Megacolon en la enfermedad inflamatoria intestinal: respuesta a infliximab / No disponible

El megacolon es una complicación grave de la enfermedad inflamatoria intestinal que con frecuencia requiere colectomía. Infliximab sería una alternativa terapéutica cuando fracasa el tratamiento convencional, antes de la cirugía. En la actualidad, su uso se basa en la publicación de casos aislados. Presentamos nuestra serie de 12 pacientes con megacolon (cinco con signos de toxicidad sistémica) tratados con infliximab. El 75% de los pacientes evitaron la colectomía durante el episodio agudo tras la instauración precoz del tratamiento con infliximab (2,45 días desde el diagnóstico del megacolon), apreciando un mayor riesgo de cirugía entre los pacientes con colitis ulcerosa y criterios de toxicidad. Pese a mantener infliximab a largo plazo, dos pacientes más requirieron cirugía en el seguimiento. Ningún paciente sufrió efectos adversos relevantes en relación con el tratamiento ni complicaciones posquirúrgicas significativas

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Megacolon in inflammatory bowel disease: response to infliximab.

Megacolon is a serious complication of inflammatory bowel disease that often requires a colectomy. Infliximab is a therapeutic alternative when conventional treatment fails, before resorting to surgery. Its use is currently based on the publication of isolated cases. We present a series of 12 patients with megacolon treated with infliximab, five with signs of systemic toxicity. Seventy-five percent of the patients avoided a colectomy during their acute episode after early infliximab treatment, 2.45 days after the megacolon diagnosis. There was a greater risk of surgery among patients with ulcerative colitis and toxicity criteria. Two more patients required follow-up surgery despite long-term infliximab treatment. No patient suffered significant treatment-related adverse effects or significant post-surgery complications.

Downhill varices: an uncommon cause of upper gastrointestinal bleeding.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common condition in gastroenterology, but "Downhill Varices" (DHV) or varices of the upper oesophagus are an uncommon cause of UGIB, with different aetiology from lower third oesophageal varices and different therapeutic implications. CASE REPORT: A 28-year-old male patient, with a history of chronic kidney failure secondary undergoing haemodialysis and superior vena cava syndrome (SCVS) due to multiple catheter replacements, was admitted to the Emergency Department with haematemesis secondary to a varicose vein rupture in the proximal third of oesophagus, treated initially with ethanolamine. Subsequent diagnostic studies showed the collateral circulation secondary to the SCVS. No further endoscopic or endovascular therapy could be performed and the patient will finally undergo a surgical bypass. DISCUSSION: DHVs are a very uncommon condition and endoscopic band ligation emerges as the appropriate therapeutic approach for the bleeding event. The definitive therapy continues to be that for the cause of the SVCS.

'Downhill varices': una causa poco frecuente de hemorragia digestiva alta / Downhill varices: an uncommon cause of upper gastrointestinal bleeding

Introducción: la hemorragia digestiva alta (HDA) es una entidad común en gastroenterología, pero las ‘Downhill varices’ (DHV) son una causa infrecuente de HDA, con diferente etiología de las varices esofágicas de tercio inferior y con diferentes implicaciones terapéuticas. Caso clínico: varón de 28 años de edad, con antecedentes de insuficiencia renal crónica sometido a hemodiálisis y síndrome de vena cava superior(SVCS) debido a múltiples sustituciones catéter, acude a urgencias por hematemesis secundaria a ruptura de una variz en tercio proximal de esófago, que inicialmente se trata con etanolamina. El estudio diagnóstico posterior demostró la circulación colateral secundaria al SVCS. No se pudo realizar terapia endoscópica o endovascular y el paciente finalmente se someterá a un bypass quirúrgico. Discusión: las DHV son una entidad infrecuente y la ligadura endoscópica con bandas se erige como el abordaje terapéutico apropiado para el evento hemorrágico. La terapia definitiva sigue siendo la de la causa del SVCS (AU)

Background: Upper gastrointestinal bleeding (UGIB) is a common condition in gastroenterology, but ‘Downhill Varices’ (DHV) or varices of the upper oesophagus are an uncommon cause of UGIB, with different aetiology from lower third oesophageal varices and different therapeutic implications. Case report: A 28-year-old male patient, with a history of chronic kidney failure secondary undergoing haemodialysis and superior vena cava syndrome (SCVS) due to multiple catheter replacements, was admitted to the Emergency Department with haematemesis secondary to a varicose vein rupture in the proximal third of oesophagus, treated initially with ethanolamine. Subsequent diagnostic studies showed the collateral circulation secondary to the SCVS. No further endoscopic or endovascular therapy could be performed and the patient will finally undergo a surgical bypass. Discussion: DHVs are a very uncommon condition and endoscopic band ligation emerges as the appropriate therapeutic approach for the bleeding event. The definitive therapy continues to be that for the cause of the SVCS (AU)

Tratamiento con inmunosupresores en paciente con enfermedad de Crohn e inmunodeficiencia común variable / Treatment with immunosupressants in a patient with Crohn's disease and common variable immunodeficiency

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Listeria monocytogenes y su relación con terapia no biológica en la enfermedad inflamatoria intestinal / Listeria monocytogenes and its relationship with non-biological therapy in inflammatory bowel disease

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Correlación entre la localización del depósito amiloide y las manifestaciones endoscópicas y clínicas en amiloidosis digestiva sintomática / Correlation between location of amyloid deposits and endoscopic and clinical manifestations in symptomatic gastrointestinal amyloidosis

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Influencia del control de la actividad inflamatoria del colon en la respuesta a infliximab de la anemia hemolítica autoinmune asociada a colitis ulcerosa / inflammatory activity in the colon on the response to infliximab of autoimmune haemolytic anaemia associated with ulcerative colitis

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Treatment with adalimumab in a patient with regenerative nodular hyperplasia secondary to azathioprine.

