Long-term follow-up of 1,000 patients cured of Helicobacter pylori infection following an episode of peptic ulcer bleeding.

OBJECTIVES: To evaluate the effect of Helicobacter pylori (H. pylori) eradication on ulcer bleeding recurrence in a prospective, long-term study including 1,000 patients. METHODS: Patients with peptic ulcer bleeding were prospectively included. Prior non-steroidal anti-inflammatory drug (NSAID) use was not considered exclusion criteria. H. pylori infection was confirmed by rapid urease test, histology, or (13)C-urea breath test. Several eradication therapies were used. Subsequently, ranitidine 150 mg o.d. was administered until eradication was confirmed by (13)C-urea breath test 8 weeks after completing therapy. Patients with therapy failure received a second, third, or fourth course of eradication therapy. Patients with eradication success did not receive maintenance anti-ulcer therapy and were controlled yearly with a repeat breath test. NSAID use was not permitted during follow-up. RESULTS: Thousand patients were followed up for at least 12 months, with a total of 3,253 patient-years of follow-up. Mean age 56 years, 75% males, 41% previous NSAID users. In all, 69% had duodenal ulcer, 27% gastric ulcer, and 4% pyloric ulcer. Recurrence of bleeding was demonstrated in three patients at 1 year (which occurred after NSAID use in two cases, and after H. pylori reinfection in another one), and in two more patients at 2 years (one after NSAID use and another after H. pylori reinfection). The cumulative incidence of rebleeding was 0.5% (95% confidence interval, 0.16-1.16%), and the incidence rate of rebleeding was 0.15% (0.05-0.36%) per patient-year of follow up. CONCLUSION: Peptic ulcer rebleeding virtually does not occur in patients with complicated ulcers after H. pylori eradication. Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved. However, NSAID intake or H. pylori reinfection may exceptionally cause rebleeding in H. pylori-eradicated patients.

Endoscopic localization of colorectal cancer: study of its accuracy and possible error factors.

INTRODUCTION: accurate preoperative localization of colorectal cancer (CRC) is very important, with a wide range of published error rates. AIMS: to determine accuracy of endoscopic localization of CRC in comparison with preoperative computed tomography (CT). To analyse variables that could be associated with a wrong endoscopic localization. PATIENTS AND METHODS: endoscopic and CT localization of a series of CRC without previous surgery were reviewed. We studied the concordance between endoscopic and radiologic localization against operative findings comparing accuracy of endoscopy and CT. We analysed the frequency of wrong endoscopic diagnoses with regard to a series of patient, endoscopy and tumor variables. RESULTS: two hundred thirty seven CRC in 223 patients were studied. Concordance with surgical localization was: colonoscopy = 0.87 and CT = 0.69. Endoscopic localization accuracy was:91.1%; CT: 76.2%: p = 0.00001; OR = 3.22 (1.82-5.72). Obstructive cancer presented a higher rate of wrong localization: 18 vs. 5.7% in non-obstructive tumors (p = 0.0034; OR = 3.65 (1.35-9.96). Endoscopic localization mistakes varied depending on tumor location, being more frequent in descending colon: 36.3%, p = 0.014; OR = 6.23 (1.38-26.87) and cecum: 23.1%, p = 0.007; OR = 3.92 (1.20-12.43). CONCLUSIONS: endoscopic accuracy for CRC localization was very high and significantly better than CT accuracy. Obstructive tumor and those located in the descending colon or cecum wereassociated with a significant increase of the error risk of CRC endoscopic localization.

[The role of endoscopic ultrasonography in the etiological evaluation of idiopathic acute pancreatitis]. / Papel de la ecoendoscopia en el estudio etiológico de la pancreatitis aguda idiopática.

Up to 30% of patients with acute pancreatitis are diagnosed of idiopathic acute pancreatitis after an initial evaluation including a complete clinical history, physical examination, analysis with calcium and triglycerides determination, and at least one transabdominal ultrasonography. Unexplained pancreatitis represents a diagnostic challenge, although after different explorations a cause is found in the majority of these patients. During the last years endosonography has proved to be a low morbidity exploration very useful in the evaluation of patients with this entity. In this article we review the role of endosonography in the etiologic study of patients with idiopathic acute pancreatitis.

