outpatient clinics; and d) management of patients with chronic complex digestive pathology. Standards for organization and management of the unit were classified within the group of support processes, and training and research as strategic processes. Standards have also been developed for some functional and monographic units such as endoscopy, hepatology and inflammatory bowel disease; as well as for certain procedures including endoscopic retrograde cholangiopancreatography, colonoscopy and gastroscopy. The standards will be set for other units and procedures as they are developed. The standards developed must be reviewed within a maximum period of five years.

Development and validation of a scoring index to predict the presence of lesions in capsule endoscopy in patients with suspected Crohn's disease of the small bowel: a Spanish multicenter study.

BACKGROUND: Capsule endoscopy (CE) is the first-line investigation in cases of suspected Crohn's disease (CD) of the small bowel, but the factors associated with a higher diagnostic yield remain unclear. OBJECTIVE: Our aim is to develop and validate a scoring index to assess the risk of the patients in this setting on the basis of biomarkers. PATIENTS AND METHODS: Data on fecal calprotectin, C-reactive protein, and other biomarkers from a population of 124 patients with suspected CD of the small bowel studied by CE and included in a PhD study were used to build a scoring index. This was first used on this population (internal validation process) and after that on a different set of patients from a multicenter study (external validation process). RESULTS: An index was designed in which every biomarker is assigned a score. Three risk groups have been established (low, intermediate, and high). In the internal validation analysis (124 individuals), patients had a 10, 46.5, and 81% probability of showing inflammatory lesions in CE in the low-risk, intermediate-risk, and high-risk groups, respectively. In the external validation analysis, including 410 patients from 12 Spanish hospitals, this probability was 15.8, 49.7, and 80.6% for the low-risk, intermediate-risk, and high-risk groups, respectively. CONCLUSION: Results from the internal validation process show that the scoring index is coherent, and results from the external validation process confirm its reliability. This index can be a useful tool for selecting patients before CE studies in cases of suspected CD of the small bowel.

Aspectos diagnósticos y terapéuticos de la afectación del intestino delgado en la hipertensión portal / Diagnostic and therapeutic features of small bowel involvement in portal hypertension

La enteropatía es la menos conocida de entre las complicaciones de la hipertensión portal y consiste en una serie de cambios en la mucosa del intestino delgado que dan lugar a la aparición de lesiones vasculares e inflamatorias sobre la misma. Aunque puede ser un cofactor importante en la anemia de la población cirrótica, y a pesar de que en la actualidad es posible realizar un diagnóstico de la misma de modo simple y no invasivo gracias a los estudios de cápsula endoscópica, es rara vez tenida en consideración en el manejo de los pacientes con hipertensión portal. Aspectos como su patogenia o su incidencia real siguen sin ser aclarados, y tampoco existen consenso ni recomendaciones en las guías de práctica clínica sobre su diagnóstico o tratamiento. Se ha realizado una revisión narrativa de la literatura disponible sobre los aspectos más importantes de esta entidad (AU)

Enteropathy is a lesser known complication of portal hypertension and consists of different changes in the mucosal layer of the small bowel which lead to the appearance of vascular and inflammatory lesions. It can be an important co-factor in the development of anemia in the cirrhotic population, and nowadays an easy and non-invasive diagnosis can be made thanks to capsule endoscopy. However, it is rarely considered in the management of patients with portal hypertension. Some aspects such as pathogenesis or incidence remain unclear and no specific recommendations are included in the guidelines regarding diagnosis or treatment. A review of the available literature was performed with regards to the most relevant aspects of this entit (AU)

Diagnostic and therapeutic features of small bowel involvement in portal hypertension.

Enteropathy is a lesser known complication of portal hypertension and consists of different changes in the mucosal layer of the small bowel which lead to the appearance of vascular and inflammatory lesions. It can be an important co-factor in the development of anemia in the cirrhotic population, and nowadays an easy and non-invasive diagnosis can be made thanks to capsule endoscopy. However, it is rarely considered in the management of patients with portal hypertension. Some aspects such as pathogenesis or incidence remain unclear and no specific recommendations are included in the guidelines regarding diagnosis or treatment. A review of the available literature was performed with regards to the most relevant aspects of this entity.

