Eosinophilic esophagitis. The North against the South? A bio-economic-social mechanistic approach and clinical implications. / La esofagitis eosinofílica. ¿El Norte contra el Sur? Enfoque mecanicista bio-económico-social e implicaciones clínicas.

Eosinophilic esophagitis is a chronic antigen-mediated disease characterized by esophageal symptoms, esophageal eosinophilia, and the absence of response to proton pump inhibitors. It is the most frequent cause of dysphagia and food impaction in adults. Its incidence and prevalence is very high in the developed countries (USA, Europe, Australia), where its connotation is that of an emerging epidemic. While studies have been published with large case series in the developed countries, those published in Latin America are small or consist of isolated case reports. The differences in the prevalence of the disease between the developed and developing regions are unknown. Genetic or racial causes have been cited. Nevertheless, the epidemic nature of the disease suggests that environmental causes are the most powerful. Based on the published hypotheses, as well as on epidemiologic studies, the present review discusses some of the possible causes of the disparity in the prevalence of eosinophilic esophagitis between the two types of countries. The 'hygiene hypothesis' is reviewed, together with the possible relation of Helicobacter pylori, intestinal parasites, and modifications of the esophageal microbiota in patients with eosinophilic esophagitis. In reference to studies conducted in the United States, the clinical behavior and progression of eosinophilic esophagitis in Hispanics is reviewed and a possible predominant phenotype in Mexican and other Latin American patients is discussed. Finally, based on the above, an algorithm for studying the disease in the Latin American countries is proposed.

Prevalence of Barrett's esophagus: An observational study from a gastroenterology clinic. / Prevalencia de esófago de Barrett: estudio observacional en una clínica de gastroenterología.

INTRODUCTION AND AIMS: Barrett's esophagus is a condition that predisposes to esophageal adenocarcinoma. Our aim was to establish the prevalence of Barrett's esophagus at our center, as well as determine its associated factors. MATERIALS AND METHODS: We retrospectively assessed the endoscopic reports of 500 outpatients seen at our Gastroenterology Service from November 2014 to April 2016. We determined the prevalence of Barrett's esophagus and analyzed the demographic, clinical, and endoscopic findings associated with that pathology. RESULTS: The prevalence of Barrett's esophagus was 1.8%. The mean age of the patients with Barrett's esophagus was 58.7 years (range: 45-70) and there was a predominance of men (66%). In the subgroup of patients with symptoms of gastroesophageal reflux (n=125), Barrett's esophagus prevalence was 7.2%. In the multivariate analysis, the factors that were independently associated with Barrett's esophagus were gastroesophageal reflux (P=.005) and hiatal hernia (P=.006). CONCLUSIONS: The overall prevalence of Barrett's esophagus was 1.8% in our population, with a prevalence of 7.2% in patients that had symptoms of gastroesophageal reflux.

Hypoalbuminemia in the outcome of patients with non-variceal upper gastrointestinal bleeding. / Hipoalbuminemia en el desenlace clínico de pacientes con sangrado de tubo digestivo alto no variceal.

INTRODUCTION AND AIM: The role of serum albumin level in patients with non-variceal upper gastrointestinal bleeding (NVUGB) has not been extensively studied. Our aim was to evaluate the role of serum albumin on admission in terms of in-hospital mortality in patients with NVUGB. MATERIALS AND METHODS: Patients admitted with NVUGB during a 4-year period were prospectively included. Demographic, clinical, and laboratory data were collected. ROC curve analysis was used to determine the cutoff value for serum albumin on admission that made a distinction between deceased patients and survivors with respect to serum albumin on admission, as well as its overall performance compared with the Rockall score. RESULTS: 185 patients with NVUGB were evaluated. Men predominated (56.7%) and a mean age of 59.1±19.9 years was found. Mean serum albumin on admission was 2.9±0.9g/dl with hypoalbuminemia (< 3.5g/dl) detected on admission in 71.4% of cases. The ROC curve found that the best value for predicting hospital mortality was an albumin level of 3.1g/dl (AUROC 0.738). Mortality in patients with albumin ≥ 3.2g/dl was 1.2% compared with 11.2% in patients with albumin<3.2g/dl (P=.009; OR 9.7, 95%CI 1.2-76.5). There was no difference in overall performance between the albumin level (AUORC 0.738) and the Rockall score (AUROC 0.715) for identifying mortality. CONCLUSIONS: Patients with hypoalbuminemia presenting with NVUGB have a greater in-hospital mortality rate. The serum albumin level and the Rockall score perform equally in regard to identifying the mortality rate.

