Fístula gastrocólica como causa infrecuente de diarrea persistente en un paciente portador de gastrostomía radiológica percutánea / Gastrocolic fistula as infrequent cause of chronic diarrhea in a patient with percutaneous radiological gastrostomy

Introducción: la fístula gastrocólica supone una complicación infrecuente pero potencialmente grave de las sondas de gastrostomía. La sospecha clínica ante una diarrea de origen incierto que comienza tras el recambio de la sonda es clave para la detección y el tratamiento precoces. Caso clínico: se presenta el caso de un paciente portador de gastrostomía radiológica percutánea (PRG) que comienza con diarrea persistente tras el primer recambio de la sonda y desnutrición grave secundaria. Tras el fracaso de las medidas terapéuticas iniciales se amplían los estudios, con hallazgo de esta complicación en la imagen de TC. Se suspende el uso de esta sonda con resolución de la diarrea y evolución nutricional favorable. Discusión: este caso pone de manifiesto la importancia de incluir la fístula gastrocólica en el diagnóstico diferencial de la diarrea persistente en un paciente portador de sonda de gastrostomía.(AU)

Introduction: gastrocolic fistula is an infrequent but severe complication of percutaneous gastrostomy. Clinical suspicion in the presence of chronic diarrhea of unknown etiology manifesting after percutaneous radiological gastrostomy (PRG) tube replacement is key to early detection and treatment. Case report: we report the case of a patient with PRG that began with chronic diarrhea after tube replacement and developed severe malnutrition. Initial treatment was not effective, studies were extended with the finding of this complication in a CT image. The use of this tube was discontinued with resolution of diarrhea and a favorable nutritional outcome. Discussion: this case report shows the importance of considering gastrocolic fistula in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.(AU)

Epidemiological characteristics of mortality from infectious intestinal diseases (diarrhea) Paraguay (2015-2019)

Introduction: Infectious intestinal diseases (diarrhea) are a major cause of morbidity and mortality worldwide. In 2015, it constituted the ninth leading cause of death for all ages. Objective: To describe the epidemiological characteristics of mortality due to infectious intestinal diseases (diarrhea) in Paraguay from 2015 to 2019. Methods: Descriptive, ecological, cross-sectional, retrospective, and non-probabilistic sampling of consecutive cases was performed. ICD-10 deaths included cholera (A01), typhoid and paratyphoid fever (A01), shigellosis (A03), other bacterial intestinal infections (A04), other bacterial food poisoning (A05), amebiasis (A06), other intestinal diseases due to protozoa (A07), intestinal infections due to viruses (A08), and diarrhea and gastroenteritis of presumed infectious origin (A09). Open access data were obtained from the WEB page of the General Directorate of Strategic Information in Health of the MSP and BS of all the Departments of the country. Crude and adjusted rates (per 100,000 inhabitants) were calculated. Excel and EPI INFO 7.0 were used. Results: 495 deaths were registered; the highest prevalence was in 2019 (adjusted rate of 1.83) and the lowest in 2017 (1.36). The months with the highest mortality rates were January and July (9.9%). 51.72% were women (256), 30.91% were over 80 years old and 28.28% (140) were under 5 years old, average age 50.8, single 56.77% (281) and without any type of education 41.82% (207). A total of 80.61% (399) of the respondents resided in urban areas. The highest rates were registered in Boquerón (33.3) and Amambay (15.2). Diarrhea and gastroenteritis of infectious origin accounted for 95.56% of the cases (473). Discussion: There was a high percentage of mortality from infectious diarrhea. Extremes of life were the most vulnerable populations.

Introducción: Las enfermedades infecciosas intestinales (diarrea) son una causa importante de morbilidad y mortalidad a nivel mundial. En 2015, constituyeron la novena causa principal de muerte para todas las edades. Objetivo: describir las características epidemiológicas de la mortalidad por enfermedades infecciosas intestinales (diarreas) en Paraguay durante los años 2015 al 2019. Metodología: Estudio descriptivo, ecológico, transversal, retrospectivo, muestreo no probabilístico de casos consecutivos. Se consideraron los óbitos del CIE - 10, que incluyen al cólera (A01), fiebres tifoidea y paratifoidea (A01), shigelosis (A03), otras infecciones intestinales bacterianas (A04), otras intoxicaciones alimentarias bacterianas (A05), amebiasis (A06), otras enfermedades intestinales debidas a protozoarios (A07), infecciones intestinales debidas a virus (A08) y diarrea y gastroenteritis de presunto origen infeccioso (A09). Se utilizaron datos de acceso abierto de la página WEB de la Dirección General de Información Estratégica en Salud del MSP y BS de todos los Departamentos del país. Se calcularon tasas crudas y ajustadas (por 100.000 habitantes). Se utilizaron Excel y EPI INFO 7.0. Resultados: Se registraron 495 muertes, la mayor prevalencia fue en 2019 (tasa ajustada de 1,83) y menor en 2017 (1,36). Los meses con mayor mortalidad fueron enero y julio (9,9%). El 51,72% fueron mujeres (256), 30,91% mayores de 80 años y 28,28% (140) menores de 5 años, edad promedio 50,8, solteros 56,77% (281) y sin ningún tipo de educación 41,82% (207). El 80,61% (399) residía en área urbana. Las mayores tasas se registraron en Boquerón (33,3) y Amambay (15,2). El 95,56% (473) fueron diarreas y gastroenteritis de origen infeccioso. Discusión: Se registra alto porcentaje de mortalidad de diarreas de origen infeccioso. Los extremos de la vida constituyen la población más vulnerable.

Prevalence of irritable bowel syndrome and other functional gastrointestinal disorders in Uruguay.