INTRODUCTION: regenerative nodular hyperplasia (RNH) is a rare liver disease with an etiology that is not well understood. Among the etiological factors are purine-analogue drugs such asazathioprine. CASE REPORT: we present a case of a 47-year-old patient diagnosed with Crohn´s disease in treatment with azathioprine due to corticosteroid dependency who developed RNH with clinical and laboratory signs of portal hypertension one year after starting treatment. After discontinuation of azathioprine, the patient started treatment and, given the poor disease progression, started treatment with adalimumab. This was continued with an excellent response and without deleterious effects on the liver. DISCUSSION: the relevance of this case is twofold: First, this is a rare and early side effect of azathioprine treatment and this is an irreversible disease with potentially serious complications. Second, because treatment was carried out with biological drugs (adalimumab) despite the patient having advance liver disease with portal hypertension without any evidence of it worsening, nor signs of deleterious effects or complications, given that there is scarce or no experience with adalimumab treatment in this type of situation.

Tratamiento con adalimumab en un paciente con hiperplasia nodular regenerativa secundaria a azatioprina / Treatment with adalimumab in a patient with regenerative nodular hyperplasia secondary to azathioprine

Introducción: la hiperplasia nodular regenerativa (HNR) es una rara enfermedad hepática de etiología no bien conocida. Entre los factores etiológicos se encuentran los fármacos análogos de las purinas, como la azatioprina. Caso clínico: presentamos un caso de un paciente de 47 años de edad diagnosticado de enfermedad de Crohn en tratamiento con azatioprina por corticodependencia que desarrolló una HNR con datos clínicos y analíticos de hipertensión portal al año del inicio del tratamiento. Tras la suspensión de la azatioprina inició tratamiento y dada la mala evolución de su enfermedad se inició tratamiento con adalimumab, el cual mantiene con excelente respuesta y sin efectos deletéreos a nivel hepático. Discusión: la relevancia del caso es doble; primero por ser un efecto secundario raro y precoz del tratamiento con azatioprina y tratarse de una enfermedad irreversible y con complicaciones potenciales graves; segundo por realizarse tratamiento de mantenimiento con fármacos biológicos (adalimumab) a pesar de padecer una hepatopatía avanzada con hipertensión portal sin evidenciarse peor evolución de esta, ni efectos deletéreos o complicaciones, dado que existe escasa o nula experiencia de tratamiento con adalimumab en este tipo de situaciones(AU)

Introduction: regenerative nodular hyperplasia (RNH) is a rare liver disease with an etiology that is not well understood. Among the etiological factors are purine-analogue drugs such as azathioprine. Case report: we present a case of a 47-year-old patient diagnosed with Crohn’s disease in treatment with azathioprine due to corticosteroid dependency who developed RNH with clinical and laboratory signs of portal hypertension one year after starting treatment. After discontinuation of azathioprine, the patient started treatment and, given the poor disease progression, started treatment with adalimumab. This was continued with an excellent response and without deleterious effects on the liver. Discussion: the relevance of this case is twofold: First, this is a rare and early side effect of azathioprine treatment and this is an irreversible disease with potentially serious complications. Second, because treatment was carried out with biological drugs (adalimumab) despite the patient having advance liver disease with portal hypertension without any evidence of its worsening, nor signs of deleterious effects or complications, given that there is scarce or no experience with adalimumab treatment in this type of situation(AU)

Utilidad del tratamiento con infliximab en la enterorragia severa asociada a la enfermedad de Crohn. Experiencia de tres casos / Utility of infliximab therapy in severe enterorrhagia associated with Crohn's disease. Report of three cases

La hemorragia digestiva baja severa es una complicación poco frecuente en la enfermedad de Crohn. Presentamos 3 pacientes con enfermedad de Crohn, de diferente localización que desarrollaron una enterorragia severa, con necesidad transfusional múltiple y que respondieron favorablemente a la administración de infliximab, consiguiendo el cese de la hemorragia que comprometía la vida del paciente y evitando una resección quirúrgica de urgencia que parecía inevitable para la resolución del episodio hemorrágico. Sobre la base de esta experiencia clínica y tras revisar la literatura comparando infliximab con otras opciones farmacológicas, consideramos este fármaco, como primera opción terapéutica a emplear en pacientes con enfermedad de Crohn, que presenten una hemorragia digestiva severa, evitando la cirugía en algunos casos, si conseguimos que la hemorragia ceda por rápida cicatrización de las profundas ulceraciones mucosas, responsables del cuadro hemorrágico (AU)

Severe lower gastrointestinal (GI) bleeding is an infrequent complication in Crohn's disease. We report the cases of three patients with Crohn's disease, localized in distinct areas, who developed severe enterorrhagia requiring multiple transfusions. All three patients responded favorably to infliximab administration, which resolved the life-threatening hemorrhages and avoided emergency surgical resection, which had seemed inevitable. Based on this clinical experience and a review of the literature comparing infliximab with other pharmacological options, we believe that this drug should be the treatment of choice in patients with Crohn's disease who develop severe lower gastrointestinal bleeding. This strategy can, in some cases, avoid surgery if the bleeding stops due to rapid healing of the deep mucosal lesions causing the hemorrhagic episode (AU)