Cardiorespiratory complications directly related to endoscopy: associated or not with sedation?

With the advent of routine sedation in digestive endoscopy, specifically the use of propofol, multiple reports have focused on the complications that may potentially emerge because of sedation, and whether administration is safer by anesthetists or trained gastroenterologists. Complications associated with endoscopy itself, whether diagnostic or therapeutic, have also been described. However, the fact that both upper and lower endoscopy per se may be accompanied by complications, both during the procedure or thereafter, is usually overlooked.

Gastric ulcers with upper gastrointestinal bleeding in patients with severe SARS-CoV-2.

A new coronavirus, SARS-CoV-2, was identified earlier this year and spread rapidly globally. The clinical manifestations that it produces have gradually become known and the typical clinical picture is respiratory. Although gastrointestinal symptoms have been described in several communications, information on endoscopic findings in these patients is practically zero. We describe two cases of upper gastrointestinal bleeding in patients with COVID-19. In both cases, the presence of gastric ulcers was identified in an unusual location, the gastric fundus. After ruling out malignancy, our suspicion was an ischemic etiology that is consistent with terminal gastric vascularization at the gastric fundus level and increased thrombotic phenomena in patients with COVID-19.

The effect of Adacolumn® on ulcerative colitis with COVID-19.

Crespo et al. comment on the influence of immunomodulators and biological drugs on ulcerative colitis and SARS-CoV-2 infection. Granulo-monocytoapheresis is a treatment used in ulcerative colitis outbreaks, whose mechanism of action is to selectively retain activated granulocytes and monocytes, in order to reduce the inflammatory process.

Economic evaluation of endoscopic radiofrequency ablation for the treatment of dysplastic Barrett's esophagus in Spain.

BACKGROUND AND STUDY AIMS: To assess the cost-effectiveness of introducing endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection in selected patients into the standard of care of Barrett's esophagus patients with high-grade dysplasia or low-grade dysplasia in Spain. METHODS: The disease evolution was modeled via a semi-Markov model. The treatment strategies compared included endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection and the Standard of Care (esophagectomy or palliative chemoradiotherapy according to disease status for high-grade dysplasia and endoscopic surveillance for low-grade dysplasia). Efficacy rates, transition probabilities and utility values were obtained from the literature. Clinical management patterns and resource use were modeled according to Spanish clinical expert opinion. Costs were expressed in euros (€) from 2016 reflecting the Spanish National Health System perspective. Sensitivity analyses were performed to assess the robustness of the model. RESULTS: With respect to the Spanish Standard of Care, endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection was a dominant strategy for high-grade dysplasia patients. When a willingness-to-pay threshold of €30,000 per quality-adjusted life-years gained was considered, this was cost-effective for low-grade dysplasia patients (€12,865 per quality-adjusted life-years gained). The sensitivity analyses supported the base case analysis results and pointed towards the main drivers of uncertainty in the model. CONCLUSIONS: From a health care decision-maker, endoscopic treatment based on radiofrequency ablation plus endoscopic mucosal resection is the intervention of choice for dysplasic Barrett's esophagus patients in Spain.

Pancreatic stents in ERCP. Where are we?

Post-ERCP pancreatitis (PEP) is a common complication most feared by endoscopists. Incidence ranges widelly from 2.1% to 24.4%, which results from patient heterogeneity and differences in endoscopist expertise, method, PEP definition, and severity. Pathophysiology is multifactorial, and involves a combination of chemical, thermal, mechanical, hydrostatic, enzymatic, allergic, and microbiological factors resulting from papillary instrumentation and/or contrast administration within the pancreatic duct (volume and osmolarity). Even genetic abnormalities may represent a risk factor, as is the case with homozygous alpha-1-antitrypsin deficiency, which leads to an increase in hemorrhagic PEP rates.

ERCP during pregnancy.

BACKGROUND AND AIMS: ERCP during pregnancy is always challenging for the entire team performing the endoscopic intervention. In this study techniques and different interventional aspects used at several centres about the clinical experience on ERCP in pregnant women are analyzed. PATIENTS AND METHODS: the practice on ERCP in pregnant women in six centres during a period of ten years is reported. RESULTS: eleven patients were included in the study. Mean age was 30.6 years. Indication for ERCP was always symptomatic common bile duct stone (CBDS) disease. Before the procedure abdominal ultrasound was performed at all times and magnetic resonance cholangiopancreatography in four occasions. Conscious sedation by means of midazolam and fentanyl or meperidine was applied. Sphincterotomes and guidewires were used for bilary cannulation. Sometimes, rapid exchange platforms with short-length guidewires controlled by the same endoscopist were employed. Biliary cannulation was confirmed in 9 occasions by bile aspiration. In five procedures, a mean of 30 seconds of fluoroscopy was used, both to verify cannulation and to corroborate complete CBDS clearance. These patients had the pelvic zone protected with a lead shield and radiation dose was measured. Ten biliary sphincterotomies were performed followed by CBDS extraction. Two plastic stents were inserted. Relief of biliary obstruction was attained in all circumstances. Only one patient had hyperamylasemia after ERCP. All pregnant women had healthy foetuses with normal deliveries. CONCLUSIONS: with experience, ERCP appears to be a safe technique during pregnancy. With simple measures fluoroscopic time can be diminished or even abolished. It seems that ERCP during pregnancy is underused in our working areas, although it has shown to be a useful technique for relieving biliary obstruction.