INTRODUCTION AND AIMS: Irritable bowel syndrome (IBS) is one of the most frequent functional gastrointestinal disorders. Prevalence worldwide is estimated at 11%. There is little information on the prevalence of the other functional bowel disorders (FBDs). Our aim was to establish the prevalence of IBS and other FBDs according to the Rome IV criteria, in Uruguay. MATERIALS AND METHODS: An observational, population-based prevalence study was conducted. Data were collected through an online questionnaire, utilizing the Rome IV criteria. RESULTS: Of the 1,052 participants (79% women, mean patient age 44 years), 47.2% met the Rome IV diagnostic criteria for at least one of the FBDs analyzed. Functional constipation (FC) was the most frequent, at 18.7% (16.4-21.1), followed by IBS at 17.1% (14.9-19.4) and functional diarrhea (FD) at 15.4% (13.3-17.6). IBS with constipation (IBS-C) was the most frequent IBS subtype (35%) and the IBS with diarrhea (IBS-D) subtype predominated in men. All FBDs were more prevalent in women and youths. Of the survey participants with a FBD, 59% stated that they perceived no worsening of their symptoms related to the COVID-19 pandemic. CONCLUSIONS: Ours is the first prevalence study on FBDs conducted on the Uruguayan general population. Half of the participants surveyed presented with a FBD analyzed in the study. FC was the most frequent, followed by IBS and FD. The prevalence rate of IBS was the highest, based on the Rome IV diagnostic criteria, and constipation was the most frequent subtype.

[Syndromic approach in migrant patients: Fever, diarrhea, anemia, eosinophilia and chronic cough]. / Abordaje sindrómico en el paciente inmigrante: fiebre, diarrea, anemia, eosinofilia y tos crónica.

Migrant patients share the same diseases as natives, but biological or environmental differences may lead to distinct prevalence and manifestations of certain syndromes. Some common conditions in Primary Care stand out, such as fever, diarrhea, anemia, eosinophilia, and chronic cough, where it is important to have a special consideration. Fever may indicate a serious imported illness, and malaria should always be ruled out. Diarrhea is generally of infectious origin, and in most cases, management is outpatient. Anemia may indicate malnutrition or malabsorption, while eosinophilia may indicate a parasitic infection. Lastly, chronic cough may be a sign of tuberculosis, especially in immigrants from endemic areas. Family medicine holds a privileged position for the comprehensive, culturally sensitive, and person-centered approach to these conditions.

Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH–AEG–SEPD–SEOM–GETECCU / Manejo de las toxicidades digestivas secundarias al tratamiento con inhibidores de checkpoint: documento de posicionamiento de la AEEH-AEG-SEPD-SEOM-GETECCU

The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2% to 40%, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events.(AU)

El descubrimiento de los inhibidores de checkpoint inmunológicos (ICI) es uno de los logros más importantes en los últimos años en Oncología. Sin embargo, su uso en aumento ha conlllevado a un incremento de los efectos adversos inmunomediados (irAEs). Los eventos hepáticos y gastrointestinales incluyen la hepatitis, colitis y síntomas de tracto digestivo superior, que son de los irAEs más frecuentes, con incidencias entre el 2 y 40%, ésta última en paciente tratados con combo de ICI. Basados en la evidencia científica tanto de ensayo clínicos randomizados como de estudio de vida real, este documento de consenso aporta recomendaciones sobre el diagnóstico, tratamiento y pronóstico de los efectos adversos hepáticos y gastrointestinales asociados con la inmunoterapia.(AU)

[Gastrocolic fistula as infrequent cause of chronic diarrhea in a patient with percutaneous radiological gastrostomy]. / Fístula gastrocólica como causa infrecuente de diarrea persistente en un paciente portador de gastrostomía radiológica percutánea.

Introduction: Introduction: gastrocolic fistula is an infrequent but severe complication of percutaneous gastrostomy. Clinical suspicion in the presence of chronic diarrhea of unknown etiology manifesting after percutaneous radiological gastrostomy (PRG) tube replacement is key to early detection and treatment. Case report: we report the case of a patient with PRG that began with chronic diarrhea after tube replacement and developed severe malnutrition. Initial treatment was not effective, studies were extended with the finding of this complication in a CT image. The use of this tube was discontinued with resolution of diarrhea and a favorable nutritional outcome. Discussion: this case report shows the importance of considering gastrocolic fistula in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.

Introducción: Introducción: la fístula gastrocólica supone una complicación infrecuente pero potencialmente grave de las sondas de gastrostomía. La sospecha clínica ante una diarrea de origen incierto que comienza tras el recambio de la sonda es clave para la detección y el tratamiento precoces. Caso clínico: se presenta el caso de un paciente portador de gastrostomía radiológica percutánea (PRG) que comienza con diarrea persistente tras el primer recambio de la sonda y desnutrición grave secundaria. Tras el fracaso de las medidas terapéuticas iniciales se amplían los estudios, con hallazgo de esta complicación en la imagen de TC. Se suspende el uso de esta sonda con resolución de la diarrea y evolución nutricional favorable. Discusión: este caso pone de manifiesto la importancia de incluir la fístula gastrocólica en el diagnóstico diferencial de la diarrea persistente en un paciente portador de sonda de gastrostomía.

Enterocolitis and other immunotherapy and targeted therapy-related gastrointestinal manifestations: A review for gastroenterologist.