[Synchronous neoplastic lesions in colorectal cancer. An analysis of possible risk factors favouring presentation]. / Lesiones neoplásicas sincrónicas en el cáncer colorectal. Análisis de posibles factores que favorezcan su presentación.

AIM: few data have been published regarding the causes of synchronous lesions in patients with colorectal cancer. The aim of our study was to identify potential factors that might be implicated in the development of multicentric lesions, since this knowledge could be useful for tailored follow-up once initial synchronous lesions have been removed. METHODS: we retrospectively reviewed 382 colorectal cancer cases diagnosed by total colonoscopy and histological study of surgical specimens. We divided our population into 2 groups, based on whether they had synchronous lesions or otherwise. Several data related to personal and family history, habits, symptoms, and tumor characteristics were assessed. Univariate and multivariate statistical analyses were performed. RESULTS: 208 (54.5%) patients had synchronous adenomas and 28 (7.3%) had synchronous cancer. A multivariate analysis showed that the following parameters were consistently related to the presence of multicentric lesions--male gender: OR = 1.97; CI = 1.13-3.45; p = 0.017; age = 59 years: OR = 2.57; CI = 1.54-4.29; p < 0.001; personal history of colonic adenomas: OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructive tumors: OR = 0.48; CI = 0.27-0.85; p = 0.012. CONCLUSION: our results show that several parameters that are easy to measure could be considered risk factors for the development of multicentric lesions. These factors need to be confirmed with follow-up studies analyzing their role in patients with and without metachronic lesions once all synchronous lesions have been removed.

[Study of frequency, distribution and diagnostic performance in synchronic neoplastic lesions of colorectal carcinoma]. / Estudio de la frecuencia, distribución y rendimiento diagnóstico en las lesiones neoplásicas sincrónicas del carcinoma colo-rectal.

AIM: To analyse the frequency, characteristics and diagnosis of synchronic neoplastic lesions in colorectal cancer. METHODS: A review was carried out of 384 colorectal cancers, diagnosed through complete colonoscopy and resected. The synchronic cancers and the characteristics of the adenomas were determined: number, size, histological type, dysplasia, as well as their localisation in the colon and with respect to the carcinoma. RESULTS: Twenty-eight synchronic cancers were found (7.3% of the total); 8 developed tumours and 20 malignant polyps. In 54.4% of the cases there was a synchronic adenoma. In patients with synchronic lesions, 43% showed an advanced adenoma. Twenty percent of the synchronic polyps found were proximal to the splenic flexure; 41% were distal and 38% had both localisations. Fifty-nine point one percent of the patients had some adenoma proximal to the cancer, with criteria of advanced adenoma in 13.9%. The distribution of the adenomas was more uniformly spread in the cancers with a proximal localisation (p = 0.038). Seventeen percent of the distal cancers presented synchronic lesions with a proximal colon localisation exclusively. Partial endoscopies would diagnose the distal cancers, but would omit a synchronic adenoma in 42.3% of the sigmoidoscopies and 40% of the short colonoscopies. CONCLUSIONS: High rates of carcinoma and synchronic adenomas were registered. We underline the high index of advanced adenomas and the frequency of synchronic lesions proximal to the cancer, which is why incomplete colonoscopies, although allowing the diagnosis of the distal cancer, omit a high percentage of synchronic adenomas, including advanced lesions. All of this confirms the need to perform a complete pre-, intra- and post operational colonoscopy in resectable colorectal cancer.

[Rectal cancer staging with endoscopic ultrasonography: correlation with pathological staging]. / Estadificación del cáncer de recto mediante ultrasonografía endoscópica: correlación con la estadificación histológica.

