[Poorly differentiated neuroendocrine carcinoma of the colon with liver metastases]. / Carcinoma neuroendocrino de colon poco diferenciado con metástasis hepáticas.

Neuroendocrine tumors of the gastrointestinal tract are highly infrequent. We report the case of a 57-year-old woman who presented with toxic syndrome, vomiting and a 3-month history diarrhea, with a final diagnosis of poorly-differentiated neuroendocrine tumor. Based on this case, we review the clinical characteristics, diagnostic procedures, prognostic factors and therapeutic possibilities in this type of tumor. Neuroendocrine tumors should be considered in the diagnosis of colonic tumors with hyperechoic liver metastases.

[Emergency care of patients with upper gastrointestinal bleeding in regional hospitals in Catalonia]. / Asistencia urgente a los pacientes con hemorragia digestiva alta en los hospitales comarcales catalanes.

OBJECTIVE: To evaluate the resources available in Catalan regional hospitals for the emergency care of upper gastrointestinal hemorrhage. METHODS: We analyzed a survey sent to 32 hospitals on the availability, composition and resources of a duty endoscopy service for the year 2009. RESULTS: Responses were obtained from 24 centers, covering 3,954,000 inhabitants. Duty endoscopists were available in 12 hospitals. A total of 1,483,000 inhabitants were unable to access a duty endoscopist in the referral center. Centers with duty endoscopists had more beds and had a larger catchment area. Duty services were composed of 4.5 endoscopists (range 2-11), covering 82.1 (33.2-182.5) duty shifts/year. Seventeen centers reported 1,571 episodes (51%, range: 3-280, 39.68/100,000 inhabitants). Centers with a duty service reported a greater number of cases (76 vs. 43, p=0.047). Centers without this service referred a greater number of patients (147 vs. 17, p=0.001). Patients in the emergency department were under the care of the internal medicine department in four centers, the surgery department in 14 centers and under the care of both departments in six. Admitted patients were under the care of the gastroenterology department in only six hospitals. The most widely used procedures were ligation of varicose bleeding and injection therapies in non-varicose bleeding. Twenty-one percent of centers did not perform combined treatment. CONCLUSIONS: A significant proportion of the population does not have access to a duty endoscopist in referral centers. Duty shifts represent significant workload in regional hospitals. Coordination among health professionals and centers would allow the efficient application of therapeutic resources and a duty endoscopy service to be established in centers lacking this resource.

[Coordination between primary and specialized care in gastroenterology is insufficient. A survey of gastroenterologists and general practitioners]. / La coordinación entre atención primaria y especializada de digestivo es insuficiente. Resultados de una encuesta realizada a gastroenterólogos y médicos de familia.

BACKGROUND AND OBJECTIVES: Collaboration between general practitioners (GPs) and specialists is considered crucial to provide high-quality healthcare. The objective of this study was to analyze the relationship between gastroenterologists and GPs in regional hospitals and their referring primary care centers in Catalonia (Spain). MATERIALS AND METHODS: A descriptive, observational, cross-sectional study was carried out using anonymous questionnaires between January and April 2008. RESULTS: A total of 314 surveys were administered (261 GPs and 53 gastroenterologists). The overall relationship was considered highly deficient or insufficient by 62.3% of gastroenterologists (95% CI, 47.9-74.9) and by 55.6% of GPs (95% CI, 49.3-61.7). More than half (56.6%) of the gastroenterologists did not know any GPs, or only a very few, and the situation was the same for 80.4% of GPs. Sixty-four percent of gastroenterologists considered that the quality of care for digestive diseases in primary care was highly deficient or insufficient while 21.1% of GPs considered that the care provided by gastroenterologists was highly deficient or insufficient. The perception of healthcare in both primary and specialized settings was substantially better when there was good interaction between gastroenterologists and GPs. CONCLUSIONS: Practitioners acknowledge that the degree of interaction between different levels of healthcare is insufficient. Moreover, gastroenterologists consider that the management of digestive diseases in primary care is deficient. Establishing a personal relationship between the two types of practitioners substantially improves mutual assessment.

[Prolonged fever and jaundice in a patient with alcoholic liver disease]. / Fiebre prolongada e ictericia en un paciente con hepatopatía alcohólica.

We report the case of a 40-year-old man with underlying alcoholic liver disease who presented with prolonged fever, jaundice and liver failure associated with Coxiella burnetii infection. After diagnosis and appropriate antibiotic treatment, the patient made a complete recovery. We describe aspects of this case and provide a practical review of the literature on the topic. We also discuss the importance of this infection and the need for its inclusion in the differential diagnosis of this clinical picture.

Prevalence and factors related to hepatitis B and C in inflammatory bowel disease patients in Spain: a nationwide, multicenter study.