New oncologic treatments, particularly immunotherapy (IT), have revolutionized the treatment of advanced-stage malignant tumors. Immune checkpoint inhibitors are the main form of IT and act by increasing T cell activity and the organism's immune response against neoplastic cells. Targeted therapy is another form of IT that acts by inhibiting oncogenes or inflammation signaling and tumor angiogenesis pathways. However, these mechanisms of tumor destruction can interfere with the host's immune self-tolerance or with the mechanisms of epithelial tissue repair and predispose to immune system-mediated adverse events that can affect multiple organs, including the digestive tract. The gastrointestinal manifestations of damage caused by IT can range from low-grade mucositis to ulceration, and in some cases, necrosis and perforation. Any part of the gastrointestinal tract can be affected, but there is greater involvement of the small bowel and colon, with a pattern similar to that seen in inflammatory bowel disease. The most common clinical manifestation is chronic diarrhea. The differential diagnosis includes enteropathogenic infections, especially those caused by opportunistic microorganisms; adverse drug reactions; and other inflammatory and malabsorption disorders. Treatment is guided by damage severity. Mild cases can be treated with antidiarrheals and rehydration in the outpatient setting; moderate cases with hospitalization, systemic steroids, and temporary suspension of IT; and severe cases with immunosuppressants or biologic agents and definitive suspension of IT.

Duración de la diarrea aguda infecciosa con el uso de leche deslactosada vs leche con lactosa en la población pediátrica: Revisión sistemática / Duration of acute infectious diarrhea with the use of lactose-free milk vs. lactose-containing milk in the pediatric population: A systematic review

Introducción: La diarrea aguda es una entidad frecuente en pediatría, constituyendo una de las principales causas de mortalidad en países en desarrollo y en niños menores de cinco años. Si bien la alimentación representa uno de los pilares fundamentales en el tratamiento de la misma, no existe consenso entre los profesionales en cuanto a la indicación de leche deslactosada durante el curso del cuadro. Objetivos: Realizar una revisión sistemática para estudiar el impacto del consumo de leche deslactosada vs leche regular en la duración de la diarrea aguda infecciosa en niños. Materiales y métodos: Se realizó una revisión sistemática incluyendo artículos publicados desde el año 2008 al 2023, utilizando para la búsqueda las bases de datos PubMed, Lillacs, Cochrane Library y literatura gris. Se incluyeron estudios experimentales, observacionales, revisiones, guías de atención y metaanálisis, realizados en pacientes pediátricos sin patologías de base, cursando cuadro de diarrea aguda infecciosa, que compararan el uso de leche deslactosada frente a leche regular. Resultados: Se seleccionaron doce artículos. En 9 de ellos se constató una disminución en la duración de la diarrea en los pacientes que recibieron leche deslactosada con una diferencia de medias de 18 horas (en un rango entre 4 y 32.6 horas). No se reportaron diferencias estadísticamente significativas en la mortalidad entre el uso de una u otra fórmula láctea. En relación al uso de una u otra fórmula no se objetivaron variaciones en el peso estadísticamente significativas. La necesidad de hospitalización fue similar entre ambos grupos. Solo un artículo analizó la frecuencia o volumen de deposiciones sin encontrar diferencias significativas (AU)

Introduction:Acute diarrhea is frequent in pediatrics, and constitutes one of the main causes of mortality in developing countries and in children under five years of age. Although feeding is one of the fundamental pillars in the treatment of diarrhea, there is no consensus among professionals regarding the indication of lactose-free milk during the course of the symptoms. Objectives: To conduct a systematic review to study the impact of lactose-free milk vs. regular milk consumption on the duration of acute infectious diarrhea in children. Materials and methods: A systematic review was conducted including articles published between 2008 and 2023, using PubMed, Lillacs, Cochrane Library databases, and gray literature for the search. Experimental and observational studies, reviews, care guidelines and meta-analysis were included, conducted in pediatric patients without underlying diseases, with acute infectious diarrhea, comparing the use of lactose-free milk versus regular milk. Results: Twelve articles were selected. Nine of them showed a decrease in the duration of diarrhea in patients who received lactose-free milk with a mean difference of 18 hours (ranging from 4 to 32.6 hours). No statistically significant differences in mortality were reported between the use of one or the other milk formula. Regarding the use of one or the other formula, there were no statistically significant variations in weight. The need for hospital admission was similar between the two groups. Only one article analyzed stool frequency or volume with no significant differences (AU)

Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU.

The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2% to 40%, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events.

Evaluation of chronic diarrhea in patients newly diagnosed with HIV infection through the FilmArray® gastrointestinal panel.

INTRODUCTION: The treatment and diagnosis of chronic diarrhea in the immunocompromised patient depends on the ability to rapidly detect the etiologic agents. AIMS: Our aim was to evaluate the results of the FilmArray® gastrointestinal panel in patients newly diagnosed with HIV infection that presented with chronic diarrhea. MATERIAL AND METHODS: Utilizing nonprobability consecutive convenience sampling, 24 patients were included that underwent molecular testing for the simultaneous detection of 22 pathogens. RESULTS: In 24 HIV-infected patients with chronic diarrhea, enteropathogen bacteria were detected in 69% of the cases, parasites in 18%, and viruses in 13%. Enteropathogenic Escherichia coli and enteroaggregative Escherichia coli were the main bacteria identified, Giardia lamblia was found in 25%, and norovirus was the most frequent viral agent. The median number of infectious agents per patient was three (range of 0 to 7). The biologic agents not identified through the FilmArray® method were tuberculosis and fungi. CONCLUSIONS: Several infectious agents were simultaneously detected through the FilmArray® gastrointestinal panel in patients with HIV infection and chronic diarrhea.