Effects of melatonin on the acute inflammatory response associated with endoscopic retrograde cholangiopancreatography: A randomized, double-blind, placebo-controlled trial. / Efectos de la melatonina en la respuesta inflamatoria aguda asociada con la colangiopancreatografía retrógrada endoscópica: un ensayo clínico aleatorizado, doble ciego y controlado con placebo.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with an acute inflammatory response and melatonin has a variety of immunomodulatory and antioxidant effects studied experimentally in pancreatobiliary pathology. AIMS: The aim of our study was to evaluate the effects of peri-procedural administration of melatonin on the inflammatory response and lipid peroxidation associated with ERCP. METHODS: In this proof-of-concept clinical trial, 37 patients with a high probability of choledocholithiasis were randomized to receive peri-procedure (ERCP) melatonin or placebo. We measured the serum concentration of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), vascular endothelial growth factor (VEGF), lipid peroxidation, amylase, and liver function tests 24h before and after the procedure. RESULTS: We found no pre-procedure or post-procedure differences between the melatonin group or the placebo group (P>.05) in the serum concentrations of TNF-alpha (melatonin: 153.8 vs. 149.4ng/m; placebo: 103.5 vs. 107.3ng/ml), IL-6 (melatonin: 131.8 vs. 133.3ng/ml; placebo: 177.8 vs. 197.8ng/ml), or VEGF (melatonin: 157.3 vs. 157.8pg/ml; placebo: 97.3 vs. 97.8pg/ml), or in relation to lipid peroxidation (melatonin: 39.2 vs. 72.3µg/ml; placebo: 66.4 vs. 90.5µg/ml). After ERCP, a significant decrease in the AST, ALT, and total bilirubin levels was found only in the melatonin group (P<.05). The administration of melatonin was safe and tolerable. CONCLUSIONS: Melatonin is safe and tolerable in patients undergoing ERCP, but it does not appear to affect inflammatory cytokine concentrations or lipid peroxidation.

Papilla of Vater morphology as an influencing factor in successful cannulation during resident training in advanced endoscopy. A prospective clinical study.

INTRODUCTION AND AIM: Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure. Clinical guidelines assess competence in ERCP through a defined number of procedures, but multiple factors are involved. Our aim was to analyze the morphology of the papilla of Vater as an independent factor in selective common bile duct cannulation during resident training. MATERIAL AND METHODS: Patients that underwent ERCP were studied consecutively. All ERCPs were begun by a resident in training. The type of papilla was classified according to Haraldsson, including those with previous sphincterotomy. Cannulation difficulty and success and their relation to the type of papilla were documented. The analysis was divided into three 4-month periods. RESULTS: Of the 429 patients, cannulation was difficult in 101 (23.5%). The residents achieved selective cannulation of the common bile duct in 276 (64.3%) and the cannulation success rate at the end of their training was 81.7%. Cannulation was performed with the least difficulty in papillae with previous sphincterotomy (2.8%), unlike the type 4 papilla, which was difficult to cannulate in 50% of the cases. The lowest overall cannulation success was in the type 2 papilla (81.8%). CONCLUSION: Papilla type can influence cannulation success, but it is not the only related factor. Patients that underwent previous sphincterotomy appear to be the cases in whom ERCP training can be started.