OBJECTIVES: Limited information suggests the existence of a high prevalence of hepatitis B (HBV) and C virus (HCV) infection in inflammatory bowel disease (IBD). This knowledge is relevant because the viruses may reactivate under immunosuppressive therapy. The objectives of this study are to assess the prevalence of HBV and HCV infection in IBD, in a nationwide study, and to evaluate associated risk factors. METHODS: This cross-sectional multicenter study included 2,076 IBD patients, consecutively recruited in 17 Spanish hospitals. Factors related to IBD (severity, invasive procedures, etc.) and to infection (transfusions, drug abuse, etc.) were registered. Independent risk factors for viral infection were evaluated using logistic regression analysis. RESULTS: Present and/or past HBV and HCV infection was found in 9.7% of patients of both ulcerative colitis (UC) and Crohn's disease (CD) (UC: HBsAg 0.8%, anti-HBc 8%, anti-HCV 1.3%; CD: HBsAg 0.6%, anti-HBc 7.1%, anti-HCV 2.3 %). Effective vaccination (anti-HBs, without anti-HBc) was present in 12% of patients. In multivariate analysis, age (odds ratio (OR) 1.04; 95% confidence interval (CI) 1.02-1.06; P=0.000), family history of hepatitis (OR 2.48; 95% CI 1.3-4.74; P=0.006) and moderate-to-severe IBD disease (OR 2.5; 95% CI 1.02-6.15; P=0.046) were significantly related to HBV, whereas transfusions (OR 2.66; 95% CI 1.2-5.87; P=0.015) and antibiotic use (OR 2.66; 95% CI 1.1-6.3; P=0.03) were significantly related to HCV. The significance for transfusions was lost if they were administered after 1991, when HCV markers became mandatory in blood banks. CONCLUSIONS: Prevalence of HBV and HCV infection in IBD is similar to that of the general population of reference and lower than that in previously published series. This fact, in addition to the lack of association with invasive procedures, suggests the existence of adequate preventive measures in centers attending to these patients. The low percentage of effective vaccination makes it mandatory to intensify B virus vaccination in IBD.

Cost-effectiveness of a 'score and scope' strategy for the management of dyspepsia.

OBJECTIVE: It is important to identify the best initial work-up in patients with uninvestigated dyspepsia because of its epidemiological and economical relevance. The objective of the study was to assess systematically the effectiveness and cost-effectiveness of invasive and non-invasive strategies for the management of dyspepsia. METHODS: A decision analysis was performed to compare prompt endoscopy, score and scope, test and scope, test and treat, and empirical antisecretory treatment. Published and local data on the prevalence of different diagnoses, rates of Helicobacter pylori infection, accuracy values of diagnostic tests, and effectiveness of drug treatments were used. The perspective of analysis was that of the public healthcare payer, and only direct costs were included, with a one-year post-therapy time horizon. The main outcome measure was cost per asymptomatic patient, valued in 2003 Euros. RESULTS: Endoscopy was found to be the most effective strategy for the management of dyspepsia (38.4% asymptomatic patients), followed by test and scope (35.5%), test and treat (35.3%), score and scope (34.7%), and empirical treatment (28.5%). Incremental cost-effectiveness ratios showed that score and scope was the most cost-effective alternative (483.17 Euros per asymptomatic patient), followed by prompt endoscopy (1396.85 Euros). Sensitivity analyses showed variations when varying the values of prevalence of duodenal ulcer, and the values of healing of functional dyspepsia with antisecretory and eradication drugs. There were no changes when varying the prevalence of H. pylori in dyspepsia. CONCLUSIONS: We would recommend stratifying patients by a score system, referring first to endoscopy those patients at higher risk of organic dyspepsia.

[Prospective validation of a clinical scoring system for the diagnosis of organic dyspepsia]. / Estudio prospectivo de un modelo clínico predictivo de dispepsia orgánica.

BACKGROUND AND OBJECTIVE: Predictive symptomatic scoring models have been proposed to select patients with dyspepsia, who may be candidates to endoscopy. In a previous study performed by gastroentrologists from our group, we obtained three scales of symptoms to predict organic dyspepsia, peptic ulcer and esophagitis, respectively. Here we analyze the reproducibility of those scoring models of symptoms when used either by other gastroenterologists or general practitioners. PATIENTS AND METHOD: It was a clinical prospective study of 230 patients from the Viladecans hospital area (120 from primary healthcare and 110 from the gastroenterologist's consultation). The three validation scales were performed in each patient. Then, we performed a diagnostic gastroscopy which allowed to classify patients into those with organic dyspepsia (ulcer, esophagitis, cancer) or those with functional dyspepsia. We calculated the overall predictive accuracy for the gastroenterologist and the general practitioner and for the three diagnoses (organic dyspepsia, ulcer or esophagitis) using the C statistic. RESULTS: Discriminative capacities were 0.75 and 0.82 for organic dyspepsia, 0.78 and 0.86 for ulcer disease, and 0.78 and 0.82 for esophagitis, for the general practitioner and the gastroenterologist, respectively. In this validation study, the best cut-off value, namely the one combining good sensitivity and specificity, was found to be 7. CONCLUSIONS: A correct predictive capacity of the symptomatic score models when used by other gastroenterologists or by primary healthcare practioners confirms its reproducibility and transferability. The use of predictive symptomatic score models in everyday clinical practice can allow to rationalize the referral for endoscopy in our local setting.