RESUMO
INTRODUCTION: Risk factors for developing pancreatitis due to thiopurines in patients with inflammatory bowel disease (IBD) are not clearly identified. Our aim was to evaluate the predictive pharmacogenetic risk of pancreatitis in IBD patients treated with thiopurines. METHODS: We conducted an observational pharmacogenetic study of acute pancreatitis events in a cohort study of IBD patients treated with thiopurines from the prospectively maintained ENEIDA registry biobank of GETECCU. Samples were obtained and the CASR, CEL, CFTR, CDLN2, CTRC, SPINK1, CPA1, and PRSS1 genes, selected based on their known association with pancreatitis, were fully sequenced. RESULTS: Ninety-five cases and 105 controls were enrolled; a total of 57% were women. Median age at pancreatitis diagnosis was 39 years. We identified 81 benign variants (50 in cases and 67 in controls) and a total of 35 distinct rare pathogenic and unknown significance variants (10 in CEL, 21 in CFTR, 1 in CDLN2, and 3 in CPA1). None of the cases or controls carried pancreatitis-predisposing variants within the CASR, CPA1, PRSS1, and SPINK1 genes, nor a pathogenic CFTR mutation. Four different variants of unknown significance were detected in the CDLN and CPA1 genes; one of them was in the CDLN gene in a single patient with pancreatitis and 3 in the CPA1 gene in 5 controls. After the analysis of the variants detected, no significant differences were observed between cases and controls. CONCLUSION: In patients with IBD, genes known to cause pancreatitis seem not to be involved in thiopurine-related pancreatitis onset.
Assuntos
Doenças Inflamatórias Intestinais , Pancreatite , Sistema de Registros , Humanos , Feminino , Pancreatite/induzido quimicamente , Pancreatite/genética , Masculino , Adulto , Estudos de Casos e Controles , Doenças Inflamatórias Intestinais/genética , Doenças Inflamatórias Intestinais/tratamento farmacológico , Pessoa de Meia-Idade , Predisposição Genética para Doença , Fatores de Risco , Variação Genética , Mercaptopurina/efeitos adversos , Mercaptopurina/uso terapêuticoRESUMO
BACKGROUND AND AIMS: Familial inflammatory bowel disease (IBD) history is a controversial prognostic factor in IBD. We aimed to evaluate the impact of a familial history of IBD on the use of medical and surgical treatments in the biological era. METHODS: Patients included in the prospectively maintained ENEIDA database and diagnosed with IBD after 2005 were included. Familial forms were defined as those cases with at least one first-degree relative diagnosed with IBD. Disease phenotype, the use of biological agents, or surgical treatments were the main outcomes. RESULTS: A total of 5263 patients [2627 Crohn's disease (CD); 2636 ulcerative colitis (UC)] were included, with a median follow-up of 31 months. Of these, 507 (10%) corresponded to familial forms. No clinical differences were observed between familial and sporadic IBD forms except a lower age at IBD diagnosis and a higher rate of males in familial forms of UC. In CD, the proportions of patients treated with thiopurines (54.4% vs 46.7%; P = .015) and survival time free of thiopurines (P = .009) were lower in familial forms. No differences were found regarding the use of biological agents. Concerning surgery, a higher rate of intestinal resections was observed in sporadic CD (14.8% vs 9.9%, P = .027). No differences were observed in UC. CONCLUSIONS: In the era of biological therapies, familial and sporadic forms of IBD show similar phenotypes and are managed medically in a similar way; whether these is due to lack of phenotypical differences or an effect of biological therapies is uncertain. What is already known on this topic: IBD's etiopathogenesis points to an interaction between environmental and genetic factors, being familial history a controversial prognostic factor. Biological agents use and need for surgery regarding familial or sporadic forms of IBDs present conflicting results. What this study adds: Familial and sporadic forms of IBD have similar phenotypes and are managed medically and surgically in a similar way. How this study might affect research, practice or policy: Familial aggregation should not be considered a factor associated with more aggressive disease.
RESUMO
Background: Infliximab seems to be the most efficacious of the three available anti-TNF agents for ulcerative colitis (UC) but little is known when it is used as the second anti-TNF. Objectives: To compare the clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in UC patients. Design: Retrospective observational study. Methods: Patients from the ENEIDA registry treated consecutively with infliximab and a subcutaneous anti-TNF (or vice versa), naïve to other biological agents, were identified and grouped according to the administration route of the first anti-TNF into IVi (intravenous initially) or SCi (subcutaneous initially). Results: Overall, 473 UC patients were included (330 IVi and 143 SCi). Clinical response at week 14 was 42.7% and 48.3% in the IVi and SCi groups (non-statistically significant), respectively. Clinical remission rates at week 52 were 32.8% and 31.4% in the IVi and SCi groups (nonsignificant differences), respectively. A propensity-matched score analysis showed a higher clinical response rate at week 14 in the SCi group and higher treatment persistence in the IVi group. Regarding long-term outcomes, dose escalation and discontinuation due to the primary failure of the first anti-TNF and more severe disease activity at the beginning of the second anti-TNF were inversely associated with clinical remission. Conclusion: The use of a second anti-TNF for UC seems to be reasonable in terms of efficacy, although it is particularly reduced in the case of the primary failure of the first anti-TNF. Whether the second anti-TNF is infliximab or subcutaneous does not seem to affect efficacy.