Use of audiovisual devices in transnasal endoscopy without sedation to improve tolerance. A prospective clinical trial.

INTRODUCTION AND AIM: Transnasal endoscopy (TNE) has proven its diagnostic utility, but it has not been widely accepted given that it is performed without sedation. There are no previous studies on the use of methods to improve its tolerability. Our aim was to evaluate the tolerability of TNE, when simultaneously performed with an audiovisual device as a distractor. METHODS: We evaluated 50 patients, 10 of whom did not agree to participate. The performance of the procedure was explained, using an audiovisual device. Before randomization, we applied anxiety and depression scores. Patients were divided into 2 groups: Group I (using an audiovisual device during the procedure) and Group II (without a device). Anxiety and numeric pain rating scales were used, and vital signs were monitored and recorded before, during, and after the endoscopy. An overall procedure satisfaction score was applied at the end of the study and 24 h later. RESULTS: Mean age was 41.6 years and 35 of the patients were women (87.5%). The most frequent indication for TNE was refractory gastroesophageal reflux disease. There were no severe comorbidities, and none of the patients had a significant anxiety or depression score. One patient in Group II did not tolerate TNE due to nasal pain. There was no statistically significant difference between groups, regarding anxiety, pain, vital signs, and satisfaction scale. CONCLUSION: Our study showed that TNE was well tolerated and had a high acceptance rate in our patients. The use of distracting audiovisual devices did not increase tolerance to the endoscopic procedure.

[Clinical characteristics of acute pancreatitis in Mexico]. / Características clínicas de la pancreatitis aguda en México.

BACKGROUND: Acute pancreatitis (AP) etiology and frequency vary in relation to geographic region. AIMS: To determine the etiology, frequency, and mortality of AP in a Mexican population. PATIENTS AND METHODS: We carried out a prospective study of first episode AP patients over a period of 6 years. RESULTS: A total of 605 patients with a mean age of 40 years were included in the study. Sixty-four percent of them presented with overweight and/or obesity determined through BMI. Etiology was biliary in 66.60%, it was due to alcohol consumption in 15.90%, hypertriglyceridemia in 7.80%, it was post-endoscopic retrograde cholangiopancreatography (ERCP) in 2.10%, and was undetermined in 7.20%. Pancreatic infection was suspected in 70 patients and they underwent CT-guided fine needle aspiration. Thirty-two of those patients were diagnosed with pancreatic infection in which Staphylococcus spp was the most common microorganism. Overall mortality was 5.00% (2.60% < 30 years and 10.00% > 70 years). Necrosis, pancreatic infection, and mortality were more frequent in the cases in which etiology was due to alcohol ingestion. CONCLUSIONS: The most frequent AP etiology was biliary, but that caused by alcohol presented with more complications. Overall mortality was 5.00% and was higher in the elderly patients.

Efficacy of octreotide in bleeding recurrence from small bowel angioectasia: A comparative study.

INTRODUCTION: Fifty percent of small bowel bleeding is caused by angioectasia and the rebleeding rate due to small bowel angioectasia (SBA) is 80%. Its endoscopic treatment is difficult. Beneficial effects of octreotide on gastrointestinal angioectasia have been described, but no studies have reported its efficacy in SBA. AIM: Our aim was to investigate the effectiveness of octreotide in the prevention of rebleeding due to SBA. MATERIAL AND METHODS: Sixteen patients with bleeding caused by SBA were assigned to treatment with octreotide 100 µg/24 h SC, for at least 6 months, and compared with a non-treatment group of 36 patients. The primary outcome was the rebleeding rate, and the secondary outcomes were the number of hospital readmissions, bleeding-related death, and adverse effects. RESULTS: Octreotide was administered for 10.5 ± 8.4 months. Follow-up was 12.9 ± 17.3 months and 15.3 ± 17.7 months, in the treatment and non-treatment groups, respectively (p = 0.09). At the end of follow-up, 4 (25%) treatment group patients and 26 (72.2%) non-treatment group patients presented with rebleeding (p = 0.002). In the treatment group and non-treatment group, the cumulative probability of remaining rebleeding-free at one year was 79% vs 44.2%, and 79% vs 34.6% at 2 years, respectively (p = 0.05). Through the multiple logistic regression analysis, treatment was the protective variable. Six patients presented with adverse events. One of those patients (6.25%) had a major adverse event. CONCLUSIONS: Our results suggest that treatment with octreotide could be efficacious in the prevention of rebleeding due to SBA.