OBJECTIVE: our aim was to evaluate the accuracy of endosonography (EUS) in our experience, to stage rectal cancer. MATERIAL AND METHODS: we prospectively included all patients with rectal cancer staged in our unit from September 2002 until February 2006 in a database. We selected those patients who had a complete EUS examination and were surgically treated without neoadjuvant therapy. Once we had the results of the histopathological staging (pTN), which was considered the gold standard, we compared the results of the previous EUS staging (uTN) with those of the pTN. We calculated the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for each T stage, and for N staging considered as N positive or negative. We also calculated the global accuracy for T stage. We also calculated the agreement of uTN with pTN staging using the kappa index for N stage, and quadratic weighted kappa index for T stage. RESULTS: we staged 120 patients with rectal cancer during the mentioned period. Of these, 36 patients met inclusion criteria and were evaluated, 21 women and 15 men. Mean age was 68,53+/-10,15 yo (range: 48-90). Global T stage accuracy was 83%. N stage accuracy was 72%. We obtained a S, E, PPV, NPV and A of 91, 100, 100, 96 and 97% for T1; 82, 88, 75, 91 and 86% for T2; 86, 91, 86, 91 and 89% for T3; and 14, 86, 20, 80 and 72% for N stage respectively. Kappa value for T stage was 0,87 indicating a "very good" agreement between uT and pT according to the kappa index criteria. Kappa value for N stage agreement was 0,005; "poor" according to the same criteria. CONCLUSIONS: in our experience, the diagnostic accuracy of EUS for T and N staging of rectal cancer is 83% and 72% respectively, similar results as previously published. uT staging for rectal cancer shows a "very good" agreement with pT staging.

[Relation between preoperative prognostic Onodera's Index and postsurgery complications in the R0 gastric carcinoma resection]. / Relación entre el índice de Onodera pre-operatorio y las complicaciones post-cirugía R0 en el cáncer de estómago.

BACKGROUND: It has been postulated in the Asian literature that a low prognostic nutritional index (OI) could be associated with a higher rate of complications following radical gastric cancer surgery, but there is a lack of data concerning western countries. The aim is to analyze the relationship between a low preoperative OI and the frequency and severity of surgical complications in R0 gastric cancer resection. PATIENTS AND METHODS: In the present article, 124 cases of gastric cancer with R0 resection were reviewed. An OI <45 was considered pathologically low. The complication rate was compared between both groups: OI <45 vs OI =45. A multivariate analysis was performed adjusting for: age > 68 years, ASA score, preoperative hemoglobin level <12 g/dL, pTNM stage, administration of neoadyuvant therapy and type of gastrectomy. The relationship between a PNI<45 and the severity of complications graded according to the Clavien-Dindo classification was determined. RESULTS: We registered mild complications in 11.3% of cases, severe complications in 9.7% and a mortality rate of 2.4%. Patients with a OI <45 showed a higher complication rate: 37.7% versus 12.7% [odds ratio (OR) = 4.17; CI95% = (1.71 - 10.20 p = 0.001)], confirmed by multivariate analysis: [OR = 4.17; CI95% = (1.54 - 11.30); p = 0.005]. Patients with OI <45 had more severe complication-exitus: 20.8% versus 5.6% [OR = 4.39; CI95% = (1.31 - 14.68); p = 0.011]. CONCLUSIONS: We confirmed that patients with a low preoperative OI show a higher independent risk of complications after a R0 gastric cancer resection in a western country as well. Complications, in these cases with OI <45, registered a significantly higher severity grade.

Informed consent document in gastrointestinal endoscopy: understanding and acceptance by patients.

OBJECTIVE: We wanted to know if patients read and understand the informed consent (IC) document used for endoscopic procedures, and to evaluate the readability of IC. METHOD: During two months we gave patients studied in our endoscopy unit an anonymous questionnaire with different items concerning reading degree, knowledge of the technique, complications, sedation used, and information received. We evaluated IC readability using the Flesch index. RESULTS: 309 patients were included (mean age: 53 years, 55% males, 86% outpatients, 50% with basic education); 85% of patients read the IC, 96% considered they understood the exploration technique, 22% were not aware of severe complications, and 82% knew which kind of sedation would be used; 88% of patients received additional information from their doctors. Outpatients read the IC in a greater percentage versus inpatients (p < 0.05); patients with only basic education tended to ignore the possibility of complications (p < 0.05). Doctors gave more information to rural patients (p = 0.08), offered better information about complications to urban patients (p = 0.09), and offered more information on other diagnostic procedures to patients older than 50 years (p < 0.05). With the Flesch index we found that gastroscopy and colonoscopy ICs had a "standard" level of readability, while ERCP ICs were more complex. CONCLUSIONS: The majority of our patients read and understands the IC. Doctors adapt information to patient characteristics. Our IC documents have an acceptable level of readability, but given that 50% of our patients have only a basic educational status, we should attempt to provide an easier IC document.