OBJECTIVES: To compare the clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in UC patients. DESIGN: Retrospective observational study. METHODS: Patients from the ENEIDA registry treated consecutively with infliximab and a subcutaneous anti-TNF (or vice versa), naïve to other biological agents, were identified and grouped according to the administration route of the first anti-TNF into IVi (intravenous initially) or SCi (subcutaneous initially). RESULTS: Overall, 473 UC patients were included (330 IVi, 143 SCi). Clinical response at week 14 was 42.7% and 48.3% in the IVi and SCi groups (non-statistically significant), respectively. Clinical remission rates at week 52 were 32.8% and 31.4%, in the IVi and SCi groups (nonsignificant differences), respectively. A propensity-matched score analysis showed a higher clinical response rate at week 14 in the SCi group and higher treatment persistence in the IVi group. Regarding long-term outcomes, dose escalation and discontinuation due to the primary failure of the first anti-TNF and more severe disease activity at the beginning of the second anti-TNF were inversely associated with clinical remission. CONCLUSION: The use of a second anti-TNF for UC seems to be reasonable in terms of efficacy, although it is particularly reduced in the case of the primary failure of the first anti-TNF. Whether the second anti-TNF is infliximab or subcutaneous does not seem to affect efficacy.
Clinical and treatment outcomes of a second subcutaneous or intravenous anti-TNF in patients with ulcerative colitis treated with two consecutive anti-TNF agents. Data from the ENEIDA registry Background: Infliximab seems to be the most efficacious of the three available anti-TNF agents for ulcerative colitis (UC), but little is known when it is used as the second anti-TNF.
RESUMO
The COVID-19 pandemic has been a challenge for countries and health professionals worldwide. Viral entry by ACE-2 receptor and an excessive activation of the immune system are key to understand both incidence and severity of disease. Inflammatory Bowel Disease (IBD) represents a special condition associated with an inordinate response of the immune system to external agents. IBD treatments have been associated to an increased risk of bacterial and viral infections. This has raised the question of possible higher incidence and severity of COVID-19 infection in IBD patients. Several papers have been published during this year of pandemic to answer that question. Moreover, COVID-19 vaccination offers great promise in controlling infection in patients with IBD. Based on current evidence, patients with IBD do not have a higher incidence of COVID-19 than the general population, and they do not have worse disease evolution. Advanced age and presence of a greater number of comorbidities have been associated with worse outcomes, similar to the general population. Corticosteroids are associated to an increased risk of COVID-19 infection, higher hospitalization rate and higher risk of severe COVID-19. 5-ASA/Sulfasalazine and Thiopurines have a possible increased risk of severe COVID-19, although studies are lacking. On the other hand, Anti-TNF may have a possible protective effect. It is recommended to maintain the treatment. Anti-IL-12/23, anti-integrins and tofacitinib have results comparable to anti-TNF. Based on the efficacy, expert recommendations, and the absence of other evidence, it is recommended that patients with IBD be vaccinated.(AU)
La pandemia por COVID-19ha supuesto un reto para los países y sus profesionales sanitarios. La entrada viral en el hospedador a través del receptor ACE-2 y una activación excesiva del sistema inmunológico son claves para comprender tanto la incidencia como la gravedad de la enfermedad. La enfermedad inflamatoria intestinal (EII) representa una condición especial asociada con una respuesta descontrolada del sistema inmunológico a agentes externos. Los tratamientos para la EII se han asociado con un mayor riesgo de infecciones bacterianas y virales, lo que ha planteado la cuestión de una posible mayor incidencia y gravedad de la infección por COVID-19 en pacientes con EII. A lo largo del año 2021 se han publicado varios artículos que tratan de responder esta cuestión. La vacunación contra la COVID-19 ofrece una gran promesa para controlar la infección en pacientes con EII. Según la evidencia actual, los pacientes con EII no tienen mayor incidencia de COVID-19 ni peor evolución de la enfermedad en comparación con la población general. La edad avanzada y la presencia de un mayor número de comorbilidades se han asociado con peores resultados. Los corticosteroides están asociados con un mayor riesgo de infección por COVID-19, una mayor tasa de hospitalizaciones y un mayor riesgo de enfermedad grave. La mesalazina/sulfasalazina y las tiopurinas presentan un posible aumento del riesgo de COVID-19 grave, aunque se requieren más estudios para demostrar esta asociación. Dentro de los fármacos biológicos, los anti-TNF pueden tener un posible efecto protector. Los anti-IL-12/23, anti-integrinas y tofacitinib presentan resultados comparables con anti-TNF. Se recomienda mantener el tratamiento con agentes biológicos. Con base en la eficacia, las recomendaciones de los expertos y la ausencia de otra evidencia, se recomienda la vacunación de pacientes con EII.(AU)
Assuntos
Humanos , Masculino , Feminino , Vacinas , Betacoronavirus/imunologia , Doenças Inflamatórias Intestinais/complicações , Doenças Inflamatórias Intestinais/tratamento farmacológico , Pandemias , Gastroenterologia , Doenças TransmissíveisRESUMO
