Urgent endoscopy versus early endoscopy: Does urgent endoscopy play a role in acute non-variceal upper gastrointestinal bleeding? / Endoscopia urgente frente a endoscopia precoz: ¿tiene algún papel la endoscopia urgente en la hemorragia digestiva alta aguda no varicosa?

INTRODUCTION: The main clinical practice guidelines recommend endoscopy within 24hours after admission to the Emergency Department in patients with non-variceal upper gastrointestinal bleeding. However, it is a wide time frame and the role of urgent endoscopy (<6hours) is controversial. MATERIAL AND METHODS: Prospective observational study carried out at La Paz University Hospital, where all patients were selected, from January 1, 2015 to April 30, 2020, who attended the Emergency Room and underwent endoscopy for suspected upper gastrointestinal bleeding. Two groups of patients were established: urgent endoscopy (<6hours) and early endoscopy (6-24hours). The primary endpoint of the study was 30-day mortality. RESULTS: A total of 1096 were included, of whom 682 underwent urgent endoscopy. Mortality at 30days was 6% (5% vs 7.7%, P=.064) and rebleeding was 9.6%. There were no statistically significant differences in mortality, rebleeding, need for endoscopic treatment, surgery and/or embolization, but there were differences in the necessity for transfusion(57.5% vs 68.4%, P<.001) and the number of concentrates of transfused red blood cells (2.85±4.01 vs 3.51±4.09, P=.008). CONCLUSION: Urgent endoscopy, in patients with acute upper gastrointestinal bleeding, as well as the high-risk subgroup (GBS ≥12), was not associated with lower 30-day mortality than early endoscopy. However, urgent endoscopy in patients with high-risk endoscopic lesions (ForrestI-IIB), was a significant predictor of lower mortality. Therefore, more studies are required for the correct identification of patients who benefit from this medical approach (urgent endoscopy).

Cambios hemodinámicos posligadura con bandas de varices esofágicas: un estudio de cohortes / No disponible

INTRODUCCIÓN: existe controversia sobre la necesidad de mantener el tratamiento vasoconstrictor tras lograr una adecuada hemostasia mediante ligadura endoscópica, en la hemorragia aguda por varices esofágicas. Dado que es muy complejo hacer un gradiente "pre y posligadura urgente" en el sangrante por varices, nuestro objetivo es conocer las variaciones hemodinámicas tras la terapia endoscópica, midiendo un gradiente venoso hepático "pre" y otro 24 horas "posprocedimiento" en los cirróticos con ligadura programada como profilaxis de la hemorragia varicosa. MATERIAL Y MÉTODOS: estudio prospectivo, de cohorte, unicéntrico. Los pacientes, en protocolo de erradicación endoscópica, fueron sometidos a un gradiente de presión venosa hepática basal (GPVH PRE), sin modificar su tratamiento habitual con beta-bloqueantes. Después, se procedió a ligadura endoscópica, según guías de práctica clínica. Tras 24 horas del procedimiento, se realizó una segunda medida de presiones (GPVH POST). RESULTADOS: 30 pacientes. Las medianas de los GPVH PRE y POST ligadura fueron 16,5 mmHg (14-20) y 19,5 mmHg (17-21) respectivamente, con un aumento significativo tras el procedimiento (p < 0,001). Las variaciones porcentuales de presión portal, según cifra de gradiente basal (12, 16 y 20 mmHg), eran mayores en pacientes con menor GVPH frente a mayor GPVH basal en cualquiera de las categorías comparadas (p = 0,087, p = 0,016 y p < 0,001, respectivamente). En nuestra serie, el 36,7 % de los pacientes presentó un incremento de gradiente ≥ 20 % tras la ligadura. CONCLUSIÓN: la ligadura con bandas de varices esofágicas condiciona un aumento de presión portal, al menos transitorio, objetivado mediante gradiente de presión venosa hepática

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Hemodynamic changes after endoscopic variceal ligation: a cohort study.