Enteropatía pierde-proteínas en un paciente en diálisis peritoneal / Protein-losing enteropathy in a patient on peritoneal dialysis

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Riesgo de sangrado en la colangiopancreatografía retrógrada endoscópica: impacto del uso de fármacos antitrombóticos / Bleeding risk in endoscopic retrograde cholangiopancreatography. Impact of the use of antithrombotic drugs

Objetivos: analizar los factores de riesgo de hemorragia en la colangiopancreatografía retrógrada endoscópica así como el impacto sobre la misma del uso de los fármacos antitrombóticos. Material y métodos: fuentes de datos: valoración de los artículos indexados en PubMed así como de los detectados en el análisis de la bibliografía de metaanálisis y revisiones. Criterios de elegibilidad del estudio, participantes e intervenciones: se valoraron los artículos por los abstracts y, al detectar los más significativos (principalmente ensayos clínicos aleatorizados y series de casos bien diseñadas), se analizaron los estudios completos. Métodos de evaluación del estudio y síntesis: para el análisis de la bibliografía y la elaboración de los diferentes niveles de evidencia se han utilizado los criterios establecidos por el Centro de Medicina Basada en Evidencia de Oxford. Resultados: se han encontrado 765 referencias, de las cuales 753 fueron obtenidas de la búsqueda en PubMed y Cochrane Library. Doce trabajos fueron seleccionados a partir del análisis de otros estudios publicados (revisiones sistemáticas, metaanálisis y guías clínicas). Después de analizar el título o el resumen de los estudios, fueron eliminados 655 trabajos. Definitivamente, se han incluido en el análisis final 83 ensayos clínicos o estudios descriptivos de calidad. Conclusiones: se han definido siete conclusiones con referencia a los factores de riesgo de sangrado y al impacto de los fármacos antitrombóticos (AU)

Aims: To analyze the risk factors for hemorrhage during endoscopic retrograde cholangiopancreatography and the impact of antithrombotic drugs. Material and methods: Data sources: papers indexed in PubMed have been reviewed, as well as those found during the analysis of the bibliography of meta-analysis and reviews. Selection criteria: the references have been firstly evaluated by review of the abstract. After selecting the most significant articles (mainly randomized trials and well-designed case series) these have been deeply analyzed. Evaluation of the studies and synthesis: criteria by the Oxford Centre for Evidence-Based Medicine have been used for the analysis of the references and elaboration of evidence levels. Results: Seven hundred and sixty-five references were found, 753 in PubMed and the Cochrane Library. Twelve studies were selected during the analysis of other published articles (systematic reviews, meta-analysis and clinical practice guidelines). After analyzing the title or the abstract, 655 studies were excluded. Finally, 83 high quality trials or descriptive studies have been included in the analysis. Conclusion: Seven conclusions regarding the risk factors for bleeding and the impact of antithrombotic drugs have been defined (AU)

Análisis histórico de la experiencia en cápsula endoscópica de intestino delgado en un hospital terciario español / Historical analysis of experience with small bowel capsule endoscopy in a spanish tertiary hospital