Las recomendaciones son consejos dados por considerarse beneficiosos y no dejan de ser sugerencias, abiertas por tanto a diferentes interpretaciones. En ese sentido, el objetivo final de la revisión ha sido, con las evidencias disponibles, intentar homogeneizar al máximo la aproximación al diagnóstico y tratamiento medicoquirúrgico de una de las manifestaciones más complejas de la enfermedad de Crohn como son las fístulas perianales simples y complejas
Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas
Assuntos
Humanos , Fístula Retal/terapia , Doença de Crohn/epidemiologia , Colite Ulcerativa/terapia , Doença de Crohn/cirurgia , Doença de Crohn , Consenso , Índice de Gravidade de DoençaRESUMO
Los trastornos motores y funcionales anorrectales son frecuentes en la población general. La manometría anorrectal permite estudiar la actividad motora anorrectal en reposo y simulando diferentes situaciones fisiológicas. La manometría anorrectal de alta resolución (MAR-AR) y de alta definición (MAR-AD) están utilizándose cada vez con más frecuencia en la práctica clínica. Con respecto a la técnica convencional, los catéteres de la MAR-AR y los de la MAR-AD proporcionan un mayor número de puntos de registro, ya que disponen de muchos sensores circunferenciales muy próximos entre sí. Ello permite la visualización en relación témporo-espacial (modo topográfico en 2 o 3 planos) al obtener un registro de presión continuo en el espacio por interpolación entre sensores muy próximos. La MAR-AR y la MAR-AD nos permiten realizar la técnica de una forma más estandarizada y reproducible y obtener un mejor estudio y comprensión de la anatomía funcional del complejo esfinteriano. Están desarrollándose nuevos parámetros específicos apropiados para utilizarse en la actualidad con estos sistemas y están siendo evaluados por diversos grupos de investigación, por lo que muchos de ellos no están disponibles para utilizarse en la práctica clínica. No obstante, aportan información muy relevante que está permitiendo redefinir la anatomía y la fisiología anorrectales. El objetivo de la presente revisión es describir las técnicas existentes para MAR-AR y MAR-D, exponer los valores publicados de normalidad y analizar los nuevos parámetros que estas técnicas permiten evaluar y que, posiblemente, en un futuro próximo serán de gran utilidad en la práctica clínica
Anorectal motor and functional disorders are common among the general population. Anorectal manometry allows the study of anorectal motor activity both at rest and mimicking different physiological situations. High-resolution anorectal manometry (HR-ARM) and high-definition anorectal manometry (HD-ARM) are increasingly used in clinical practice. In comparison with the conventional technique, HR-ARM and HD-ARM catheters provide a higher number of recording points because of their many, closely packed circumferential sensors. This allows time-space visualization (topographic or 2-3-plane mode) as spatially continuous measurements are obtained by interpolation between near sensors. HR-ARM and HD-ARM allow a more standardized, reproducible technique, and a better assessment and understanding of the functional anatomy of the sphincter complex. Newer specific parameters are now being developed for use with these systems. They are being currently assessed by multiple research teams, and many of them remain unavailable for clinical practice as of today. However, they provide highly relevant information, which is now prompting a redefinition of anorectal anatomy and physiology. The goal of the present review was to describe the currently available HR-ARM and HD-ARM techniques, to discuss the normal values so far reported, and to analyze the newer parameters that may be assessed with these techniques, and which will likely be highly useful for clinical practice in the upcoming future
Assuntos
Humanos , Manometria/métodos , Canal Anal/fisiologia , Constipação Intestinal/reabilitação , Incontinência Fecal/reabilitação , Fenômenos Fisiológicos do Sistema DigestórioRESUMO
Objetivos. Establecer recomendaciones para el manejo de los aspectos psicológicos de los pacientes con enfermedad inflamatoria intestinal (EII). Métodos. Se llevó a cabo una reunión con un grupo de expertos en EII formado por médicos, psicólogos, enfermeras y representantes de pacientes. Se presentaron resultados de: 1) un grupo focal previo, 2) encuestas a médicos y pacientes y 3) una revisión sistemática sobre instrumentos de cribado de ansiedad y depresión. Se realizó una discusión guiada sobre los aspectos psicológicos y emocionales más importantes en EII, los criterios de derivación apropiados y situaciones a evitar. Se seleccionó el instrumento validado más aplicable a la práctica clínica. Se diseñó un documento con recomendaciones, así como una encuesta Delphi. La encuesta fue enviada al grupo y a un comité científico seleccionado del grupo GETECCU, con el objetivo de establecer el grado de apoyo a las recomendaciones establecidas. Resultados. Se establecieron 15 recomendaciones, pertenecientes a 3 procesos clave: 1) qué pasos dar para identificar problemas psicológicos en consulta de EII, 2) criterios de derivación a profesionales de la salud mental y 3) abordaje de los problemas psicológicos. Conclusiones. Se deben facilitar recursos a los profesionales sanitarios para que puedan tratar estos aspectos en consulta, identificar los trastornos que puedan afectar el curso de la enfermedad o su impacto en la vida del paciente, para ser tratados y seguidos por el profesional más adecuado. Estas recomendaciones pueden servir de base para el rediseño de los servicios o procesos de EII y como justificación para la formación del personal sanitario (AU)