[Obscure gastrointestinal bleeding due to duodenal infiltration of a non-functioning pancreatic neuroendocrine tumor diagnosed by capsule endoscopy: a case report]. / Hemorragia gastrointestinal de origen obscuro secundaria a infiltración duodenal de tumor neuroendocrino pancreático no funcional diagnosticada por cápsula endoscópica; informe de un caso.

Non-functioning pancreatic neuroendocrine tumors (PNETs) are infrequent slow-growing, clinically-silent tumors. They are incidentally detected and some of them may present in advanced stages with local involvement of surrounding structures. The diagnostic accuracy of endoscopio ultrasound (EUS) and fine needle aspiration (FNA) biopsy is significantly lower in neuroendocrine tumors (46.7%) compared with adenocarcinoma (81.4%) and other histologies (75%). Therefore, preoperative diagnosis is very difficult. Exceptionally, hey present with gastrointestinal bleeding. We present a case of a non-functioning PNET initially diagnosed as cystic serous tumor of pancreas with EUS and FNA biopsy. Two years later patient presented obscure gastrointestinal bleeding due to duodenal infiltration. Diagnosis was made by capsule endoscopy.

The impact of pregnancy on the outcome of biliary acute pancreatitis. / El impacto del embarazo en el desenlace de pancreatitis biliar aguda.

BACKGROUND AND OBJECTIVE: Acute pancreatitis is one of the most common gastrointestinal conditions requiring hospitalization. Even though its presentation during pregnancy is uncommon, it is a medical challenge. Currently, no studies compare the clinical outcomes between pregnant patients with acute pancreatitis and nonpregnant patients with acute pancreatitis. Our aim was to compare the characteristics and clinical outcomes of pregnant and nonpregnant women with acute pancreatitis. METHODS: We conducted a retrospective study that included all patients admitted to our hospital with acute pancreatitis over a 10-year period. Demographics, general characteristics, and clinical outcomes were evaluated and compared between pregnant and nonpregnant women with acute pancreatitis, at a ratio of 1:5. RESULTS: Over 10 years, 27 pregnant patients with acute pancreatitis were treated. Etiology was biliary in 96% and hypertriglyceridemia was the cause in 3.4% (1 patient). The mean patient age was 26.2 years (range 15-36 years). The main cause of acute pancreatitis was biliary disease (96%). Patients in the study group were in their first, second, or third trimester of pregnancy, at 7.4%, 33.3%, and 59.3%, respectively. In the comparison of pregnant versus nonpregnant patients with acute pancreatitis, there were no differences in age, hospital stay (7.37 vs. 10.8, P=.814), severity (severe 3.7% vs. 16.7%, P=.79), local complications (0% vs. 1.9%, P=.476), or mortality (0% vs. 1.9%, P=.476). CONCLUSIONS: The clinical evolution of both groups with biliary acute pancreatitis was similar, with low morbidity and mortality.

The Mexican consensus on nonalcoholic fatty liver disease. / Consenso mexicano de la enfermedad por hígado graso no alcohólico.

Nonalcoholic fatty liver disease (NAFLD) affects nearly one third of the population worldwide. Mexico is one of the countries whose population has several risk factors for the disease and its prevalence could surpass 50%. If immediate action is not taken to counteract what is now considered a national health problem, the medium-term panorama will be very bleak. This serious situation prompted the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología to produce the Mexican Consensus on Fatty Liver Disease. It is an up-to-date and detailed review of the epidemiology, pathophysiology, clinical forms, diagnosis, and treatment of the disease, whose aim is to provide the Mexican physician with a useful tool for the prevention and management of nonalcoholic fatty liver disease.