INTRODUCCIÓN: el uso de la enteroscopia con videocápsula fue aprobado por la FDA en 2001. La hemorragia digestiva y la enfermedad inflamatoria intestinal son sus principales indicaciones. En nuestro centro se realiza desde 2004. MATERIAL Y MÉTODOS: Hemos recogido de forma retrospectiva los pacientes tratados mediante cápsula de intestino delgado desde octubre de 2004 hasta abril de 2015. Las indicaciones se han dividido en grupos: hemorragia digestiva de origen oscuro, tanto oculta como manifiesta; enfermedad inflamatoria intestinal; otras indicaciones. Los hallazgos se han dividido: lesiones vasculares; lesiones inflamatorias; otras lesiones; estudios normales; estudios no concluyentes. RESULTADOS: De un total de 1.291 estudios se ha incluido 1.027 en el análisis. La edad media es 56,45 años, con 471 hombres y 556 mujeres. La enfermedad más frecuentemente observada fueron las lesiones vasculares, asociadas o no a otras lesiones. Cuando la indicación era una hemorragia digestiva, el impacto diagnóstico fue del 80%. En la enfermedad inflamatoria esta cifra solo alcanza el 50%. El rendimiento diagnóstico es mucho menor en el grupo de «otras indicaciones». No se han registrado complicaciones mayores. DISCUSIÓN: La cápsula de intestino delgado tiene un alto rendimiento diagnóstico en los casos de hemorragia digestiva; el número de estudios con hallazgos positivos es menor en los de enfermedad inflamatoria intestinal. CONCLUSIONES: Se trata de una modalidad diagnóstica segura y de gran utilidad para el diagnóstico de enfermedad del intestino delgado, aunque se precisa mejorar el índice de sospecha en la enfermedad inflamatoria intestinal

INTRODUCTION: Capsule endoscopy was approved by the FDA in 2001. Gastrointestinal bleeding and inflammatory bowel disease are the main indications. It has been available in our hospital since 2004. METHODS: We retrospectively analysed data from patients who underwent small bowel capsule endoscopy in our hospital from October 2004 to April 2015. Indications were divided into: Obscure gastrointestinal bleeding (occult and overt), inflammatory bowel disease, and other indications. Findings were divided into: Vascular lesions, inflammatory lesions, other lesions, normal studies, and inconclusive studies. RESULTS: A total of 1027 out of 1291 small bowel studies were included. Mean patient age was 56.45 years; 471 were men and 556 women. The most common lesion observed was angiectasia, as an isolated finding or associated with other lesions. Findings were significant in up to 80% of studies when the indication was gastrointestinal bleeding, but in only 50% of studies in inflammatory bowel disease. Diagnostic yield was low in the group «other indications». No major complications were reported. DISCUSSION: Small bowel capsule endoscopy has high diagnostic yield in patients with gastrointestinal bleeding, but yield is lower in patients with inflammatory bowel disease. CONCLUSIONS: Our experience shows that capsule endoscopy is a safe and useful tool for the diagnosis of small bowel disease. The diagnostic yield of the technique in inflammatory bowel disease must be improved

Bleeding risk in endoscopic retrograde cholangiopancreatography. Impact of the use of antithrombotic drugs.

AIMS: To analyze the risk factors for hemorrhage during endoscopic retrograde cholangiopancreatography and the impact of antithrombotic drugs. MATERIAL AND METHODS: Data sources: papers indexed in PubMed have been reviewed, as well as those found during the analysis of the bibliography of meta-analysis and reviews. SELECTION CRITERIA: the references have been firstly evaluated by review of the abstract. After selecting the most significant articles (mainly randomized trials and well-designed case series) these have been deeply analyzed. Evaluation of the studies and synthesis: criteria by the Oxford Centre for Evidence-Based Medicine have been used for the analysis of the references and elaboration of evidence levels. RESULTS: Seven hundred and sixty-five references were found, 753 in PubMed and the Cochrane Library. Twelve studies were selected during the analysis of other published articles (systematic reviews, meta-analysis and clinical practice guidelines). After analyzing the title or the abstract, 655 studies were excluded. Finally, 83 high quality trials or descriptive studies have been included in the analysis. CONCLUSION: Seven conclusions regarding the risk factors for bleeding and the impact of antithrombotic drugs have been defined.

Historical analysis of experience with small bowel capsule endoscopy in a spanish tertiary hospital. / Análisis histórico de la experiencia en cápsula endoscópica de intestino delgado en un hospital terciario español.