Aims. To establish recommendations for the management of psychological problems affecting patients with inflammatory bowel disease (IBD). Methods. A meeting of a group of IBD experts made up of doctors, psychologists, nurses and patient representatives was held. The following were presented: 1) Results of a previous focal group, 2) Results of doctor and patient surveys, 3) Results of a systematic review of tools for detecting anxiety and depression. A guided discussion was then held about the most important psychological and emotional problems associated with IBD, appropriate referral criteria and situations to be avoided. The validated instrument most applicable to clinical practice was selected. A recommendations document and a Delphi survey were designed. The survey was sent to the group and to a scientific committee of the GETECCU group in order to establish the level of agreement with these recommendations. Results. Fifteen recommendations were established linked to 3 key processes: 1) What steps should be taken to identify psychological problems at an IBD appointment; 2) What are the criteria for referring patients to a mental health specialist; 3) How to approach psychological problems. Conclusions. Resources should be made available to healthcare professionals so that they can treat these problems during consultations, identify the disorders which could affect the clinical course of the disease and determine their impact on the patient's life in order that these can be treated and followed up by the most suitable professional. These recommendations could serve as a basis for redesigning IBD services or processes and as justification for the training of healthcare personnel (AU)
Assuntos
Humanos , Doença de Crohn/psicologia , Colite Ulcerativa/psicologia , Doenças Inflamatórias Intestinais/psicologia , Depressão/diagnóstico , Transtornos de Ansiedade/diagnóstico , Padrões de Prática Médica , Técnicas PsicológicasRESUMO
No disponible
Assuntos
Humanos , Masculino , Adulto , Doenças do Colo/genética , Doenças do Colo , Fístula Intestinal , Duodenopatias , Doenças em Gêmeos , Doença de Crohn/complicações , Gêmeos Monozigóticos/genética , Fístula Cutânea/complicações , Duodenopatias/complicações , Fístula Cutânea , Trânsito Gastrointestinal/efeitos da radiaçãoRESUMO
Objetivo: evaluar analítica y descriptivamente la evidencia publicada hasta la actualidad sobre el uso del polietilenglicol, solo o con electrolitos, en el tratamiento de pacientes con estreñimiento funcional. Metodología: búsqueda en las bases de datos MEDLINE, EMBASE y Cochrane hasta mayo de 2016 de todas las publicaciones que se ajustaran a los siguientes términos: constipation and/or fecal impaction and (PEG or polyethilene or macrogol or movicol or idralax or miralax or transipeg or forlax or golytely or isocolan or mulytely) not colonoscopy. Lectura crítica de los artículos seleccionados (únicamente en inglés o español) clasificando la descripción de los mismos en función de grupos de edad (adulto/ edad pediátrica) y, dentro de ellos, en función de las características de los estudios (evaluación de eficacia frente a placebo, búsqueda de dosis, seguridad, comparación con otros laxantes, estudios observacionales y artículos de revisión monográficos para poletilenglicol o metaanálisis). Resultados: se han seleccionado para análisis descriptivo 58 publicaciones; de ellas, 41 son ensayos clínicos, ocho son estudios observacionales y nueve son revisiones sistemáticas o metaanálisis. Doce ensayos clínicos evalúan la eficacia frente a placebo, ocho frente a lactulosa, seis estudio de dosis, cinco comparan entre sí el polietilenglicol con y sin electrolitos, dos comparan la eficacia con respecto a leche de magnesia y el resto de ensayos evalúan el polietilenglicol comparando con enemas (dos), ispágula (uno), tegaserod (uno), prucaloprida (uno), aceite de parafina (uno), combinaciones de fibras (uno) y Descurainia sophia (uno). Conclusiones: los preparados con polietilenglicol, únicos o asociados a electrolitos, son más eficaces que el placebo en el tratamiento del estreñimiento funcional tanto en adultos como en edad pediátrica con gran seguridad y tolerancia. Constituyen el laxante osmótico más eficaz (superior a la lactulosa) y de primera línea para el tratamiento de esta afección a corto y largo plazo. En la impactación fecal son tan eficaces como los enemas, evitan la necesidad de ingreso hospitalario y son muy bien tolerados por los pacientes (fundamentalmente, en su presentación sin electrolitos) (AU)