Management of liver and gastrointestinal toxicity induced by immune checkpoint inhibitors: Position statement of the AEEH-AEG-SEPD-SEOM-GETECCU

The development of the immune checkpoint inhibitors (ICI) is one of the most remarkable achievements in cancer therapy in recent years. However, their exponential use has led to an increase in immune-related adverse events (irAEs). Gastrointestinal and liver events encompass hepatitis, colitis and upper digestive tract symptoms accounting for the most common irAEs, with incidence rates varying from 2 % to 40 %, the latter in patients undergoing combined ICIs therapy. Based on the current scientific evidence derived from both randomized clinical trials and real-world studies, this statement document provides recommendations on the diagnosis, treatment and prognosis of the gastrointestinal and hepatic ICI-induced adverse events (AU)

El descubrimiento de los inhibidores de checkpoint inmu nológicos (ICI) es uno de los logros más importantes en los últimos años en Oncología. Sin embargo, su uso en aumen to ha conlllevado a un incremento de los efectos adversos inmunomediados (irAEs). Los eventos hepáticos y gastroin testinales incluyen la hepatitis, colitis y síntomas de tracto digestivo superior, que son de los irAEs más frecuentes, con incidencias entre el 2 % y 40 %, esta última en paciente tratados con combo de ICI. Basados en la evidencia científica tanto de ensayo clínicos randomizados como de estudio de vida real, este documento de consenso aporta recomenda ciones sobre el diagnóstico, tratamiento y pronóstico de los efectos adversos hepáticos y gastrointestinales asociados con la inmunoterapia. (AU)

Revisão de literatura sobre os aspectos fisiológicos e nutricionais em bezerros alimentados com colostro acidificado / Literature review on physiological and nutritional aspects in calves fed acidified colostrum / Revisión de la literatura sobre aspectos fisiológicos y nutricionales en terneros alimentados con calostro acidificado

A colostragem é essencial para a saúde dos bezerros neonatos, uma vez que não há a transferência de imunidade através da placenta, ou seja, o contato inicial do organismo com anticorpos se dá através da primeira mamada, onde há transferência da imunidade passiva. Sendo assim, o objetivo do trabalho é revisar os benefícios da acidificação ou silagem do colostro para otimizar a conservação da dieta líquida em fazendas; analisar o impacto no desempenho de bezerros em comparação com o colostro tradicional refrigerado em aleitamentos convencionais. O volume ideal preconizado é, no mínimo, 10% do peso vivo do animal nas primeiras duas horas e mais 5% do peso vivo nas seis a oito horas seguintes a primeira ingestão, para que se obtenha um bom desenvolvimento durante o crescimento, caso contrário, a falta da administração do colostro nas primeiras horas de vida predispõe enfermidades, tais como pneumonia e diarreia, prejudicando assim a saúde e consequentemente o desempenho em relação a outros animais que receberam uma colostragem adequada. Problemas com a qualidade do colostro surgem devido ao armazenamento inadequado, especialmente em propriedades sem refrigeração. A falta de sistemas de congelamento resulta em administração de leite em temperatura ambiente por períodos prolongados, prejudicando assim a imunidade e nutrição dos bezerros durante a colostragem. Todavia, há alternativas para o problema tal como o fornecimento de silagem de colostro. Em alguns casos, o processo de acidificação demanda a adição de ácidos no leite, a fim de evitar o crescimento de microrganismos patogênicos. O principal aspecto positivo do leite acidificado é a manutenção em temperatura ambiente, ou seja, não há a necessidade de passar por processos de refrigeração.

Colostrum is essential for the health of newborn calves, since there is no transfer of immunity through the placenta, that is, the body's initial contact with antibodies occurs through the first feeding, where there is a transfer of passive immunity. Therefore, the objective of the work is to review the benefits of acidifying or colostrum silage to optimize the conservation of liquid diets on farms; analyze the impact on calf performance compared to traditional refrigerated colostrum in conventional sucklers. The recommended ideal volume is at least 10% of the animal's live weight in the first two hours and a further 5% of its live weight in the six to eight hours following the first ingestion, so that good development is achieved during growth, otherwise, the lack of colostrum administration in the first hours of life predisposes diseases, such as pneumonia and diarrhea, thus harming health and consequently performance in relation to other animals that received adequate colostrum. Problems with colostrum quality arise due to inadequate storage, especially in unrefrigerated properties. The lack of freezing systems results in milk being administered at room temperature for prolonged periods, thus damaging the calves immunity and nutrition during colostrum. However, there are alternatives to the problem such as the supply of colostrum silage. In some cases, the acidification process requires the addition of acids to the milk in order to prevent the growth of pathogenic microorganisms. The main positive aspect of acidified milk is that it remains at room temperature, that is, there is no need to undergo refrigeration processes.

El calostro es esencial para la salud de los terneros recién nacidos, ya que no existe transferencia de inmunidad a través de la placenta, es decir, el contacto inicial del cuerpo con los anticuerpos ocurre a través de la primera alimentación, donde existe una transferencia de inmunidad pasiva. Por lo tanto, el objetivo del trabajo es revisar los beneficios de acidificar o ensilar el calostro para optimizar la conservación de dietas líquidas en granjas; analizar el impacto en el rendimiento de los terneros en comparación con el calostro refrigerado tradicional en lechones convencionales. El volumen ideal recomendado es al menos el 10% del peso vivo del animal en las dos primeras horas y otro 5% de su peso vivo en las seis a ocho horas siguientes a la primera ingesta, para que se consiga un buen desarrollo durante el crecimiento, en caso contrario. la falta de administración de calostro en las primeras horas de vida predispone a enfermedades, como neumonía y diarrea, perjudicando la salud y consecuentemente el rendimiento en relación a otros animales que recibieron el calostro adecuado. Los problemas con la calidad del calostro surgen debido a un almacenamiento inadecuado, especialmente en propiedades no refrigeradas. La falta de sistemas de congelación provoca que la leche se administre a temperatura ambiente durante períodos prolongados, dañando así la inmunidad y la nutrición de los terneros durante el calostro. Sin embargo, existen alternativas al problema como el suministro de ensilaje de calostro. En algunos casos, el proceso de acidificación requiere la adición de ácidos a la leche para evitar el crecimiento de microorganismos patógenos. El principal aspecto positivo de la leche acidificada es que se mantiene a temperatura ambiente, es decir, no es necesario someterse a procesos de refrigeración.

