Colorectal cancer screening and surveillance in patients with inflammatory bowel disease in 2021.

The detection of dysplasia in patients with inflammatory bowel disease (IBD) continues to be important given the increased risk of colorectal cancer in this population. Therefore, in 2017, we performed a review and update of the recommendations for the management and follow-up of patients with IBD based on the clinical practice guidelines of various scientific societies. The present manuscript focuses on new aspects of the detection, follow-up, and management of dysplasia according to the latest studies and recommendations. While chromoendoscopy with targeted biopsy continues to be the technique of choice for the screening and detection of dysplasia in IBD, the associated difficulties mean that it is now being compared with other techniques (virtual chromoendoscopy), which yield similar results with less technical difficulties. Furthermore, the emergence of new endoscopy techniques that are still being researched but seem promising (e.g., confocal laser endomicroscopy and full-spectrum endoscopy), together with the development of devices that improve endoscopic visualization (e.g., Endocuff Vision), lead us to believe that these approaches can revolutionize the screening and follow-up of dysplasia in patients with IBD. Nevertheless, further studies are warranted to define the optimal follow-up strategy in this patient population.

The Impact of Sleeve Gastrectomy on Gastroesophageal Reflux Disease in Patients with Morbid Obesity.

INTRODUCTION: The impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) has not been widely quantified, and the data in the literature remain controversial. MATERIALS AND METHODS: Candidates for LSG underwent barium swallow, esophageal manometry, ambulatory 24-h esophageal pH monitoring (APM), and gastric emptying scintigraphy before and after surgery (1 and 18 months). Symptoms were evaluated using a gastroesophageal reflux disease questionnaire (GERDq). Esophagogastroduodenoscopy was performed preoperatively in all patients and at 18 months postoperatively in patients who had suffered from preoperative esophagitis. RESULTS: Fifty-two patients were included in the study (64.4% women and 34.6% men) with a median age of 46 years (25-63 years) and BMI of 45.0 ± 5.6 kg/m2. The follow-up rates at 1 and 18 months were 82.7% and 80.8%. At 18 months, the percentage of weight loss (%TWL) was 33.6 ± 10.4% and the percentage of excess BMI loss (%EBMIL) was 77.6 ± 25%. Postoperatively, a significant increase in accelerated gastric emptying and impaired esophageal body motility occurred at 1 and 18 months. A significant worsening of all the values obtained at both 1 and 18 months postoperatively becomes evident when comparing the results of the APM. After surgery, 76.4% of patients had developed "de novo" GERD at 1 month and 41% at 18 months. No improvement was found in patients with symptomatic GERD. CONCLUSION: Based on the results of this study, LSG led to a considerable rate of postoperative "de novo" GERD. In addition, no improvement was found in patients with symptomatic GERD.

Diagnostic-therapeutic management of bile duct cancer.

Biliary tract cancer, or cholangiocarcinoma, comprises a heterogeneous group of malignant tumors that can emerge at any part of the biliary tree. This group is the second most common type of primary liver cancer. Diagnosis is usually based on symptoms, which may be heterogeneous, and nonspecific biomarkers in serum and biopsy specimens, as well as on imaging techniques. Endoscopy-based diagnosis is essential, since it enables biopsy specimens to be taken. In addition, it can help with locoregional staging of distal tumors. Endoscopic retrograde cholangiopancreatography is a key technique for the evaluation and treatment of malignant biliary tumors. Correct staging of cholangiocarcinoma is essential in order to be able to determine the degree of resectability and assess the results of treatment. The tumor is staged based on the TNM classification of the American Joint Committee on Cancer. The approach will depend on the classification of the tumor. Thus, some patients with early-stage disease could benefit from surgery; complete surgical resection is the cornerstone of cure. However, only a minority of patients are diagnosed in the early stages and are suitable candidates for resection. In the subset of patients diagnosed with locally advanced or metastatic disease, chemotherapy has been used to improve outcome and to delay tumor progression. The approach to biliary tract tumors should be multidisciplinary, involving experienced endoscopists, oncologists, radiologists, and surgeons.