Objective: The objective of this study was to evaluate in an analytical and descriptive manner the evidence published so far on the use of polyethylene glycol (PEG), with or without electrolytes, in the management of functional constipation and the treatment of fecal impaction. Methodology: Search on MEDLINE, EMBASE and Cochrane databases until May 2016 of all publications adjusted to the following terms: constipation AND/OR fecal impaction AND (PEG OR polyethylene glycol OR macrogol OR movicol OR idralax OR miralax OR transipeg OR forlax OR golytely OR isocolan OR mulytely) NOT colonoscopy. Critical reading of selected articles (English or Spanish), sorting their description according to group age (adult/pediatric age) and within those, in accordance with study features (efficacy evaluation versus placebo, doses query, safety, comparison with other laxatives, observational studies and monographic review articles of polyethylene glycol or meta-analysis). Results: Fifty-eight publications have been chosen for descriptive analysis; of them, 41 are clinical trials, eight are observational studies and nine are systematic reviews or meta-analysis. Twelve clinical trials evaluate PEG efficacy versus placebo, eight versus lactulose, six are dose studies, five compare polyethylene glycol with and without electrolytes, two compare its efficacy with respect to milk of magnesia, and the rest of the trials evaluate polyethylene glycol with enemas (two), psyllium (one), tegaserod (one), prucalopride (one), paraffin oil (one), fiber combinations (one) and Descurainia sophia (one). Conclusions: Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability. These preparations constitute the most efficacious osmotic laxatives (more than lactulose) and are the first-line treatment for functional constipation in the short and long-term. They are as efficacious as enemas in fecal impaction, avoid the need for hospital admission and are well tolerated by patients (mainly when administered without electrolytes) (AU)
Assuntos
Humanos , Masculino , Feminino , Polietilenoglicóis/uso terapêutico , Constipação Intestinal/tratamento farmacológico , Impacção Fecal/tratamento farmacológico , Eletrólitos/uso terapêutico , Estudos de Avaliação como Assunto , Laxantes/uso terapêutico , Estudos Prospectivos , Estudos Retrospectivos , Placebos/uso terapêutico , Resultado do Tratamento , Lactulose/uso terapêuticoRESUMO
En esta Guía de Práctica Clínica analizamos el manejo diagnóstico y terapéutico de pacientes adultos con estreñimiento y molestias abdominales, bajo la confluencia del espectro del síndrome del intestino irritable y el estreñimiento funcional. Ambas patologías están encuadradas en los trastornos funcionales intestinales y tienen una importante repercusión personal, sanitaria y social, afectando a la calidad de vida de los pacientes que las padecen. La primera es el subtipo de síndrome de intestino irritable en el que el estreñimiento es la alteración deposicional predominante junto con dolor abdominal recurrente, hinchazón y distensión abdominal frecuente. El estreñimiento se caracteriza por la dificultad o la escasa frecuencia en relación con las deposiciones, a menudo acompañado por esfuerzo excesivo durante la defecación o sensación de evacuación incompleta. En la mayoría de los casos no tiene una causa orgánica subyacente, siendo considerado un trastorno funcional intestinal. Son muchas las similitudes clínicas y fisiopatológicas entre ambos trastornos, con respuesta similar del estreñimiento a fármacos comunes, siendo la diferencia fundamental la presencia o ausencia de dolor, pero no de un modo evaluable como «todo o nada». La gravedad de estos trastornos depende no sólo de la intensidad de los síntomas intestinales sino también de otros factores biopsicosociales: asociación de síntomas gastrointestinales y extraintestinales, grado de afectación, y formas de percepción y comportamiento. Mediante los criterios de Roma, se diagnostican los trastornos funcionales intestinales. Esta Guía de Práctica Clínica está adaptada a los criterios de Roma IV difundidos a finales de mayo de 2016 y analiza los criterios de alarma, las pruebas diagnósticas y los criterios de derivación entre Atención Primaria y Aparato Digestivo. Asimismo, se revisan todas las alternativas terapéuticas disponibles (ejercicio, ingesta de líquidos, dieta con alimentos ricos en fibra soluble, suplementos de fibra, otros componentes de la dieta, laxantes osmóticos o estimulantes, probióticos, antibióticos, espasmolíticos, esencia de menta, prucaloprida, linaclotida, lubiprostona, biofeedback, antidepresivos, tratamiento psicológico, acupuntura, enemas, neuroestimulación de raíces sacras o cirugía), efectuando recomendaciones prácticas para cada una de ellas (AU)
In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an «all or nothing» manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Síndrome do Intestino Irritável/complicações , Síndrome do Intestino Irritável/epidemiologia , Síndrome do Intestino Irritável/prevenção & controle , Constipação Intestinal/complicações , Constipação Intestinal/epidemiologia , Síndrome do Intestino Irritável/fisiopatologia , Síndrome do Intestino Irritável , Qualidade de Vida , Atenção Primária à Saúde/métodosRESUMO
Aunque un elevado porcentaje de pacientes con colitis ulcerosa debería recibir tratamiento tópico por vía rectal, los estudios de práctica clínica han demostrado que este está infrautilizado. El propósito de este artículo es el de responder a 10 preguntas concretas sobre qué fármacos están disponibles para uso tópico, su forma de presentación, formulación y métodos de aplicación, así como cuál de ellos es más eficaz e idóneo en los distintos escenarios clínicos de la colitis ulcerosa. Asimismo, se evalúa la posibilidad de combinar diferentes formulaciones y vías de administración, y la utilidad en la fase de remisión de la enfermedad. Por último, se hacen una serie de recomendaciones para una mejor información de los pacientes acerca de una correcta aplicación y administración