Complete rectal prolapse clinical and functional outcome with Delorme's procedure.

INTRODUCTION: Many surgical techniques -both through the perineal and abdominal routes- have been described for the treatment of rectal prolapse. The aim of this work is to evaluate the clinical and functional outcome with Delorme's perineal procedure. PATIENTS AND METHODS: Twenty-one patients with complete rectal prolapse were studied from July 2000 to October 2005. Age, gender, anesthetic risk, and accompanying symptoms were all assessed. Diagnostic tests performed included: colonoscopy, anorectal manometry before and after surgery, and 360 masculine endoanal ultrasonography. Delorme's procedures were carried out by only one surgical team. RESULTS: No mortality occurred, and morbidity was minimal. Prolapse relapse rate was 9.52% with a mean follow-up of 34 months. Anal continence improved in 87.5% of patients, and no surgery-associated constipation ensued. Mean hospital stay was 2 (range 1-4) days. During the postoperative period no pain developed in 17 patients, and 4 patients had mild pain. Satisfaction with surgery was high in 16 cases (76.19%), moderate in 3 (14.28%), and low in 2 (9.52%). CONCLUSIONS: Delorme's procedure for the management of complete rectal prolapse is associated with low morbidity, improves anal continence, gives rise to no postsurgical constipation, and has an acceptable relapse rate. Patient satisfaction with this procedure is high because of its high comfortability (intradural anesthesia, short hospital stay, and little postoperative pain) and optimal results.

[Utility of bolus somatostatin administration in preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a controlled, non-randomized study]. / Utilidad de la somatostatina administrada en bolo para prevenir la pancreatitis tras CPRE: estudio controlado no aleatorizado.

INTRODUCTION: Somatostatin is one of the most extensively evaluated drugs in the prophylaxis of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP), but its utility remains controversial. PATIENTS AND METHODS: The aim of this study was to evaluate the role of somatostatin as prophylaxis of ERCP-induced acute pancreatitis. A group of consecutive patients that underwent ERCP in our endoscopy unit was prospectively studied for 8 months. Patients in this group were administered an endovenous bolus of 250 micrograms of somatostatin immediately before introducing the catheter in the papilla of Vater (somatostatin group). This group was compared with another group composed of consecutive patients who had undergone ERCP in the 8 previous months, without somatostatin administration (placebo group). Both groups contained the same number of patients. The following variables were recorded; sex, age, contrast injection in the duct of Wirsung, endoscopist, therapeutic maneuvers, and the development of post-ERCP pancreatitis. RESULTS: During the 16 months of patient inclusion, we performed 320 ERCP in our unit, of which 248 were included in the study: 142 in the somatostatin group and 142 in the placebo group. Of these patients, 152 (53.5%) were men and 132 (46.5%) were women. The mean age was 70.05 +/- 13.83 years (range: 27-93 years). Acute pancreatitis occurred in 10 patients in the somatostatin group and in 5 in the placebo group; this difference was not statistically significant (p > 0.05). No significant differences were found between the two groups in the remaining variables studied. CONCLUSION: Somatostatin does not seem to be useful in preventing post-ERCP acute pancreatitis.

[Predictive pre-treatment value of the Prognostic Nutritional Index on survival in gastric carcinoma]. / Valor predictivo pre-tratamiento del Índice Pronóstico Nutricional sobre la supervivencia del carcinoma gástrico.