[Microalbuminuria and renal insufficiency in chronic hepatitis C virus infection]. / Microalbuminuria e insuficiencia renal en la infección crónica por el virus de la hepatitis C.

INTRODUCTION: Chronic hepatitis C virus (HCV) infection is associated with glomerular disease, which is manifested by proteinuria with or without renal dysfunction. METHOD: To determine the prevalence of HCV-associated renal injury and associated risk factors, we performed an observational, analytic, cross-sectional study of 120 HCV-positive patients and 145 HCV-negative controls. Data were gathered from medical records and history-taking and at least three blood and urine analyses were performed over a 1-year period. Renal insufficiency was defined as an estimated glomerular filtration rate of less than 60ml/min/1.73 m2 and/or microalbuminuria of more than 20mg/l or a microalbumin/creatinine ratio higher than 30 mcg/mg. RESULTS: The prevalence of microalbuminuria and renal insufficiency was 19.3% and 11.7% in HCV-positive patients versus 10.5% and 0.7% in HCV-negative controls (p 0.04), respectively. A total of 26.1% of HCV-positive patients had signs of renal injury compared with 11.8% of HCV-negative controls (p 0.003). HCV infection was independently and significantly associated with the probability of worsening of renal function. The prevalence of microalbuminuria and renal insufficiency progressively increased with greater age. CONCLUSION: HCV-positive patients show a high prevalence of microalbuminuria and renal insufficiency compared with HCV-negative individuals. The risk of HCV-associated renal insufficiency is independent of the presence of other predisposing factors such hypertension and diabetes.

Antral localization worsens the efficacy of enteral stents in malignant digestive tumors.

BACKGROUND AND AIMS: Malignant gastric outlet obstruction can be treated by means of enteral stenting or surgical gastrojejunalanatomosis. We evaluated in a prospective and multicentre study the efficacy of the enteral stent on food intake, the quality of life impact, and the relationship between efficacy and determined clinical and technical parameters. PATIENTS AND METHODS: Seventy one patients affected by symptoms arising from gastroduodenal obstruction due to malignant tumors, with criteria of irresecability, metastatic disease or very high surgical risk, were treated by means of self expanding metal stents. We used the GOOSS index to evaluate efficacy, and the Euro Qol-5D index to evaluate quality of life. RESULTS: Before stenting patients with GOOSS 0 and 1 were 68 (98.5%). After stenting patients with GOOSS 2 and 3 (semisolid and solid food) were 58 (84,1%) (P<.0001). The Euro Qol-5D index measured before and a month after stenting were 10.17 and 10.04 respectively (P=.6). The median survival was 91 days (9-552). The enteral stents for localised tumors in the duodenum and the gastrojejunalanastomosis were effective in 26 patients (70.2%) and 13 patients respectively (86.6%), while the enteral stents of tumors in the antrum were effective in only 5 patients (29.4%). CONCLUSIONS: The palliative treatment of malignant gastric outlet obstruction with a uncovered metal stent produces a significant improvement of oral food intake and maintains the overall quality of life index. The antral localization is associated with a lower efficacy of the procedure.

[Reversibility of hepatitis B virus-induced liver cirrhosis after prolonged antiviral therapy]. / Desaparición de cirrosis hepática por VHB tras tratamiento prolongado con antivirales.

Reversibility of liver fibrosis or cirrhosis involves complete restoration of normal liver architecture. This phenomenon has been well documented in chronic liver diseases such as autoimmune hepatitis, biliary obstruction, hemochromatosis, nonalcoholic steatohepatitis, and viral hepatitis. There are very few reports of reversal of cirrhosis after antiviral therapy in patients with chronic hepatitis B virus (HBV) infection. We report a case of disappearance of HBV-induced liver cirrhosis after years of treatment with distinct antiviral drugs, documented by successive biopsy results. This disappearance was accompanied by normalization of platelet count, gammaglobulin titers, and radiologic findings.

[New techniques to extract impacted partially covered metallic biliary stents]. / Nuevas técnicas para extraer prótesis biliares metálicas recubiertas impactadas.