INTRODUCTION: Capsule endoscopy was approved by the FDA in 2001. Gastrointestinal bleeding and inflammatory bowel disease are the main indications. It has been available in our hospital since 2004. METHODS: We retrospectively analysed data from patients who underwent small bowel capsule endoscopy in our hospital from October 2004 to April 2015. Indications were divided into: Obscure gastrointestinal bleeding (occult and overt), inflammatory bowel disease, and other indications. Findings were divided into: Vascular lesions, inflammatory lesions, other lesions, normal studies, and inconclusive studies. RESULTS: A total of 1027 out of 1291 small bowel studies were included. Mean patient age was 56.45 years; 471 were men and 556 women. The most common lesion observed was angiectasia, as an isolated finding or associated with other lesions. Findings were significant in up to 80% of studies when the indication was gastrointestinal bleeding, but in only 50% of studies in inflammatory bowel disease. Diagnostic yield was low in the group «other indications¼. No major complications were reported. DISCUSSION: Small bowel capsule endoscopy has high diagnostic yield in patients with gastrointestinal bleeding, but yield is lower in patients with inflammatory bowel disease. CONCLUSIONS: Our experience shows that capsule endoscopy is a safe and useful tool for the diagnosis of small bowel disease. The diagnostic yield of the technique in inflammatory bowel disease must be improved.

Hemorragia digestiva alta como forma de presentación de hematoma retroperitoneal espontáneo gigante secundario a anticoagulación en una mujer con reordenación del gen JAK2 / Spontaneous retroperitoneal hematoma in a patient under anticoagulant agents presenting as upper gastrointestinal bleeding

Presentamos el caso de una mujer de 44 años de edad con antecedentes de abortos de repetición y síndrome de Budd-Chiari secundario a una mielofibrosis primaria en tratamiento anticoagulante. Consulta por melenas y astenia, presentando anemización progresiva. En una gastroscopia inicial se aprecia una compresión extrínseca a nivel supraampular de segunda porción duodenal, con una úlcera asociada en cara posterior de bulbo y primera rodilla. Posteriormente se diagnostica mediante una tomografía computarizada de un hematoma retroperitoneal espontáneo secundario a anticoagulación. Se trata con drenaje percutáneo y retirada de anticoagulación con buena respuesta inicial. No obstante, presenta complicaciones trombóticas (trombosis subclavia y yugular) y se reintroducen los anticoagulantes con dosis en el límite bajo del rango terapéutico (AU)

We present the case of a 44-year-old woman with past history of repeated miscarriage and Budd-Chiari syndrome secondary to primary myelofibrosis. Because of this she was under treatment with oral anticoagulant agents. The patient was admitted in hospital as she presented with gastrointestinal bleeding (melena), asthenia and progressive anemia. In an initial upper endoscopy an extrinsic duodenal compression associated with an ulcer on the posterior face of the first portion of duodenum and upper duodenal knee was observed. In the following days a huge spontaneous retroperitoneal hematoma due to anticoagulation was diagnosed by computed tomography. This was treated with a percutaneous drainage and withdrawal of the antithrombotic drugs. The evolution of the patient was initially satisfactory but she suffered subclavian and jugular vein thrombosis, and reintroduction of anticoagulant agents at the lowest therapeutic doses was required (AU)

Utilidad de la elastografía percutánea con la técnica de radiación acústica de la fuerza de impulso para el diagnóstico no invasivo de la pancreatitis crónica / Usefulness of percutaneous elastography by acoustic radiation force impulse for the non-invasive diagnosis of chronic pancreatitis