BACKGROUND: The Prognostic Nutritional Index (PNI) combines the values of circulating lymphocytes and serum albumin and, in the Asian literature; it has been related with the prognosis following R0 resection of gastric cancer. No results are available in Western countries. We study the possible independent prognostic value, at the moment of the tumour's diagnosis, of PNI on survival. PATIENTS AND METHODS: We review 234 consecutive gastric carcinomas, calculating global survival and tumour-specific survival. We considered pre-treatment PNI values of < 40 to be pathological. We carried out a univariate and multivariate analysis of cases of survival according to PNI, including the following adjustment variables: age > 70 years, ASA anaesthetic at the time of diagnosis, size of the neoplasia > 5cm, macroscopic type, undifferentiated degree and TNM clinical stage through echoendoscopy and/or CAT. RESULTS: The univariate analysis registered greater global and specific survival in cases with PNI ≥ 40 versus PNI < 40: [HR = 2.28; CI 95% = (1.60-3.26); p< 0.001] and [HR = 2.35; CI 95% = (1.63-3.39); p< 0.001], respectively. The multivariate analysis confirmed a better independent prognosis in cases with OI ≥ 40: global survival: [HR = 1.48; CI 95% = (1.02-2.16); p = 0.040], specific survival: [HR = 1.51; CI 95% = (1.03-2.23); p = 0.036]. CONCLUSIONS: At the moment of diagnosis of gastric cancer and including all registered cases, a PNI ≥ 40 is accompanied by a signifi-cantly greater global and tumour-specific survival. In our series, this better prognosis is independent of the patient's age group, his/her ASA classification, the size and degree of differentiation of the neoplasia and its TNM clinical stage.

Subcutaneous venous reservoir implant: our experience in 1200 cases.

We present our experience in subcutaneous venous reservoir (SVR) implanting, laying emphasis on the surgical technique, the protocol followed for assessing difficulty, implant care and per- and post-implant complications and their management. Between March 1996 and December 2002 we installed 1200 SVRs on an outpatient basis, with subsequent result follow-up. The reservoir was successfully installed by the standard procedure in 99.33% of cases (1194), while in the remaining six patients (0.67%) the participation of the Intervention Radiology Department was required for correct implantation. Results were excellent with a morbidity of 3.3% and we had to single out two cases of immediate infection (0.16%), nine of tardive infection (over three months); twelve cases of pneumothorax (1%); seven episodes of venous thrombosis (0.58%) and four cases of catheter migration (0.3%). SVR implanting is possible on an outpatient basis but requires strict measures of asepsis and an experienced team and personnel responsible for its handling and maintenance, although there are a small number of complications inherent in the patient's general state.

Indications, diagnostic tests and Helicobacter pylori eradication therapy. Recommendations by the 2nd Spanish Consensus Conference.

The results of the 2nd Spanish Consensus Conference for appropriate practice regarding indications for eradication, diagnostic tests, and therapy regimens for Helicobacter pylori infection are summarized. The Conference was based on literature searches in Medline, abstracts from three international meetings, and abstracts from national meetings. Results were agreed upon and approved by the whole group. Results are supplemented by evidence grades and recommendation levels according to the classification used in the Clinical Practice Guidelines issued by Cochrane Collaboration. Convincing indications (peptic ulcer, duodenal erosions with no history of ASA or NSAIDs, MALT lymphoma), and not so convincing indications (functional dyspepsia, patients receiving low-dose ASA for platelet aggregation, gastrectomy stump in patients operated on for gastric cancer, first-degree relatives of patients with gastric cancer, lymphocytic gastritis, and Ménétrier s disease) for H. pylori eradication are discussed. Diagnostic recommendations for various clinical conditions (peptic ulcer, digestive hemorrhage secondary to ulcer, eradication control, patients currently or recently receiving antibiotic or antisecretory therapy), as well as diagnostic tests requiring biopsy collection (histology, urease fast test, and culture) when endoscopy is needed for clinical diagnosis, and non-invasive tests requiring no biopsy collection (13C-urea breath test, serologic tests, and fecal antigen tests) when endoscopy is not needed are also discussed. As regards treatment, first-choice therapies (triple therapy using a PPI and two antibiotics), therapy length, quadruple therapy, and a number of novel antibiotic options as "rescue" therapy are prioritized, the fact that prolonging PPI therapy following effective eradication is unnecessary for patients with duodenal ulcer but not for all gastric ulcers is documented, the fact that cultures and antibiograms are not needed for all eradicating therapies is indicated, and finally the test and treat strategy is considered adequate, however only under certain circumstances.