Although most patients with ulcerative colitis should be given topical treatment, different studies have shown that they are underused in clinical practice. The purpose of this article is to answer 10 specific questions about which drugs are available for topical use in the treatment of ulcerative colitis, and their characteristics in terms of formulation, dosage, presentation, application and proximal distribution of rectal-administered drugs. The efficacy of available topical drugs and the benefits of combining different formulations and routes of administration, and their usefulness during disease remission are evaluated. Finally, a series of recommendations addressed to patients are given on the correct application of topical treatment
Assuntos
Humanos , Consenso , Colite Ulcerativa/terapia , Administração Tópica , Doença de Crohn/terapia , Resultado do Tratamento , Conferências de Consenso como Assunto , Espanha , Mesalamina/uso terapêutico , Budesonida/uso terapêutico , Triancinolona/uso terapêutico , Beclometasona/uso terapêutico , Hidrocortisona/uso terapêuticoRESUMO
BACKGROUND AND PURPOSE: Information received by IBD patients about their disease is of particular importance. The objective of the study was to determine the information resources these patients used, together with their perceived information gaps and expected preferences. Patients and methods: A prospective, observational, cross-sectional study conducted on IBD patients attending 13 Spanish hospitals during 2008. Patients completed a semi-structured 52-question survey. Results: Survey was adequately completed by 379 of 385 patients (98%), of whom 57% had Crohn's disease and 43% ulcerative colitis. Mean patient age was 37.9 years (range, 1676 years). Gastroenterologists were the most commonly used resource (98%), followed by the Internet (60%), and general practitioners (50%). More than 90% reported good to excellent satisfaction with gastroenterologists, nurses, and patients associations. Only 56% considered their information needs to be covered. The Internet was mostly used by young patients and those with a high education level. In the future, 85% of the patients would like to receive information from the gastroenterologists, and 92% by face-to-face interviews. Patients mainly want additional information on treatment (medical and surgical), clinical manifestations, cancer, and mortality risks. They also think that they are poorly informed about their social and work rights, risks of cancer and death, and research trials. Conclusions: Patients with IBD use and prefer gastroenterologists as the main source of information, but only half of them consider their information needs to be covered
ANTECEDENTES Y OBJETIVOS: La información recibida por los pacientes con EII sobre su enfermedad es de particular importancia. El objetivo de este estudio fue determinar los recursos informativos que utilizan estos pacientes, así como las lagunas de información que perciben y sus preferencias. PACIENTES Y MÉTODOS: Estudio prospectivo, observacional y transversal realizado en pacientes con EII atendidos en 13 hospitales españoles durante el año 2008. Los pacientes cumplimentaron un cuestionario semiestructurado de 52 preguntas. RESULTADOS: El cuestionario fue cumplimentado adecuadamente por 379 de los 385 pacientes participantes (98%). De ellos, el 57% presentaban enfermedad de Crohn y el 43% colitis ulcerosa. La edad media de los pacientes fue de 37,9 años (intervalo: 16-76 años). Los gastroenterólogos fueron el recurso más utilizado (98%), seguido de Internet (60%) y de los médicos de familia (50%). Más del 90% de los pacientes señaló un grado de satisfacción con el gastroenterólogo, el servicio de enfermería y las asociaciones de pacientes de buena a excelente. Solo el 56% considera que sus necesidades informativas están cubiertas. Los pacientes jóvenes y aquellos con un nivel educativo alto son los que más utilizan Internet. Al 85% de los pacientes le gustaría recibir información de los gastroenterólogos en el futuro, y el 92% preferiría tener entrevistas presenciales. Los pacientes quieren principalmente información adicional sobre tratamientos (médicos y quirúrgicos), manifestaciones clínicas, cáncer y riesgos de mortalidad. También piensan que están mal informados acerca de sus derechos sociales y laborales, los riesgos de cáncer y la mortalidad, así como sobre los estudios de investigación. CONCLUSIONES: Los pacientes con EII utilizan y prefieren tener a los gastroenterólogos como fuente principal de información, pero solo la mitad de ellos consideran que sus necesidades informativas están cubiertas
Assuntos
Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Doenças Inflamatórias Intestinais/diagnóstico , Doença de Crohn/diagnóstico , Colite Ulcerativa/diagnóstico , Letramento em Saúde , Monitoramento Epidemiológico/tendências , Informação de Saúde ao Consumidor , Comunicação em Saúde , Satisfação do Paciente , Comportamento de Busca de Informação , Internet , Preferência do Paciente , Médicos de Família , Relações Médico-Paciente , Gastroenterologia , Espanha/epidemiologiaRESUMO