Objetivo: determinar la precisión diagnóstica con la técnica de la radiación acústica de la fuerza de impulso (ARFI) para el diagnóstico de pancreatitis crónica (PC). Material y métodos: estudio observacional, monocentro, de pacientes a quienes, por sospecha de pancreatitis crónica entre octubre de 2012 y septiembre de 2015, se les realizó un estudio por ultrasonografía endoscópica (USE) y se les clasificó según los criterios estándar y de Rosemont. Evaluamos los mismos pacientes mediante un equipo de ultrasonido ACUSON S2000TM equipado con el software Virtual TouchTM Quantification para obtener la velocidad de onda de corte (Vc) en la cabeza, cuerpo y cola del páncreas. Los datos fueron analizados mediante análisis de la varianza y técnicas de correlación no paramétricos; la precisión diagnóstica fue obtenida mediante el análisis de las curvas ROC. Resultados: evaluamos 33 pacientes (45,5% mujeres) con media de edad de 58,3 ± 11,8 años. Diecisiete con PC y dieciséis clasificados como normal según los criterios estándar. Detectamos diferencias significativas en las medias de Vc en cuerpo de páncreas de pacientes sin (1,27 m/s) y con PC (1,57 m/s) (p = 0,037). El área bajo la curva ROC fue de 0,713 (IC 95% 0,532-0,895) y la precisión diagnóstica, de 69,7% para una Vc de 1,4 m/s en cuerpo pancreático. La media de la Vc en la cabeza (r = 0,421/p < 0,05) y cuerpo de páncreas (r = 0,455/p < 0,05) mostró correlación significativa con el número de criterios USE para PC. Conclusión: la cuantificación percutánea de la rigidez pancreática mediante la técnica ARFI resulta de utilidad para el diagnóstico no invasivo de la pancreatitis crónica (AU)

Objective: To determine the accuracy of the acoustic radiation force impulse (ARFI) technique for the diagnosis of chronic pancreatitis. Materials and methods: We present an observational, single-center study that included patients with suspected chronic pancreatitis in the period between October 2012 and September 2015 who underwent endoscopic ultrasound (EUS) and were classified according to the standard and Rosemont criteria. The same group of patients was assessed by the ARFI technology using ACUSON S2000(TM) equipment with Virtual Touch(TM) Quantification software for the assessment of pancreatic stiffness by obtaining the shear wave velocity (SWV) in the head, body and tail of the pancreas. Data were analyzed using ANOVA and nonparametric correlation methods. Diagnostic accuracy was obtained by analyzing receiver operating characteristic (ROC) curve. Results: A total of thirty-three patients were studied (45.5% women); mean age was 58.3 ± 11.8 years. Seventeen with a diagnosis of chronic pancreatitis and sixteen classified as normal according to standard criteria. A significant difference was detected between the means of SWV in pancreatic body of patients without (SWV: 1.27 m/s) and with chronic pancreatitis (SWV 1.57 m/s), p = 0.037. The area under the ROC curve was 71.3% (95% CI 0.532-0.895) and the accuracy of ARFI for diagnosing chronic pancreatitis was 69.7% for a SWV of 1.4 m/s in the pancreatic body. The SWV means in head (r = 0.421, p < 0.05) and body (r = 0.455, p < 0.05) of the pancreas showed a significant correlation with the number of EUS criteria for chronic pancreatitis. Conclusion: Quantification of pancreatic stiffness with ARFI elastography technique has proven to be useful for the non-invasive diagnosis of chronic pancreatitis (AU)

Usefulness of percutaneous elastography by acoustic radiation force impulse for the non-invasive diagnosis of chronic pancreatitis.