Hyperplastic polyposis of the colorectum and adenocarcinoma in a 24-year-old man.

Hyperplastic polyps in the large intestine are considered common after the age of 40, devoid of neoplastic transformation capability, and have a well-defined histological picture. Nevertheless, there exists evidence that hyperplastic polyps can present with adenomatous areas, eventually leading to carcinoma. There has been a suggestion in certain cases that a transformational sequence might exist in the genesis of colorectal cancer: hyperplastic polyp-adenoma-adenocarcinoma. Adenocarcinoma resulting from a pure hyperplastic polyp has also been described. These data have generated reconsideration of the significance of hyperplastic polyps in relation to cancer. In this paper we present a 24-year-old man with adenocarcinoma of the colon who underwent a right hemicolectomy. Twenty-eight hyperplastic polyps were found in the surgical specimen. Two of these polyps had adenomatous areas. The patient died 18 months after the surgical resection.

Multivariate analysis of prognostic factors in resected colorectal cancer: a new prognostic index.

OBJECTIVE: We analysed different clinicopathological variables in colorectal cancer and their independent prognostic significance in order to elaborate a prognostic index, which may be used to categorize patients into homogeneous groups and indicate adjuvant therapy. DESIGN: Retrospective study. METHODS: Patients (n = 108) undergoing surgery for colorectal cancer were studied (5-year-survival was controlled). Different clinicopathological variables and biological parameters (tumoural ploidy, proliferating cell nuclear antigen PCNA and nucleolar organizing regions NORs) were analysed. The Kaplan-Meier method and log-rank test were used for univariate analysis and the Cox regression method was used for multivariate analysis. RESULTS: Some variables with prognostic effect in univariate analysis (e.g. rectal bleeding, altered bowel habit, intestinal obstruction, type of surgery, histological type, venous and neural invasion and invasive margin) did not have independent prognostic significance after Cox analysis. Final multivariate analysis model was defined by five parameters: postoperative carcinoembryonic antigen, Astler-Coller-Turnbull staging, histological grade, lymphatic invasion and tumour ploidy. A new prognostic index was elaborated that provided information to group patients in three prognostic categories of different risk: high, medium and low. CONCLUSION: The prognostic index allowed categorization of patients into different risk groups with identical tumoural stage and histological grade. Therefore, this index provides better prognostic information that may be helpful when selecting patients for adjuvant therapy.

[Early prognosis of acute pancreatitis (author's transl)]. / Aproximación al pronóstico precoz en la pancreatitis aguda.

One hundred patients with acute pancreatitis are studied. The results in 90 cases were "favorable or very favorable", in ten cases "unfavorable or death". Various different characterisitics were analyzed statistically in relationship to the two types of outcome: sex, clinical histories, and results of physical examination. Furthermore, the individual relationships between age, main initial analytic parameters, and later development were determined. In our experience neither age nor sex, considered individually, showed a significant relationship to the seriousness of the disease. Having had pancreatitis previously proved to be a favorable factor (p less than 0.005). None of the other factors in the case histories showed any bearing of the later course of the condition. Findings in physical examination which were signs of unfavorable prognosis included jaundice (p less than 0.001), low blood pressure (p less than 0.001), tachycardia (p less than 0.005), intestinal paresia (p less than 0.001), pain following decompression (p less than 0.025), and abdominal tenderness (p less than 0.05). Abnormalities in ECG (p less than 0.005), marked leukocytosis (p less than 0.0005), hyperglycemia (p less than 0.02), hypocalcemia (p less than 0.05), and high values for the coefficient of amilase/creatinine clearance (p less than 0.01) also suggested an unfavorable course.

[Helicobacter pylori infection. The Spanish consensus report. The Spanish Consensus Conference Group]. / Conferencia Española de Consenso sobre la infección por Helicobacter pylori.