The Mexican consensus on fecal incontinence.

Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence¼ and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.

Surveillance of Shiga toxin-producing Escherichia coli associated bloody diarrhea in Argentina / Vigilancia de diarrea sanguinolenta asociada a Escherichia coli productor de toxina Shiga en Argentina

Abstract In Argentina, hemolytic uremic syndrome (HUS) caused by Shiga toxin-producing Escherichia coli (STEC-HUS) infection is endemic, and reliable data about prevalence and risk factors have been available since 2000. However, information about STEC-associated bloody diarrhea (BD) is limited. A prospective study was performed during the period October Surveillance; 2018-June 2019 in seven tertiary-hospitals and 18 referral units from different regions, aiming of STEC-HUS cases in the same hospitals and during the same period were also assessed. Twenty-nine (4.1%) of the BD patients were STEC-positive, as determined by the Shiga Toxin Quik Chek (STQC) test and/or the multiplex polymerase chain reaction (mPCR) assay. The highest fre-quencies were found in the Southern region (Neuquén, 8.7%; Bahía Blanca, 7.9%), in children between 12 and 23 month of age (8.8%), during summertime. Four (13.8%) cases progressed to HUS, three to nine days after diarrhea onset. Twenty-seven STEC-HUS in children under 5 years of age (77.8%) were enrolled, 51.9% were female; 44% were Stx-positive by STQC and all by mPCR. The most common serotypes were O157:H7 and O145:H28 and the prevalent geno-types, both among BD and HUS cases, were sfx2a-only or -associated. Considering the endemic behavior of HUS and its high incidence, these data show that the rate of STEC-positive cases is low among BD patients. However, the early recognition of STEC-positive cases is important for patient monitoring and initiation of supportive treatment.

Resumen En Argentina, el síndrome urémico hemolítico asociado a Escherichia coli productor de toxina Shiga (STEC-SUH) es endémico y, desde 2000, de notificación obligatoria. Sin embargo, la información sobre diarrea sanguinolenta (DS) asociada a STEC (DS-STEC) es limitada. Se realizó un estudio prospectivo desde octubre de 2018 hasta junio de 2019 en siete hospitales de tercer nivel y 18 unidades de referencia de diferentes provincias argentinas, con el objetivo de determinar la frecuencia de casos de DS-STEC en 714 niños de 1 a 9 años que tuvieron DS (I) y la tasa de progresión de DS a SUH en dicha cohorte (II). También se evaluó el número y distribución regional de casos de STEC-SUH en los mismos hospitales en dicho período. Veintinueve casos de DS (4,1%) fueron STEC-positivos, determinados por Shiga Toxin Quik Chek (STQC) o PCR múltiple (mPCR). Las frecuencias más altas se encontraron en el sur del área relevada (Neuquén, 8,7%; Bahía Blanca, 7,9%), en niños de 12 a 23 meses (8,8%), en verano. Cuatro casos de DS-STEC (13,8%) progresaron a SUH, de tres a nueve días después del inicio de la diarrea. Se registraron 27 niños con STEC-SUH, estos fueron mayoritariamente <5 anos (77,8%) del sexo femenino (51,9%). El 44% de estos casos fueron Stx-positivos por STQC y todos por mPCR. Los serotipos más comunes fueron O157:H7y O145:H28, y el genotipo predominante fue stx2a, solo o asociado, en DS y SUH. Considerando el comportamiento endémico del SUH y su alta incidencia, estos datos muestran que la tasa de casos de DS-STEC es baja. Sin embargo, su reconocimiento temprano es importante para el seguimiento e inicio del tratamiento de sostén.

Severe Hypocalcemia as an Atypical Manifestation of Seronegative Celiac Disease in a Patient with Systemic Lupus Erythematosus: Case Report

Aim: To describe the clinical picture and diagnosis of an episode of severe hypocalcemia in a patient with systemic lupus erythematosus (SLE) in remission, with chronic diarrhea that led to the diagnosis of celiac disease (CD). Case presentation: 22-year-old patient, diagnosed with SLE at age 10, in remission. He consulted for a two-month history of paresthesias, muscle spasms, myalgias, and episodes of tetany in the previous week, associated with malabsorptive postprandial diarrhea. His laboratory tests showed severe hypocalcemia, vitamin D deficiency, severe hypomagnesemia, and mild hypokalemia. In the study for CD, serology reported normal anti-tissue transglutaminase IgA, antigliadin IgA, and IgG and low total IgA levels. Enteroscopy revealed erosive bulbo-duodenitis, with villous atrophy and increased intraepithelial lymphocytes in the pathology, which, together with the immunohistochemical study, allowed the diagnosis of CD, Marsh 3a type. Management was initiated with a gluten-free diet, with a positive clinical response. Conclusion: CD should be suspected in patients with SLE who present with diarrhea, abdominal pain, nausea/vomiting, recurrent oral aphthosis, and anemia. In rare seronegative CD cases, other causes of villous atrophy, mainly infectious, toxic, and immunological, must be ruled out. There is an association between CD and SLE, so diagnosis must be early and timely with the best testing scheme available to achieve effective treatment before complications occur.