Octreotide therapy of large-volume refractory AIDS-associated diarrhea: a randomized controlled trial.

OBJECTIVE: To compare the effect of octreotide (a long-acting somatostatin analog) to that of antidiarrheal therapy plus placebo on large-volume refractory AIDS-associated diarrhea. DESIGN: A randomized controlled trial. SETTING: Referral-based clinic and hospital in a tertiary care center. PATIENTS: Twenty male patients with AIDS and refractory diarrhea, with stool volume > 1000 ml/day who failed to improve after initial supportive management. All patients finished the study. INTERVENTIONS: Patients were randomly given either octreotide in doses of 100, 200 and 300 micrograms subcutaneously every 8 h, or high doses of loperamide and diphenoxylate orally plus placebo subcutaneously for 10 days. MAIN OUTCOME MEASURES: Bowel movements and stool volume were registered before and every day after treatment by the patients themselves and the nursing personnel. RESULTS: Patients from both groups were similar for age, time of AIDS diagnosis, duration of diarrhea and etiology. Baseline mean bowel movements per day (9.4 +/- 2.8 in the octreotide group versus 10 +/- 3.1 in controls) and baseline mean stool volume (2753 +/- 840 versus 2630 +/- 630 ml/day, respectively) were similar in both groups before therapy (P < 0.05). Mean bowel movements per day after 10 days of therapy was 2.1 +/- 1.6 in the octreotide group versus 7 +/- 3 in controls (P < 0.05). Mean stool volume after 10 days of therapy was 485 +/- 480 in the octreotide group versus 1080 +/- 420 ml/day in controls (P < 0.05). Complete response (stool volume < 250 ml/day) was observed in two patients from the octreotide group and none from controls; partial response (decrease > 50% in stool volume) in four and two; and no response (decrease < 50% or no change) in four and eight (P < 0.05), respectively. Side-effects occurred in eight out of 10 octreotide patients and three out of 10 controls (P < 0.05), but none were significant to result in discontinuation of medication. CONCLUSION: Octreotide proved to be superior to conventional therapy in this short-term treatment of large-volume refractory AIDS-associated diarrhea.

Treatment of active gastroesophageal variceal bleeding with terlipressin or hemostatic balloon in patients with cirrhosis. A randomized controlled trial.

Gastroesophageal variceal bleeding due to portal hypertension should be treated by endoscopic sclerotherapy. This procedure, however, has some limitations. It has been established that vasoactive drugs are effective for controlling active variceal bleeding. We report the results of a randomized controlled trial comparing terlipressin to hemostatic tube (Linton-Michel tube) for the treatment of bleeding gastroesophageal varices in cirrhotic patients. Thirty-seven cirrhotic patients with a total of 40 episodes of gastroesophageal variceal bleeding were included in this trial. Patients were randomly assigned to intravenous terlipressin or Linton-Michel tube (LM tube), for 24 h. During this period, hemostasis was defined as obtaining of hemodynamic and hematocrit stabilization and/or absence of hematemesis or melena. Bleeding recurrence was assessed during a 1-month period after treatment. Twenty bleeding episodes were treated with terlipressin (Group I) and 20 with LM tube (Group II). Both groups of patients were similar in age, sex distribution, etiology of cirrhosis and degree of hepatic insufficiency. Bleeding was controlled in 70% of patients from Group I and in 95% from Group II (p < 0.05) during treatment. Bleeding recurred in 14% of patients in Group I vs. 36% in Group II 1 week following the treatment (p > 0.05) and in 16.6% in Group I vs. 83.3% in Group II 1 month after treatment (p < 0.05). Complications were more frequent in Group II than in Group I (65 vs. 15%, p < 0.05). Mortality rate was similar in both groups 1 month after treatment. In conclusion, hemostatic tubes were superior to terlipressin for the control of active gastroesophageal variceal bleeding within the first 24 h. Complications and bleeding recurrence were more frequent in patients treated by hemostatic tube within a period of 1 month after treatment. Mortality rate was similar in both groups of patients.