OBJECTIVE: To determine the accuracy of the acoustic radiation force impulse (ARFI) technique for the diagnosis of chronic pancreatitis. MATERIALS AND METHODS: We present an observational, single-center study that included patients with suspected chronic pancreatitis in the period between October 2012 and September 2015 who underwent endoscopic ultrasound (EUS) and were classified according to the standard and Rosemont criteria. The same group of patients was assessed by the ARFI technology using ACUSON S2000™ equipment with Virtual Touch™ Quantification software for the assessment of pancreatic stiffness by obtaining the shear wave velocity (SWV) in the head, body and tail of the pancreas. Data were analyzed using ANOVA and nonparametric correlation methods. Diagnostic accuracy was obtained by analyzing receiver operating characteristic (ROC) curve. RESULTS: A total of thirty-three patients were studied (45.5% women); mean age was 58.3 ± 11.8 years. Seventeen with a diagnosis of chronic pancreatitis and sixteen classified as normal according to standard criteria. A significant difference was detected between the means of SWV in pancreatic body of patients without (SWV: 1.27 m/s) and with chronic pancreatitis (SWV 1.57 m/s), p = 0.037. The area under the ROC curve was 71.3% (95% CI 0.532-0.895) and the accuracy of ARFI for diagnosing chronic pancreatitis was 69.7% for a SWV of 1.4 m/s in the pancreatic body. The SWV means in head (r = 0.421, p < 0.05) and body (r = 0.455, p < 0.05) of the pancreas showed a significant correlation with the number of EUS criteria for chronic pancreatitis. CONCLUSION: Quantification of pancreatic stiffness with ARFI elastography technique has proven to be useful for the non-invasive diagnosis of chronic pancreatitis.

Calprotectina y proteína C reactiva se asocian a hallazgos en cápsula endoscópica de pacientes con sospecha de enfermedad de Crohn de intestino delgado / Fecal calprotectin and C-reactive protein are associated with positive findings in capsule endoscopy in suspected small bowel Crohn’s disease

Introducción y objetivos: la cápsula endoscópica es una herramienta extendida en el estudio de la enfermedad de Crohn de intestino delgado pero los factores asociados a hallazgos positivos en esta técnica no han sido completamente establecidos. Nuestro objetivo es definir cuáles son estos factores. Material y métodos: se han recogido retrospectivamente los datos de pacientes sometidos a cápsula endoscópica por sospecha de enfermedad de Crohn de intestino delgado. Se han registrado datos demográficos, síntomas y los resultados de las pruebas bioquímicas más habituales: niveles de hemoglobina, recuento de leucocitos y plaquetas, y niveles de velocidad de sedimentación globular, proteína C reactiva y calprotectina fecal. Los estudios de cápsula se han clasificado como negativos (sin lesiones significativas) o positivos (con lesiones compatibles con Crohn). Se han realizado análisis descriptivo, univariante, multivariante y de capacidad diagnóstica de estas variables en su capacidad para predecir lesiones en los estudios de cápsula endoscópica. Resultados: se han incluido 124 individuos, 85 mujeres y 39 varones con una edad media de 38,21 años, en los que los niveles de proteína C reactiva y de calprotectina fecal elevados fueron los marcadores más frecuentemente asociados a presencia de lesiones inflamatorias en la cápsula. La calprotectina mostró la mejor sensibilidad como marcador aislado. La asociación de niveles alterados de proteína C reactiva y calprotectina mostró la mejor especificidad y los mejores valores predictivos. Conclusiones: la proteína C reactiva y la calprotectina fecal son buenos marcadores bioquímicos para seleccionar pacientes con sospecha de enfermedad de Crohn de intestino delgado ante estudios de cápsula endoscópica (AU)

Background and aim: Capsule endoscopy is an extended tool for the diagnosis of small bowel Crohn's disease. However, factors associated with positive findings of this technique have not been well established. Our aim is to asses which factors are associated with a better diagnostic yield of capsule endoscopy in suspected small bowel Crohn's disease. Material and methods: This was a retrospective study including patients under capsule endoscopy because of suspected small bowel Crohn’s disease. Demographic data of these patients, as well as symptoms and laboratory data including hemoglobin levels, count of leucocytes and platelets, and levels of C-reactive protein, erythrocyte sedimentation rate and fecal calprotectin were collected. Capsule endoscopy studies were classified as negative (no lesions) or positive (lesions suggestive of Crohn’s disease). Descriptive, univariate and multivariate analysis were done, as well as diagnostic yield tests of the different markers for predicting lesions in capsule studies. Results: One hundred and twenty-four patients were included (85 women and 39 men). The average age was 38.21 years. Levels of C-reactive protein and fecal calprotectin were the markers more frequently associated with positive findings in capsule endoscopy. Calprotectin presented the best sensitivity as isolated marker. The association of altered levels of C-reactive protein and calprotectin showed the best specificity and predictive values. Conclusions: C-reactive protein and fecal calprotectin are appropriate biomarkers for selecting patients with suspected Crohn’s disease of the small bowel for capsule endoscopy studies (AU)