BACKGROUND: there is controversy about the need to maintain vasoconstrictor treatment after adequate haemostasis is achieved through endoscopic band ligation (EBL) in bleeding esophageal varices (BEV). Measuring a "before and after urgent-EBL" hepatic venous pressure gradient (HVPG) in acute variceal hemorrhage is very difficult. Thus, the goal of this study was to determine hemodynamic variations after an EBL session. A "before" HVPG (PRE) was performed and another one 24 hours "after-ligation" (POST), in cirrhotic patients undergoing endoscopic band ligation as BEV prophylaxis. PATIENTS AND METHODS: this was a single-center, cohort, prospective study. Patients followed a program of repeated sessions of EBL until eradication of their varices and underwent a basal hepatic venous pressure gradient (PRE HVPG), without changing their usual treatment with beta-blockers. Subsequently, an endoscopic ligation session was performed, following the clinical practices guidelines. A second pressure measurement (POST HVPG) was taken 24 hours after the endoscopic treatment. RESULTS: 30 patients were included. PRE and POST HVPG median results were 16.5 mmHg (14-20) and 19.5 mmHg (17-21), respectively, with a significant increase after the procedure (p < 0.001). Percentage variations in portal pressure, based on the baseline gradient values (12, 16 and 20 mmHg), were higher for patients with a lower basal HVPG versus a higher HVPG for any of the categories compared (p = 0.087, p = 0.016 and p < 0.001, respectively). In our series, 36.7 % of patients showed a ≥ 20 % gradient increase after ligation. CONCLUSION: endoscopic band ligation causes an increase in portal pressure, at least for a transitional period, determined by the hepatic venous pressure gradient.

Feasibility and safety of pulmonary vein isolation by high-power short-duration radiofrequency application: short-term results of the POWER-FAST PILOT study.

PURPOSE: Pulmonary vein (PV) isolation (PVI) by point-by-point radiofrequency application (PPRF) results in longer procedures than that achieved by single-shot ablation techniques. In addition, it is associated with significant risk of oesophageal injury. The POWER-FAST pilot study evaluated the feasibility and safety of PVI by high-power short-duration (HPSD) PPRF. METHODS: HPSD PPRF around the PVs was done in 48 consecutive patients with atrial fibrillation. Fifty watts was delivered until a predefined lesion index value was reached (LSI ≥ 5 or Abl-I ≥ 350) and 60 W during 7-10 s in the first 18 and last 30 patients, respectively. A control group of 47 consecutive patients who had undergone PVI before the HPSD group with conventional PPRF (30 W for 30 s) was included for reference. Echocardiography and oesophageal endoscopy was performed shortly after ablation in all patients. RESULTS: PVI of all targeted veins was achieved in 98% and 100% of patients of the conventional and HPSD groups, respectively (p = 0.59). Total radiofrequency time was 34 ± 11, 24 ± 8, and 15 ± 5 min in groups 30 W, 50 W, and 60 W (p < 0.001). Audible steam pops occurred in 4 out of 48 (8%) patients in the HPSD group, accounting for 4 (0.08%) out of 5 269 HPSD radiofrequency applications. No patient in the HPSD group developed pericardial effusion. The incidence of oesophageal lesions was 28%, 22%, and 0% in groups 30 W, 50 W, and 60 W, respectively (p = 0.007) CONCLUSIONS: PVI can be achieved with HPSD PPRF in most patients. This approach appears safe and associated with low risk of esophageal damage.

Symptomatic exfoliative esophagitis induced by dabigatran

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Symptomatic exfoliative esophagitis induced by dabigatran.

Dabigatran is an oral anticoagulant prescribed as an alternative to warfarin which has been associated with exfoliative esophagitis and esophageal ulcer. We report a new case of dabigatran-induced exfoliative esophagitis where the mucosal injury improved after prescribing proton-pump inhibitors and ingesting medication with sufficient water.