Randomised clinical trial: intravenous vs oral iron for the treatment of anaemia after acute gastrointestinal bleeding.

BACKGROUND: Acute gastrointestinal bleeding is prevalent condition and iron deficiency anaemia is a common comorbidity, yet anaemia treatment guidelines for affected patients are lacking. AIM: To compare efficacy and safety of intravenous ferric carboxymaltose (FCM) and oral ferrous sulphate (FeSulf) in patients with anaemia secondary to non-variceal gastrointestinal bleeding METHODS: A prospective 42-day study randomised 61 patients with haemoglobin <10 g/dL upon discharge (Day 0) to receive FCM (n = 29; Day 0: 1000 mg, Day 7: 500 or 1000 mg; per label) or FeSulf (n = 32; 325 mg/12 hours for 6 weeks). Outcome measures were assessed on Days 0 (baseline), 7, 21 and 42. The primary outcome was complete response (haemoglobin ≥12 g/dL [women], ≥13 g/dL [men]) after 6 weeks. RESULTS: A higher proportion of complete response was observed in the FCM vs the FeSulf group at Days 21 (85.7% vs 45.2%; P = 0.001) and 42 (100% vs 61.3%; P < 0.001). Additionally, the percentage of patients with partial response (haemoglobin increment ≥2 g/dL from baseline) was significantly higher in the FCM vs the FeSulf group (Day 21:100% vs 67.7%; P = 0.001, Day 42:100% vs 74.2%; P = 0.003). At Day 42, normalisation of transferrin saturation to 25% or greater was observed in 76.9% of FCM vs 24.1% of FeSulf-treated patients (P < 0.001). No patient in the FCM group reported any adverse event vs 10 patients in the FeSulf group. CONCLUSION: FCM provided greater and faster Hb increase and iron repletion, and was better tolerated than FeSulf in patients with iron deficiency anaemia secondary to non-variceal acute gastrointestinal bleeding.

Screening for colorectal cancer in patients with inflammatory bowel disease. Should we already perform chromoendoscopy in all our patients?

Patients with inflammatory bowel disease (commonly known as IBD) have a greater risk of colorectal cancer than the general population. Therefore, they are included in special programs for screening and follow-up. Chromoendoscopy, which has a high diagnostic yield in the detection of neoplasia, is generally the recommended endoscopy technique. However, this procedure does have some disadvantages (long examination time, need for optimal bowel preparation, specialist training), which increase its cost. How then can we overcome these barriers? First, it is necessary to educate hospital managers and directors of the advantages of chromoendoscopy in patients with IBD. Second, at least one endoscopist per center should be a specialist in the technique. Third, we should train nursing staff in the preparation of the dye. Finally, each examination should be given the time it needs. Even though clinical practice guidelines do not yet recommend the use of virtual imaging techniques such as narrow band imaging, a recent study reported no differences between the two approaches for the detection of tumors. Therefore, we believe that all patients should undergo chromoendoscopy. In the future, centers without access to dyes or where other barriers exist should at least perform narrow band imaging.

Endoscopic progression of ulcerative proctitis to proximal disease. Can we identify predictors of progression?