Vedolizumab (VDZ), un anticuerpo monoclonal humanizado que se une específicamente a -alpha4beta7-integrina, aprobado para el tratamiento de la enfermedad de Crohn (EC) y la colitis ulcerosa (CU), ha demostrado su eficacia en ensayos clínicos controlados. OBJETIVO: Describir una población tratada con VDZ y evaluar su efectividad y seguridad a largo plazo en práctica clínica. MÉTODOS: Estudio observacional y multicéntrico en pacientes con enfermedad inflamatoria intestinal tratados con VDZ durante al menos un año. Se evaluaron los índices de actividad, niveles de calprotectina fecal y proteína C reactiva, hospitalizaciones, cirugías y eventos adversos. RESULTADOS: Se analizaron un total de 73 pacientes (43 CU y 30 EC). El 74 y 23% de CU y el 90 y 37% de EC habían llevado previamente más de un anti-TNF y más de un inmunosupresor respectivamente. VDZ se suspendió en 17 pacientes (23%), 10 CU y 7 EC, debido a la falta o pérdida de respuesta antes del primer año o a eventos adversos. Veintisiete (63%) CU y 16 (53%) pacientes con EC requirieron intensificación de la dosis. A los 6 meses, el 70 y 42% de CU y el 80 y 43% de EC lograron respuesta clínica y remisión respectivamente. Al año, el 58 y 35% de CU y el 47 y 43% de EC mantuvieron la respuesta clínica y la remisión, respectivamente. La proteína C reactiva disminuyó significativamente tanto en la EC como en la CU. Sin embargo, la disminución de la calprotectina fecal se logró durante el seguimiento solo en CU pero no en EC. Ocho pacientes con EC que habían sido tratados previamente con ustekinumab evitaron la cirugía al año. En 8 CU (18,6%) se realizó colectomía y 4 EC (13,3%) necesitaron cirugía. Seis pacientes (8%) (5 UC y una enfermedad de Crohn) tuvieron eventos adversos. El uso concomitante de corticoides o inmunomoduladores no aumentó la efectividad. A mayor número de anti-TNF previos, menos remisión en la CU y respuesta en la EC. CONCLUSIONES: Tras un año de VDZ se induce respuesta y remisión clínica en una no desdeñable proporción de pacientes refractarios a diferentes biológicos o inmunosupresores. VDZ puede considerarse una alternativa en intolerantes a inmunosupresores con pocos eventos adversos
Vedolizumab (VDZ), a human monoclonal antibody that binds specifically to alpha4beta7-integrin, and is approved for the treatment of Crohn's disease (CD) and ulcerative colitis (UC), has demonstrated its efficacy in controlled clinical trials. OBJECTIVE: To describe a population treated with VDZ and to evaluate its long-term efficacy and safety in clinical practice. METHODS: An observational and multicentre study was carried out on patients with inflammatory bowel disease treated with VDZ for at least one year. An evaluation was performed on the activity indices, faecal calprotectin and C-reactive protein levels, hospital admissions, surgeries, and adverse events. RESULTS: A total of 73 patients were analysed (43 UC and 30 CD). More than one anti-TNF and more than one immunosuppressive was previously used by 74 and 23%, respectively, of UC patients, and 90 and 37%, respectively of CD patients. VDZ was stopped in 17 (23%) patients, 10 UC and 7 CD, due to a lack or loss of response before the first year, or due to adverse events. An intensification of the dose was required in 26 (63%) UC, and 16 (53%) CD patients. At 6 months, 70 and 42% of UC patients, and 80 and 43% of CD patients achieved a clinical response and remission, respectively. At one year, 58 and 35% of UC patients and 47 and 43% of CD patients, maintained the clinical response and remission, respectively. The C-reactive protein decreased significantly in both CD and UC patients. However, the decrease in faecal calprotectin was only achieved during follow-up in UC, but not in CD patients. Eight patients with CD that had been treated previously with ustekinumab avoided surgery at one year. A colectomy was performed on 8 (18.6%) UC patients, and 4 (13.3%) CD patients needed surgery. Six patients (8%) (5 UC and 1 CD) had adverse events. The concomitant use of corticosteroids or immunomodulators did not increase the efficacy. Those with a higher number of previous anti-TNF treatments showed less remissions in UC and responses in CD. CONCLUSIONS: After one year of VDZ, a clinical response and remission was induced in a considerable percentage of patients refractory to different biological or immunosuppressive therapies. VDZ can be considered as an alternative in those intolerant to immunosuppressives, with few adverse events
Assuntos
Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Anticorpos Monoclonais Humanizados/uso terapêutico , Doença de Crohn/tratamento farmacológico , Colite Ulcerativa/tratamento farmacológico , Fatores Biológicos/uso terapêutico , Estudo Observacional , Anticorpos Monoclonais Humanizados , Anticorpos Monoclonais Humanizados/efeitos adversos , Imunossupressores/efeitos adversos , Integrinas/uso terapêutico , Proteína C-Reativa , Biomarcadores/análise , Fezes/química , Relação Dose-Resposta a DrogaRESUMO
Objetivos: valorar el estrés oxidativo en la pancreatitis aguda, su evolución a lo largo del tiempo y su relación con la gravedad de la enfermedad. Métodos: durante un periodo de dos años, se estudiaron los pacientes ingresados por pancreatitis aguda con dolor abdominal de menos de 24 horas de evolución. Se obtuvo suero de los pacientes el primer, segundo y cuarto día de ingreso, en el momento en que se detectaban complicaciones y tras la recuperación. La concentración de malondialdehído fue determinada utilizando cromatografía líquida de alta resolución. Veinte voluntarios sanos conformaron el grupo control. La concentración de malondialdehído entre los diferentes grupos se comparó utilizando el test de Mann-Whitney y el test de Kruskal-Wallis; la evolución de malondialdehído se valoró mediante el test de Wilcoxon. Resultados: se incluyeron 169 pacientes (91 mujeres, edad mediana 67 años, rango 20-95); 33 sufrieron un episodio grave. La concentración de malondialdehído descendió desde el primer al cuarto día (0,600 vs. 0,451 vs. 0,343 M, respectivamente, p < 0,05). Cuando se detectaban complicaciones, los niveles de malondialdehído eran similares a los del primer y segundo día (0,473 μM, p > 0,05). En los episodios graves la concentración de malondialdehído fue superior que en el grupo control en el día 2 (grave: 0,514; leve: 0,440; control: 0.347 μM, p < 0,05 grave vs. control). Conclusiones: en la pancreatitis aguda existe un estrés oxidativo precoz. En los episodios graves, el estrés oxidativo permanece elevado durante más tiempo que en los episodios leves. El desarrollo de complicaciones se asocia a una elevada concentración de malondialdehído(AU)