Fecal calprotectin and C-reactive protein are associated with positive findings in capsule endoscopy in suspected small bowel Crohn's disease.

BACKGROUND AND AIM: Capsule endoscopy is an extended tool for the diagnosis of small bowel Crohn's disease. However, factors associated with positive findings of this technique have not been well established. Our aim is to asses which factors are associated with a better diagnostic yield of capsule endoscopy in suspected small bowel Crohn's disease. MATERIAL AND METHODS: This was a retrospective study including patients under capsule endoscopy because of suspected small bowel Crohn's disease. Demographic data of these patients, as well as symptoms and laboratory data including hemoglobin levels, count of leucocytes and platelets, and levels of C-reactive protein, erythrocyte sedimentation rate and fecal calprotectin were collected. Capsule endoscopy studies were classified as negative (no lesions) or positive (lesions suggestive of Crohn's disease). Descriptive, univariate and multivariate analysis were done, as well as diagnostic yield tests of the different markers for predicting lesions in capsule studies. RESULTS: One hundred and twenty-four patients were included (85 women and 39 men). The average age was 38.21 years. Levels of C-reactive protein and fecal calprotectin were the markers more frequently associated with positive findings in capsule endoscopy. Calprotectin presented the best sensitivity as isolated marker. The association of altered levels of C-reactive protein and calprotectin showed the best specificity and predictive values. CONCLUSIONS: C-reactive protein and fecal calprotectin are appropriate biomarkers for selecting patients with suspected Crohn's disease of the small bowel for capsule endoscopy studies.

Spontaneous retroperitoneal hematoma in a patient under anticoagulant agents presenting as upper gastrointestinal bleeding.

We present the case of a 44-year-old woman with past history of repeated miscarriage and Budd-Chiari syndrome secondary to primary myelofibrosis. Because of this she was under treatment with oral anticoagulant agents. The patient was admitted in hospital as she presented with gastrointestinal bleeding (melena), asthenia and progressive anemia. In an initial upper endoscopy an extrinsic duodenal compression associated with an ulcer on the posterior face of the first portion of duodenum and upper duodenal knee was observed. In the following days a huge spontaneous retroperitoneal hematoma due to anticoagulation was diagnosed by computed tomography. This was treated with a percutaneous drainage and withdrawal of the antithrombotic drugs. The evolution of the patient was initially satisfactory but she suffered subclavian and jugular vein thrombosis, and reintroduction of anticoagulant agents at the lowest therapeutic doses was required.

Colangitis aguda como presentación de un hepatocarcinoma con trombosis tumoral de la vía biliar / Hepatocellular carcinoma with bile duct invasion presenting as acute cholangitis

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Management of antithrombotic drugs in association with endoscopic procedures.

The use of antithrombotic drugs (anticoagulants and antiplatelets) has increased significantly with our understanding of cardiovascular risk. Encountering patients on these therapies who require an endoscopic procedure is therefore increasingly common. At decision making the endoscopist must rely on other specialists (basically cardiologists and hematologists) as risk not only lies among increased bleeding odds but also in the possibility of thrombosis following dose discontinuation or change. Understanding the pharmacology, indications, and risks of endoscopic procedures is therefore essential if sound decisions are to be made. The efforts of four scientific societies have been brought together to provide clinical answers on the use of antiplatelets and anticoagulants, as well as action algorithms and a practical protocol proposal for endoscopy units.