Síndrome de Chilaiditi complicado con vólvulo de sigma y desplazamiento hepático / Chilaiditi syndrome complicated by a sigmoid volvulus and hepatic displacement

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Chilaiditi syndrome complicated by a sigmoid volvulus and hepatic displacement.

Chilaiditi's sign is an anatomical alteration consisting of the transposition of the small intestine or colon between the liver and diaphragm that is asymptomatic and is usually an accidental radiological finding. The onset of Chilaiditi syndrome is accompanied by clinical symptoms and is even rarer. Moreover, the combination of sigmoid volvulus and Chilaiditi syndrome is extremely rare, with only 17 previous published cases, one of which occurred in a female patient.

Extracción endoscópica de paquete de hachís / Endoscopic removal of a hashish packet

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Endoscopic removal of a hashish packet.

Illicit drug trafficking within the body ("body packers") represents a medical-legal problem currently on the rise. Endoscopic removal of drug packets is not generally recommended because of the risk of packet rupture and subsequent overdose on the spilled substance. A 40-year-old male presented with abdominal pain and diaphoresis following the ingestion of 30 g of hashish as a means of illegal trafficking, remaining in police custody during his hospital stay.

Brote psicótico agudo secundario a tratamiento erradicador de Helicobacter pylori / Acute psychotic episode secondary to Helicobacter pylori eradication treatment

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Acute psychotic episode secondary to Helicobacter pylori eradication treatment.

The side effects of Helicobacter pylori (H. pylori) eradication treatment are few, usually in the form of gastrointestinal or allergic complaints. However, occasionally, some antibiotics including clarithromycin, included in the classic eradication regimen, may result in reversible psychosis, a condition called "antibiomania" or "Hoigne syndrome".

Endoscopic management of esophageal varices.

The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis.

La hemorragia digestiva alta en el paciente anciano mayor de 80 años / Upper gastrointestinal haemorrhage in patients over 80 years-old

Objetivos. Analizar las características al ingreso, el curso evolutivo y el pronóstico de la hemorragia digestiva alta (HDA) en el paciente anciano. Material y métodos. Estudio prospectivo en el que se incluyeron 103 pacientes con edad igual o superior a 80 años, que ingresaron en una Unidad de Sangrantes por un episodio de HDA en un año. Analizamos los antecedentes personales, características de la hemorragia, realización de la endoscopia urgente diagnóstica y terapéutica y factores pronósticos asociados. Resultados. La etiología más frecuente de la HDA fue el sangrado por úlcera gastroduodenal en el 65,1%, siendo el 60,2% consumidores crónicos de antiinflamatorios no esteroideos. Se realizó endoscopia diagnóstica urgente en todos ellos, con una eficacia del 94,2% y terapéutica en el 28,2%. La tasa de resangrado fue del 8%, requiriendo cirugía urgente el 4,9%, con una mortalidad global del 5,8%. Conclusiones. La realización de endoscopia urgente y la aplicación de terapéutica endoscópica es un método seguro y eficaz para detener el sangrado por HDA en el anciano, lo cual ha reducido la necesidad de cirugía urgente, mejorando la supervivencia del enfermo anciano sangrante(AU)

Objectives. To evaluate the patient characteristics, outcome, and prognosis of upper gastrointestinal haemorrhage in the elderly. Material and methods. A prospective study was conducted on 103 patients aged 80 years and over, admitted to a Gastrointestinal Bleeding Unit after an episode of upper gastrointestinal bleeding. We analysed the personal history, the characteristics of the bleeding event, and whether an urgent diagnostic or therapeutic endoscopy was performed, in order to identify clinical data and endoscopic findings that may have an influence on the outcome of the haemorrhage. Results. The major cause of the haemorrhage was peptic ulcer in 65.1%, and 60.2% of patients were on chronic treatment with non-steroidal anti-inflammatory drugs. An urgent diagnostic endoscopy was performed in all of them, identifying the source of bleeding in 94.2%, and treatment was carried out on 28.2%. The likelihood of rebleeding was 8%, and 4.9% of patients underwent emergency surgery, with an overall mortality rate of 5.8%. Conclusions. The performance of urgent endoscopy and the application of endoscopic haemostasis are safe and effective in stopping upper gastrointestinal bleeding in the elderly. This has significantly reduced the need for emergency surgery, improving the survival of the bleeding elderly patient and preventing recurrent bleeding(AU)