Aims: to assess oxidative stress in acute pancreatitis, its evolution over time and its relationship with the severity of the disease. Methods: during a two-year period, patients with acute pancreatitis with less than 24 hours of pain were evaluated. Serum was obtained the first, second and fourth day from admittance, if complications were detected, and after recovery. Malondialdehyde was determined by high performance liquid chromatography. Twenty healthy volunteers constituted the control group. Malondialdehyde between groups was compared with Mann-Whitney and Kruskal-Wallis tests; malondialdehyde evolution was studied with Wilcoxon test. Results: one hundred and sixty-nine patients were included (91 women, median age 67 years, range 20-95); 33 suffered a severe episode. Malondialdehyde decreased from first to fourth day (0.600 vs. 0.451 vs. 0.343 μM, respectively, p < 0.05). When complications were detected, malondialdehyde level was similar to that of first and second day (0.473 M, p > 0.05). In severe attacks malondialdehyde was higher than in control group at day 2 (severe: 0.514; mild: 0.440; control: 0.347 μM, p < 0.05 severe vs. control). Conclusions: an early oxidative stress is observed in acute pancreatitis. In severe attacks, oxidative stress remains high longer than in mild episodes. The onset of complications is associated with high malondialdehyde concentration(AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Malondialdeído/uso terapêutico , Pancreatite/tratamento farmacológico , Estresse Oxidativo , Estresse Oxidativo/fisiologia , Malondialdeído/metabolismo , Dor Abdominal/diagnóstico , Dor Abdominal/etiologia , Cromatografia , Estudos Prospectivos , Curva ROC , Escala de Resultado de Glasgow , Análise Multivariada , Pancreatite/fisiopatologiaRESUMO
El tratamiento actual de la fisura anal crónica continúa basándose en medidas conservadoras convencionales, ya que solventan un alto porcentaje de casos. La denominada esfinterotomía química trata de lograr una hipotonía del esfínter anal interno reversible que permita la cicatrización de la fisura. Existen distintas alternativas, como la aplicación de pomadas de nitroglicerina o diltiazem, e inyecciones de toxina botulínica. Sin embargo, los efectos colaterales y las recidivas a medio plazo hacen que su papel definitivo esté todavía por dilucidar. No obstante, es una alternativa terapéutica que debería utilizarse como primera opción en los pacientes con riesgo larvado de incontinencia. La esfinterotomía lateral interna, "abierta" o "cerrada", realizada de forma ambulatoria con anestesia local puede considerarse actualmente el método idóneo para el tratamiento de la fisura anal crónica rebelde al tratamiento conservador, siempre que se informe al paciente sobre el riesgo de incontinencia minor que existe. Este procedimiento ofrece una rápida y permanente recuperación en más del 95% de los pacientes. Existen evidencias que demuestran que la tasa de incontinencia se reduce en relación con la menor extensión longitudinal de la esfinterotomía lateral interna y, por ello, se propugna reducir su extensión a la longitud de la fisura (AU)
Current treatment of chronic anal fissure continues to be based on conventional conservative measures in a high percentage of cases. What is known as chemical sphincterotomy aims to achieve a temporary decrease of anal pressures that allows fissures to heal. There are various alternatives such as nitroglycerine or diltiazem ointment and botulinum toxin injections. However, because of collateral effects and recurrences in the medium term, the definitive role of these treatments remains to be elucidated. Nevertheless, chemical sphincterotomy should be the first option in patients with a high risk of incontinence. "Open" or "closed" lateral internal sphincterotomy performed in the ambulatory setting with local anesthesia can currently be considered the ideal treatment of chronic anal fissure refractory to conservative measures so long as the patient is informed about the risk of minor incontinence. This procedure provides rapid and permanent recovery in more than 95% of patients. There is evidence demonstrating that the incontinence rate is related to the extent of the lateral internal sphincterotomy and consequently the extent of this procedure should be reduced to the length of the fissure (AU)
Assuntos
Humanos , Fissura Anal/terapia , Nitroglicerina/uso terapêutico , Diltiazem/uso terapêutico , Administração Tópica , Canal Anal/cirurgia , Toxinas Botulínicas/uso terapêuticoRESUMO
Las alteraciones de la continencia y de la defecación son más frecuentes en la mujer que en el hombre (incontinencia anal, estreñimiento dista¡), consecuencia de diferencias anatómicas y, fundamentalmente, de alteraciones funcionales secundarias a lesiones ocasionadas por el parto. Dentro del plan integral de asistencia a la mujer, la matrona puede detectar, prevenir, derivar y contribuir al tratamiento de esta entidad. (AU)