INTRODUCTION: Ulcerative proctitis is a type of ulcerative colitis circumscribed to the rectum. Proximal progression rates of the disease have been reported as between 27% and 54%. Several predictive factors have been identified for its progression; however, none has been established as definitive. MATERIAL AND METHODS: Retrospective study of patients diagnosed with ulcerative proctitis with at least 12 months of follow-up. Patients diagnosed between January 1992 and March 2017. Variables were collected at the time of diagnosis and during the first year of follow-up. The extent of the progression was evaluated endoscopically during follow-up. The endoscopic progression rate was determined and possible risk factors related to this progression were evaluated. RESULTS: The analysis involved 137 patients. In 77 of the patients, we performed a second colonoscopy during follow-up to evaluate endoscopic progression. The average time before the second colonoscopy performed was 5 years (SD 3.9). Of the 77 patients, 32 (41.6%) presented proximal progression to the rectosigmoid junction. Logistic regression analysis showed a statistically significant association for progression in patients who had suffered one or more flares in the first year following diagnosis. Significant progression was also observed in those with the longest time of progression at the final colonoscopy. CONCLUSIONS: Ulcerative proctitis is not a stable disease over time. In addition, during the first year of the disease progression, it is possible to predict in which patients the disease will progress to more extensive forms.

Endoscopic evaluation of immunotherapy-induced gastrointestinal toxicity.

Immunotherapy is any treatment aimed at boosting or enhancing the immune system. It includes a wide range of options, from vaccines to treatment for conditions such as allergy and cancer. In the case of cancer, unlike other available treatments, immunotherapy is not aimed at destroying the tumor cells but at stimulating the patient's immune system so that it attacks the tumor. In cancer, immunotherapy provides a series of advantages. Nevertheless, immunotherapy administered for treatment of cancer is associated with immune-mediated enterocolitis. Colitis mediated by monoclonal anti-cytotoxic T lymphocyte-associated antigen 4 and to programmed cell death protein 1 and its ligand PDL1 shares characteristics with chronic inflammatory bowel disease (IBD), and similar findings have been reported for both the endoscopy images and the segment involved. The most frequent lesions on endoscopy are ulcer and erythema, and the most frequently affected site is the sigmoid colon. A segmental pattern has been reported to be slightly more frequent than a continuous pattern. In addition, upper gastrointestinal lesions have been reported in up to half of patients, with the most frequent findings being gastritis and erosive duodenitis. As is the case in IBD, systemic corticosteroids and immunosuppressive treatment (anti-TNF agents) are the approaches used in patients with a more unfavorable progression. Immunotherapy must be suspended completely in some cases.

Endoscopic recommendations for colorectal cancer screening and surveillance in patients with inflammatory bowel disease: Review of general recommendations.

Screening for colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) is recommended by all scientific societies. However, there are differences in the recommendations they make regarding screening and surveillance. We address a series of questions that come up in the daily clinical practice of a physician. The first two questions that are raised are: (1) Who should be offered screening for CRC? and (2) When should the first colonoscopy be performed? The next step is to decide who should undergo endoscopic surveillance and at what intervals they should be performed. Chromoendoscopy is emerging as the recommended endoscopic technique for screening and surveillance. The terminology for describing lesions detected with endoscopy is also changing. The management of visible lesions or non-visible dysplasia is also a motive for the review. We end the review by addressing the follow-up for endoscopically resected lesions. These questions often cannot be answered easily due to the varying degrees of evidence available; therefore, we have made some general recommendations based on those made by the various guidelines and consensuses. The first screening colonoscopy should be offered 8 years after a IBD diagnosis and we recommend that patients be stratified according to the individual risk for each for endoscopic surveillance intervals.

[Duodenal adenocarcinoma: a rare diagnosis]. / Adenocarcinoma duodenal: un diagnóstico poco frecuente.

Duodenal adenocarcinoma is a rare disease whose symptoms are usually vomit, weight loss and lack of appetite; appearing more frequently in men in their sixties. Upper gastrointestinal endoscopy is the technique chosen for its diagnosis, also relying on other techniques such as endoscopic ultrasonography or computed tomography for the extension study. In this regard we report the case of a patient diagnosed of bulbar duodenal adenocarcinoma in our hospital.