[Upper gastrointestinal haemorrhage in patients over 80 years-old]. / La hemorragia digestiva alta en el paciente anciano mayor de 80 años.

OBJECTIVES: To evaluate the patient characteristics, outcome, and prognosis of upper gastrointestinal haemorrhage in the elderly. MATERIAL AND METHODS: A prospective study was conducted on 103 patients aged 80 years and over, admitted to a Gastrointestinal Bleeding Unit after an episode of upper gastrointestinal bleeding. We analysed the personal history, the characteristics of the bleeding event, and whether an urgent diagnostic or therapeutic endoscopy was performed, in order to identify clinical data and endoscopic findings that may have an influence on the outcome of the haemorrhage. RESULTS: The major cause of the haemorrhage was peptic ulcer in 65.1%, and 60.2% of patients were on chronic treatment with non-steroidal anti-inflammatory drugs. An urgent diagnostic endoscopy was performed in all of them, identifying the source of bleeding in 94.2%, and treatment was carried out on 28.2%. The likelihood of rebleeding was 8%, and 4.9% of patients underwent emergency surgery, with an overall mortality rate of 5.8%. CONCLUSIONS: The performance of urgent endoscopy and the application of endoscopic haemostasis are safe and effective in stopping upper gastrointestinal bleeding in the elderly. This has significantly reduced the need for emergency surgery, improving the survival of the bleeding elderly patient and preventing recurrent bleeding.

Vasculitis leucocitoclástica asociada a enfermedad de Crohn / Leukocytoclastic vasculitis associated with Crohn's disease

En el curso de la enfermedad inflamatoria intestinal pueden aparecer múltiples manifestaciones extraintestinales, y las cutáneas son bastante habituales tanto en la colitis ulcerosa como en la enfermedad de Crohn. El pioderma gangrenoso y el eritema nodoso son las más frecuentes, y existen otras manifestaciones cutáneas muy poco frecuentes, como la vasculitis leucocitoclástica. Presentamos el caso de un paciente en el que se diagnosticó de forma simultánea la enfermedad de Crohn y la vasculitis cutánea, con mejoría clínica significativa de ambos cuadros tras instaurar tratamiento con corticoides (AU)

In the course of inflammatory bowel disease (IBD) a number of extraintestinal manifestations are known to occur, being the dermatological ones often associated to both ulcerative colitis and Crohn's disease. Pyoderma gangrenosum and erythema nodosum are the most frequent, but there are other skin manifestations less frequently reported such as leukocytoclastic vasculitis. We present a case, in which Crohn's disease and leukocytoclastic vasculitis were simultaneously diagnosed, and corticoids treatment achieved complete remission of the both cutaneous and gastrointestinal manifestations (AU)

[Leukocytoclastic vasculitis associated with Crohn's disease]. / Vasculitis leucocitoclástica asociada a enfermedad de Crohn.

In the course of inflammatory bowel disease (IBD) a number of extraintestinal manifestations are known to occur, being the dermatological ones often associated to both ulcerative colitis and Crohn's disease. Pyoderma gangrenosum and erythema nodosum are the most frequent, but there are other skin manifestations less frequently reported such as leukocytoclastic vasculitis. We present a case, in which Crohn's disease and leukocytoclastic vasculitis were simultaneously diagnosed, and corticoids treatment achieved complete remission of the both cutaneous and gastrointestinal manifestations.