[Value of the transjugular venous approach to the liver in the diagnosis of cirrhosis. 333 cases]. / Intérêt de l'abord veineux transjugulaire du foie dans le diagnostic de la cirrhose. 333 cas.

The transjugular technique is very useful for the diagnosis of cirrhosis since it makes it possible, in one single exploratory procedure, to perform a needle aspiration biopsy (despite coagulation disorders and ascites) and to measure the porto-caval pressure gradient. In our series cirrhosis was diagnosed by liver biopsy alone in 249 out of 333 patients (77%), and the porto-caval gradient was found to be elevated in 313 patients (97%).

[Fitz-Hugh and Curtis syndrome]. / Le syndrome de Fitz-Hugh et Curtis.

The Fitz-Hugh and Curtis syndrome is a perihepatitis following a genital infection. It usually occurs in young women but male cases have been reported. Chlamydia trachomatis is the most frequent causal agent observed in Europe and the United States. This germ is the number one cause of salpingitis in developed countries. Clinical signs include acute or recurrent pain in the right hypochondria. Liver tests are not modified and the sonographic examination is normal. The diagnosis can be suspected on the basis of serology results using either indirect immunofluorescence with live antigens specific for serotype D or K or ELISA. Positive predictive value is 80-90% and negative predictive value 96-99%. Diagnosis is formally established with laparoscopy. In our experience with more than 100 patients, the perihepatitis (glissonitis with pseudo-membranes) is frequently associated with adherences. The peritoneum is inflammatory and there are usually a small amount of liquid. Specimens are taken for culture. Polymerase chain reaction will improve the detection of Chlamydia since this germ is very difficult to culture. Antibiotic treatment with adapted drugs given for sufficient time is effective.

[Pathogenesis of portal systemic encephalopathy]. / Conceptos actuales sobre la fisiopatogenia de la encefalopatía hepática.

Hepatic encephalopathy is a neuropsyquiatric syndrome associated to multifactorial metabolic disruptions. Several physiopathogenic theories have been proposed. In this review authors explain and analyze most of theses theories which include ammonia, mercaptans, false neurotransmitters, gamma aminobutiric acid, endogenous benzodiazepins, and zinc deficiency as well as some of the new biochemical concepts of neurotransmission.

[Sodium benzoate in portal-systemic-encephalopathy-induced blood ammonia normalization and clinical improvement. Interim report of a double-blind multicenter trial]. / Derivación metabólica del amonio plasmático con benzoato de sodio, como método de tratamiento en pacientes con cirrosis y encefalopatía portosistémica. Informe interino de un estudio multicéntrico, doble ciego.

To investigate the therapeutic efficacy of sodium benzoate (SB) in a cirrotic population with chronic portal systemic encepalopathy (PSE), we performed a double blind, randomised, multicentric, clinical trial, comparing SB versus a standard therapy of lactitol (LA). To perform the study blind, syrups containing the two drugs were prepared. To date 27 patients have been studied. Of these, 12 received SB (5.6 g/day) and 15 received LA (29 g/day). Standard PSE parameters were assessed and hippurate urinary excretion was measured before and after the trial. For the SB group, basal and final PSE index were 0.39 +/- 0.16 and 0.17 +/- 0.1 respectively (p < 0.001). The Group on LA had a PSE index of 0.40 + 0.1 and 0.23 +/- 0.18 (basal and final respectively) (p < 0.001). The final hippurate excretion for SB group was 2498.9 mg/24 h. The hippurate excretion for the LA group suffer no changes (traces). No serious side effects were observed with either therapy. We suggested that SB is a safe, efficacious and comfortable alternate treatment for PSE.