Adenocarcinoma duodenal: un diagnóstico poco frecuente / Duodenal adenocarcinoma: a rare diagnosis

El adenocarcinoma duodenal es una entidad poco prevalente que suele cursar con clínica de vómitos, pérdida de peso e hiporexia; presentándose más frecuentemente en varones en la sexta década de la vida. La endoscopia digestiva alta supone la técnica de elección para el diagnóstico, siendo útiles para el estudio de extensión tanto la ecoendoscopia como la tomografía computarizada (TC). En relación a esta rara patología presentamos el caso de un paciente diagnosticado de neoplasia de bulbo duodenal en nuestro centro...

Duodenal adenocarcinoma is a rare disease whose symptoms are usually vomit, weight loss and lack of appetite; appearing more frequently in men in their sixties. Upper gastrointestinal endoscopy is the technique chosen for its diagnosis, also relying on other techniques such as endoscopic ultrasonography or computed tomography for the extension study. In this regard we report the case of a patient diagnosed of bulbar duodenal adenocarcinoma in our hospital...

Management of primary achalasia: The role of endoscopy.

Achalasia is an oesophageal motor disorder which leads to the functional obstruction of the lower oesophageal sphincter (LES) and is currently incurable. The main objective of all existing therapies is to achieve a reduction in the obstruction of the distal oesophagus in order to improve oesophageal transit, relieve the symptomatology, and prevent long-term complications. The most common treatments used are pneumatic dilation (PD) and laparoscopic Heller myotomy, which involves partial fundoplication with comparable short-term success rates. The most economic non-surgical therapy is PD, with botulinum toxin injections reserved for patients with a higher surgical risk for whom the former treatment option is unsuitable. A new technology is peroral endoscopic myotomy, postulated as a possible non-invasive alternative to surgical myotomy. Other endoluminal treatments subject to research more recently include injecting ethanolamine into the LES and using a temporary self-expanding metallic stent. At present, there is not enough evidence permitting a routine recommendation of any of these three novel methods. Patients must undergo follow-up after treatment to guarantee that their symptoms are under control and to prevent complications. Most experts are in favour of some form of endoscopic follow-up, however no established guidelines exist in this respect. The prognosis for patients with achalasia is good, although a recurrence after treatment using any method requires new treatment.

Two-week, high-dose proton pump inhibitor, moxifloxacin triple Helicobacter pylori therapy after failure of standard triple or non-bismuth quadruple treatments.

BACKGROUND: Aim was to evaluate the efficacy and tolerability of a moxifloxacin-containing second-line triple regimen in patients whose previous Helicobacter pylori eradication treatment failed. METHODS: Prospective multicentre study including patients in whom a triple therapy or a non-bismuth-quadruple-therapy failed. Moxifloxacin (400mg qd), amoxicillin (1g bid), and esomeprazole (40 mg bid) were prescribed for 14 days. Eradication was confirmed by (13)C-urea-breath-test. Compliance was determined through questioning and recovery of empty medication envelopes. RESULTS: 250 patients were consecutively included (mean age 48 ± 15 years, 11% with ulcer). Previous (failed) therapy included: standard triple (n = 179), sequential (n = 27), and concomitant (n = 44); 97% of patients took all medications, 4 were lost to follow-up. Intention-to-treat and per-protocol eradication rates were 82.4% (95% CI, 77-87%) and 85.7% (95% CI, 81-90%). Cure rates were similar independently of diagnosis (ulcer, 77%; dyspepsia, 82%) and previous treatment (standard triple, 83%; sequential, 89%; concomitant, 77%). At multivariate analysis, only age was associated with eradication (OR = 0.957; 95% CI, 0.933-0.981). Adverse events were reported in 25.2% of patients: diarrhoea (9.6%), abdominal pain (9.6%), and nausea (9.2%). CONCLUSION: 14-day moxifloxacin-containing triple therapy is an effective and safe second-line strategy in patients whose previous standard triple therapy or non-bismuth quadruple (sequential or concomitant) therapy has failed, providing a simple alternative to bismuth quadruple regimen.

Síndrome de Zollinger-Ellison / Zollinger-Ellison syndrome

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