OBJECTIVES: taking into account the small amount of infection eradication treatments carried out in our country and some characteristics arising from the resistances to some antibiotics, the Spanish Club for the Study of Helicobacter pylori decided to organize a Spanish Consensus Conference to clarify the use of the different infection diagnostic tests, to establish the exact indications of its diagnosis and treatment, to recommend the best treatment guidelines for our country and to promote the use of eradication treatments in adequate indications. DESIGN: on April 23, 1999 in Madrid, physicians who were experts in infection by Helicobacter pylori representing the different Scientific Societies of our country were gathered. Prior to this, three work areas, diagnosis, indications and treatments, were created and the participants freely joined them. One month before the conference, all of the participants were sent the questions which would be debated. An 80% consensus level, always based on scientific evidence, was required for a recommendation. In the first session, a meeting by work areas was held and in a second session, all of the recommendations were voted on in the meeting of the representatives. CONCLUSIONS: the conference recommends the eradication of the infection in all the gastric or duodenal ulcers, in the erosive duodenitis, in the MALT lymphomas and in gastrectomized patients due to gastric cancer with residual stomach. In the de novo diagnoses of gastroduodenal ulcer, the rapid test of urease is recommended, and a histological study is recommended only if it is negative. In the case of a history of ulcers and also to know the eradication treatment result, the C13 urea breath test is recommended. The culture is reserved for primary treatment and rescue treatment failures so as to select the adequate antibiotic. The primary treatment regimes recommended for our country mean the combination of amoxicillin, clarithromycin and any proton pump inhibitor or with Ranitidine bismuth citrate. If there is allergy to penicillin, amoxycillin will be substituted by metronidazol.

[A patient with Mirizzi's syndrome. The diagnostic and therapeutic considerations]. / Paciente con síndrome de Mirizzi. Consideraciones diagnósticas y terapéuticas.

A 35-year-old woman presented with a 4-month history of jaundice and pruritus. Endoscopic retrograde cholangiography (ERC) showed a partially obstructed common hepatic duct with a smooth and curved laterally based compression defect having the appearance of being secondary to an impacted gallbladder stone. Gallbladder filled with contrast medium but the cystic duct was not visualized, thus suggesting cholecystobiliary fistula formation. According to these radiologic findings, the diagnosis of Mirizzi syndrome was made. We discuss differential diagnosis, therapeutic aspects and the importance of preoperative diagnosis.

[Analysis of suggestive endoscopic characteristics in the preoperative diagnosis of gastric lymphoma]. / Análisis de los rasgos endoscópicos sugestivos en el diagnóstico preoperatorio del linfoma gástrico.

We study the diagnostic value of some macroscopic features which might be considered suspicious of lymphoma (RESL): thickened gastric folds, diffuse involvement, shallow star shaped ulcers, net lesion limits, size > 6 cm., supracisural location and duodenal involvement. We analyze their overall incidence in 36 primary gastric lymphomas, considering possible differences of each feature between pre and post surgery diagnostic achievement. Preoperative diagnosis was related with the total number of RESL (p < 0.01). Diagnosis of lymphoma was highly suspicious when two or more of these features were present. Supracisural location (p = 0.0008) and shallow star shaped ulcers (p = 0.07) were the most significant RESL. Although RESL sensitivity has been low in the diagnosis of gastric lymphoma, we have found a high specificity for the presence of star shaped ulcers, diffuse involvement and duodenal involvement, which might be an aid in differential diagnosis.

[Massive lower digestive hemorrhage caused by colonic ulcers secondary to cholesterol embolism]. / Hemorragia digestiva baja masiva por úlceras cólicas secundarias a embolismo de colesterol.

Cholesterol crystal embolization has been considered an unusual entity with poor short term prognosis. However, it is an underestimated complication according to post-mortem findings. Patients have quite characteristic risk and precipitating factors which may be an aid to suspect the diagnosis. Gastrointestinal bleeding of different severity occurs in only 10% of patients with visceral embolization. We present the case of a patient with massive lower gastrointestinal bleeding secondary to several ulcerations in the hepatic flexure due to bowel cholesterol embolization.