Objetivo: Describir la presentación clínica y diagnóstico de un episodio de hipocalcemia grave en un paciente con lupus eritematoso sistémico (LES) en remisión, con diarrea crónica que condujo al diagnóstico de enfermedad celíaca (EC). Presentación del caso: Paciente de 22 años, con diagnóstico de LES a los 10 años, en remisión. Consultó por 2 meses de evolución de parestesias, espasmos musculares, mialgias y episodios de tetania en la semana previa, asociado a diarrea posprandial malabsortiva. Sus laboratorios mostraron hipocalcemia grave, déficit de vitamina D, hipomagnesemia grave e hipopotasemia leve. En el estudio para EC la serología reportó antitransglutaminasa tisular IgA, antigliadina IgA e IgG normales y niveles de IgA total bajos. La enteroscopia evidenció bulboduodenitis erosiva, con atrofia de las vellosidades y aumento de linfocitos intraepiteliales en la patología, que junto al estudio inmunohistoquímico permitieron concluir el diagnóstico de EC, tipo Marsh 3a. Se inició el manejo con una dieta libre de gluten, con una respuesta clínica positiva. Conclusión: La EC debe sospecharse en pacientes con LES que inicien con diarrea, dolor abdominal, náuseas/vómitos, aftosis oral recurrente y anemia. En los casos de EC seronegativa, los cuales son poco comunes, se deben descartar otras causas de atrofia de las vellosidades principalmente infecciosas, tóxicas e inmunitarias. Existe una asociación entre EC y LES, por lo cual el diagnóstico debe ser precoz y oportuno con el mejor esquema de pruebas disponible para lograr realizar un tratamiento efectivo antes de que se presenten las complicaciones.

[Pestiviruses in sheep and goats in Austria: Options for integration into the bovine viral diarrhea (BVDV) monitoring program]. / Pestiviren bei Schafen und Ziegen in ­Österreich: Möglichkeiten zur ­Einbindung in die BVDV-Überwachung.

INTRODUCTION: After the successful eradication of the bovine viral diarrhea virus (BVDV) in cattle in Austria, the risk of infections with the border disease virus (BDV) remains. Both viruses belong to the pestivirus genus. BDV infections lead to false-positive results in BVDV surveillance. This can be attributed to the contact to small ruminant populations. In particular, keeping cattle together with sheep or goats on a farm or alpine pasture are significant risk factors. Between 2015 and 2022, BDV type 3 was detected in 15 cattles in Austria. These animals were almost exclusively persistently infected calves. However, a positive antibody result for pestiviruses can lead to an extremely time-consuming and costly, and not always successful search for the source of the infection if no active virus excretor is found. This study documents how small ruminants can be integrated into pestivirus monitoring with a manageable amount of work and costs. 23 406 sheep and goat samples from two brucellosis surveillance programs in small ruminants were analyzed retrospectively. Blood samples were examined using pestivirus real-time pool RT-PCR (qPCR). Direct virus detection of BDV-3 was achieved in 40 sheep from five different federal states. Over the entire investigation period a further 37 detections of BDV-3 were found in cattle, sheep and goats outside of this study throughout Austria. This study accounts for 52 % of all border disease detections from 2015 to 2022. By including small ruminants in pestivirus monitoring, the disruptive factor BDV and the risk of its introduction into cattle herds can be significantly minimized in the future.

INTRODUCTION: Après l'éradication réussie du virus de la diarrhée virale bovine (BVDV) chez les bovins en Autriche, le risque d'infections par le virus de la Border Disease (BDV) demeure. Ces deux virus appartiennent au genre des pestivirus. Les infections par le BDV entraînent des résultats faussement positifs dans la surveillance du BVDV. Ce phénomène peut être attribué aux contacts avec les populations de petits ruminants. En particulier, la détention de bovins avec des moutons ou des chèvres sur une exploitation ainsi que les pâturages alpins sont des facteurs de risque importants pour les infections. Entre 2015 et 2022, le BDV de type 3 a été détecté chez 15 bovins en Autriche. Ces animaux étaient presque exclusivement des veaux infectés de manière persistante. Cependant, un résultat positif aux anticorps contre les pestivirus peut conduire à une recherche extrêmement longue et coûteuse et pas toujours fructueuse de la source de l'infection si aucun excréteur de virus actif n'est trouvé. Cette étude montre comment les petits ruminants peuvent être intégrés dans la surveillance des pestivirus avec une quantité de travail et des coûts gérables. À cette fin, 23 460 échantillons d'ovins et de caprins provenant de deux programmes de surveillance de la brucellose chez les petits ruminants ont été utilisés de façon rétrospective. Les échantillons de sang ont été examinés à l'aide de la RT-PCR en temps réel des pestivirus (qPCR). La détection directe du virus BDV-3 a été réalisée chez 40 moutons provenant de cinq länder différents. Sur l'ensemble de la période d'investigation (2015 ­ 2022), 37 autres détections de BDV-3 ont été effectuées chez des bovins, des ovins et des caprins en dehors de cette étude, dans toute l'Autriche. Cette étude représente 52 % de toutes les détections de Border Disease entre 2015 et 2022. En incluant les petits ruminants dans la surveillance des pestivirus, le facteur de perturbation qu'est le BDV et le risque de son introduction dans les troupeaux de bovins peuvent être considérablement minimisés à l'avenir.

Eosinophilic gastrointestinal diseases with esophageal involvement: Analysis of 212 patients / Enfermedades gastrointestinales eosinofilicas con afectación esofágica: Análisis de 212 pacientes

Background Primary eosinophilic gastrointestinal diseases (EGID) are chronic inflammatory disorders of the gastrointestinal tract with unknown etiology. Features, utility, and evolution are still unknown in screening for EGID in adult patients with eosinophilic esophagitis (EoE). Objectives To evaluate the prevalence, characteristics, comorbidities, and evolution of EGID in adults diagnosed with EoE and investigate differences between both groups. Methods Prospective unicenter observational and analytical study. Gastric and duodenal biopsies were obtained during upper baseline endoscopy in all consecutive EoE adult patients evaluated. A colonoscopy with colon biopsies was performed upon persistent diarrhea and normal duodenal biopsies. Results 212 EoE patients were included. Nine patients (4.3%) also showed significant eosinophilic infiltration in at least one organ within the digestive tract. The most common site affected was the small bowel (78%). Gastrointestinal symptoms (43% vs. 100%, p<0.002) and, more specifically, either abdominal pain or diarrhea (17% vs. 78%, p<0.001), some food sensitizations, and digestive comorbidities (p<0.05) were significantly more common in patients with EGID. Gastrointestinal symptoms were present in 94/212 (44%) patients, of whom 9 (10%) had EGID. Considering only abdominal pain or diarrhea, 20% suffered from it. Conclusions EGID rarely coexist with EoE, even when gastrointestinal symptoms are present. These findings advise against routine gastric, duodenal, or colon biopsies in adult EoE patients with gastrointestinal symptoms. Most of the characteristics of EoE do not change due to having EGID except gastrointestinal symptoms, digestive comorbidities, and sensitizations to some foods. The evolution was generally favorable despite intermittent adherence to treatment, especially maintenance (AU)

Antecedentes Las enfermedades gastrointestinales eosinofílicas primarias (EGIE) son trastornos inflamatorios crónicos del tracto gastrointestinal con etiología desconocida. Aún se desconocen las características, la utilidad y la evolución en el cribado de EGIE en pacientes adultos con esofagitis eosinofílica (EoE). Objetivos Evaluar la prevalencia, características, comorbilidades y evolución de las EGIE en adultos diagnosticados de EoE e investigar las diferencias entre ambos grupos. Métodos Estudio observacional y analítico prospectivo de un único centrro. Se obtuvieron biopsias gástricas y duodenales durante la endoscopia digestiva superior en todos los pacientes adultos con EoE consecutivos evaluados. Se realizó colonoscopia con biopsias de colon ante diarrea persistente y biopsias de duodeno normales. Resultados Se incluyeron 212 pacientes con EoE. Nueve pacientes (4,3%) también mostraron infiltración eosinofílica significativa en al menos un órgano dentro del tracto digestivo. El sitio más común afectado fue el intestino delgado (78%). Los síntomas gastrointestinales (43 vs. 100%, p < 0,002) y, más específicamente, dolor abdominal o diarrea (17 vs. 78%, p < 0,001), algunas sensibilizaciones alimentarias y comorbilidades digestivas (p < 0,05) fueron significativamente más comunes en pacientes con EGIE. Los síntomas gastrointestinales estuvieron presentes en 94/212 (44%) pacientes, de los cuales nueve (10%) tenían EGIE. Considerando solo dolor abdominal o diarrea, 20% la padecía. Conclusiones Las EGIE rara vez coexisten con EoE, incluso cuando hay síntomas gastrointestinales. Estos hallazgos desaconsejan las biopsias gástricas, duodenales o de colon de rutina en pacientes adultos con EoE con síntomas gastrointestinales. La mayoría de las características de la EoE no cambian por tener EGIE, excepto los síntomas gastrointestinales, las comorbilidades digestivas y las sensibilizaciones a algunos alimentos (AU)

Érase una vez una niña y su lindo gatito / Once upon a time there was a girl and her cute kitty

Introducción: Campylobacter es el principal patógeno de gastroenteritis transmitida por alimentos, ocurriendo generalmente por la ingesta de pollo mal cocinado, constituyendo otra importante fuente de infección los cachorros de animales domésticos. Caso clínico: escolar con gastroenteritis aguda con sospecha diagnóstica inicial de giardiasis por ambiente epidémico (gato doméstico). Se recoge coprocultivo en el que se detecta Campylobacter jejuni, prescribiéndose azitromicina, dado lo prolongado de la clínica. A lo largo del control evolutivo en el centro de salud la familia informa de que se ha solicitado nueva muestra de heces en el gato, dado persistencia de los síntomas pese a tratamiento con metronidazol. Finalmente, crece también Campylobacter jejuni en el coprocultivo de la mascota. Tras finalizar ambos el tratamiento antibiótico, permanecen asintomáticos. Como posible alimento sospechoso del origen del cuadro está el corazón de pollo no cocinado con el que alimentaban al gato de forma habitual. Conclusiones: ante un cuadro de gastroenteritis aguda es fundamental una adecuada anamnesis que incluya ambiente epidémico y alimentos sospechosos. En ocasiones las mascotas también constituyen una fuente de transmisión de la infección a nuestros pacientes. En este caso se sospecha la cadena de contaminación: corazón de pollo no cocinado-heces de gato doméstico-niña (AU)

Introduction: Campylobacter is a well-known food-borne pathogen that causes human gastroenteritis. The most common way for children to become infected with campylobacteriosis is through chicken that is not fully cooked, another important source of infection are domestic puppies.Case report: it is presented the case of an eight-year-old girl with acute gastroenteritis, the first diagnostic suspicion was giardiasis due to epidemic environment (domestic cat). A stool culture was collected in which Campylobacter jejuni was detected. Azithromycin was prescribed because of prolonged symptoms. Throughout the control in the health center, family reported that a new fecal sample has been requested from the cat due to the persistence of the symptoms despite treatment with metronidazole. Finally, Campylobacter jejuni also grew in the pet's stool culture. After both finished antibiotic treatment, they remained asymptomatic. The possible suspected infection source was the chicken heart with which the cat was regularly fed. Conclusions: the evaluation of the child with acute gastroenteritis begins with a careful history which includes epidemiological environment and suspicious food intake. Ocassionally, pets are also a source of transmission to our patients. In this case, the suspected contamination chain was: uncooked chicken heart- domestic cat faeces-girl. (AU)

Detección molecular de patógenos en deposiciones en niños consultantes por diarrea aguda en Servicios de Urgencia

Introducción: La diarrea aguda continúa siendo una de las principales causas de morbilidad en niños; sin embargo, el diagnóstico etiológico presenta limitaciones dada la baja sensibilidad de los métodos tradicionales. Objetivo: Describir los microorganismos identificados en niños que acudieron al Servicio de Urgencia (SU) de un hospital universitario en Santiago, Chile, por diarrea aguda y a los que se le solicitó panel molecular gastrointestinal. Métodos: Se revisaron fichas clínicas y resultados de panel gastrointestinal realizados entre junio de 2017 y marzo de 2020. Resultados: Se incluyeron 198 pacientes, edad promedio de 54,5 meses y 60,6% (120/198) de sexo masculino. La positividad del panel fue de 78,8% (156/198) con 35,3% (55/156) de las muestras polimicrobianas. Se identificaron 229 microorganismos, de los cuales 72,9% (167/229) corresponden a bacterias, 25,8% (59/229) a virus y 1,3% (3/229) a parásitos. Destacaron Campylobacter spp. y Escherichia coli enteropatógena (ECEP) como las bacterias más frecuentemente identificadas. Los pacientes con detección de Campylobacter spp. presentaron con mayor frecuencia fiebre (p = 0,00). ECEP se aisló principalmente (82,5%) en muestras polimicrobianas. Discusión: Los resultados enfatizan el potencial que poseen los estudios moleculares para mejorar el diagnóstico etiológico de la diarrea, pero a la vez llevan a cuestionar el rol patogénico de algunos microorganismos identificados.

Background: Acute diarrhea continues to be one of the main causes of morbidity in children, however the etiologica diagnosis presents limitations given the low sensitivity of traditional methods. Aim: To describe the microorganisms identified in children who attended the emergency department (ED) in Santiago, Chile, due to acute diarrhea and to whom a gastrointestinal panel was requested as part of their study. Material and Methods: Clinical records and results of the gastrointestinal panel carried out between June 2017 and March 2020 were reviewed. Results: 198 patients were included, the average age was 54.5 months and 60.6% (120/198) were males. Positivity was 78.8% (156/198) with 35.3% (55/156) of the samples being polymicrobial. 229 microorganisms were identified, of which 72.9% (167/229) corresponded to bacteria, 25.8% (59/229) to viruses, and 1.3% (3/229) to parasites. Campylobacter spp. and enteropathogenic Escherichia coli (EPEC) were the most frequently identified bacteria. Patients with detection of Campylobacter spp. presented a higher frequency of fever (p = 0.00). EPEC was isolated in 82.5% of the cases in polymicrobial samples. Discussion: The results emphasize the potential of molecular studies to improve the etiological diagnosis of diarrhea and at the same time lead to question the pathogenic role of some microorganisms.

Protocolo de tratamiento con polietilenglicol 3350 con electrolitos para el estreñimiento en el niño crítico / Protocol for treatment of constipation with polyethylene glycol 3350 plus electrolytes in critically ill children

Introducción y objetivos: Ningún estudio ha analizado la efectividad del tratamiento del estreñimiento en niños críticamente enfermos. El objetivo de este estudio fue evaluar la implementación, la eficacia y la seguridad de un protocolo de tratamiento con polietilenglicol 3350 con electrolitos (PEG 3350+E) para el estreñimiento en niños en estado crítico. Métodos: Estudio prospectivo unicéntrico, incluyendo niños que ingresaron en cuidados intensivos pediátricos durante más de 72h y que desarrollaron estreñimiento. Se excluyeron los niños con trastornos o afecciones gastrointestinales previas. Los pacientes fueron tratados con enemas rectales o con PEG 3350+E oral a criterio del médico tratante. Se compararon variables clínicas, demográficas y efectos secundarios (diarrea, distensión abdominal y desequilibrio electrolítico). Resultados: Se estudiaron 56 pacientes de 48,2±11,9 meses de edad, siendo el 55,4% varones. Cuarenta y cuatro pacientes (78,6%) fueron tratados con PEG 3350+E y 12 pacientes (21,4%) con enemas rectales. El porcentaje de efectividad del PEG 3350+E (79,5%) fue mayor que el de los enemas (58,3%), pero la diferencia no fue estadísticamente significativa (p=0,151). No existieron diferencias significativas en ninguno de los efectos secundarios entre los 2 grupos. El PEG 3350+E fue más efectivo en los niños menores de 2 años (100%) que en los mayores de esa edad (65,4%), p<0,01, sin diferencias significativas en la aparición de efectos secundarios. Conclusiones: El tratamiento del estreñimiento en los niños en estado crítico con PEG 3350+E es eficaz y tiene pocos efectos secundarios, incluso en niños menores de 2 años. (AU)

Introduction and objectives: No studies have analysed the effectiveness of treatment for constipation in critically ill children. The aim of this study was to assess the implementation, efficacy and safety of a treatment protocol using polyethylene glycol 3350 with electrolytes (PEG 3350+E) for constipation in critically ill children. Methods: We conducted a single-centre prospective study in children admitted to the paediatric intensive care unit for a minimum of 72h and who developed constipation. Children with previous gastrointestinal disorders or diseases were excluded. The patients were treated with rectal enemas or with the oral PEG 3350+E protocol at the discretion of the treating physician. We compared clinical and demographic variables as well as adverse events (diarrhoea, abdominal distension and electrolyte imbalances). Results: The sample included 56 patients with a mean age of 48.2±11.9 months, of who 55.4% were male. Forty-four patients (78.6%) were treated with PEG 3350+E and 12 (21.4%) with rectal enemas. The proportion of patients who responded well to treatment was greater in the PEG 3350+E group (79.5%) compared to the enema group (58.3%), but the difference was not statistically significant (P=.151). There were no significant differences between the groups in any of the adverse effects. Treatment with PEG 3350+E was more effective in children aged less than 2 years (100%) compared to older children (100% vs. 65.4%; P<.01), with no significant differences in the development of adverse events. Conclusions: The PEG 3350+E treatment protocol for constipation in critically ill children was effective and associated with few adverse events, even in children aged less than 2 years. (AU)