One of the problems affecting metallic biliary stents is the difficulty of removing them, especially after a period of months or if they have migrated. Several approaches have been used to remove both covered and uncovered stents, although with different degrees of effectiveness. We report two new approaches to removing partially covered stents that migrated proximally and that impacted in the papillary area and distal common bile duct. One stent was removed by papillectomy and the other by using duodenoscopy-guided controlled radial expansion balloon dilation. In both cases, the stents were removed without severe complications for the patient, leaving a good caliber in the stenosis.

Gastrointestinal lesions in chronic kidney disease patients with anaemia. / Lesiones gastrointestinales en pacientes con enfermedad renal crónica y anemia.

INTRODUCTION: Despite the frequency with which anaemia is present in patients with chronic kidney disease (CKD), its relationship with gastrointestinal lesions has not been studied. METHOD: A cross-sectional, analytical, observational study involving one year of recruitment was carried out to determine the prevalence of endoscopic gastrointestinal lesions and associated risk factors in asymptomatic patients with chronic kidney disease stages 1-5 and anaemia who had a positive qualitative immunochemical faecal occult blood test. RESULTS: A total of 9,658 patients with CKD were analysed, of which 286 (2.9%) had anaemia; 198 had a positive faecal occult blood test (47% male, 71.1±11.8 years). The endoscopic study revealed 255 lesions, with at least one lesion in 68.2% of patients, with the most prevalent being: adenomatous colorectal polyps (39.6%), acute lesions of the gastric mucosa (22.6%), neoplastic lesions 15.1%), angiodysplasia (14.4%), oesophagitis (8.4%), inflammatory bowel disease (4.8%) and ischaemic colitis (3.1%). Uraemia and acetylsalicylic acid were identified as risk factors for acute gastric mucosal lesions. Angiodysplasia was associated with alcoholism, a more advanced stage of chronic kidney disease, anaemia, and lack of response to erythropoiesis-stimulating agents. Age and refractory anaemia were risk factors for adenomatous polyps and colorectal cancer. CONCLUSION: Renal patients with anaemia could benefit from an endoscopic study due to their high prevalence of gastrointestinal lesions, particularly adenomatous polyps and colorectal cancer, which are more common in those over 50 years of age with CKD stages 3-5.

[Effect of Helicobacter pylori eradication on iron deficiency anemia of unknown origin]. / Efecto de la erradicación de Helicobacter pylori en la anemia ferropénica de origen incierto.

UNLABELLED: Iron deficiency anemia of unknown origin is a frequent cause of anemia in which etiological diagnosis is often not achieved, despite currently available diagnostic techniques. Recent studies suggest that, in the absence of digestive tract lesions, Helicobacter pylori infection could be the cause of iron deficiency anemia, due to the alterations produced in gastric iron absorption. OBJECTIVES: To evaluate whether H. pylori eradication resolves iron deficiency anemia and removes the need for oral iron administration. PATIENTS AND METHODS: We performed an observational descriptive study in patients with iron deficiency anemia refractory to treatment with oral iron administration and with out causes that could explain their anemia. Gastroscopy, ileocolonoscopy, intestinal transit study and/or endoscopic capsule were performed. Female patients also underwent gynecological study. All patients were H. pylori-positive and standard eradication therapy was administered until elimination was achieved. The patients were followed-up for a minimum of 3 months after H. pylori eradication and the need for oral iron intake after eradication was evaluated. RESULTS: Ten patients, aged 53+/-8.2 years, were included. Hemoglobin (Hbg) before treatment was 10.06+/-0.53 mg/dl, mean corpuscular volume (MCV) was 75.43+/-6.02 fl and ferritin was 6.1+/-3.28 ng/ml. Eradication therapy was administered until elimination of H. pylori. The mean time before disappearance of anemia was 4.5 months. Laboratory parameters after treatment were as follows: Hgb 12.86+/-0.75 mg/dl, MCV 85.02+/-4.8 fl and ferritin 28+/-22.19 ng/dl. CONCLUSIONS: In the absence of lesions that could explain iron deficiency anemia, this disease can be related to H. pylori infection. Eradication of this infection is closely followed by disappearance of anemia and ferropenia.

[Efficacy of Helicobacter pylori eradication in non-ulcer dyspepsia]. / Eficacia de la erradicación de Helicobacter pylori en la dispepsia no ulcerosa.

BACKGROUND AND OBJECTIVE: The relationship between Helicobacter pylori infection and functional dyspepsia (FD) is disputed. Although there is a greater prevalence of infection by H. pylori in subjects with non-ulcer dyspepsia than in healthy subjects, results regarding the eradication of infection have been inconclusive so far in terms of disease improvement. In this study, we administered eradicating treatment to a group of patients with both FD and infection by H. pylori to determine the possible beneficial effect of such a treatment. Thus, our objective was to study the effectiveness of eradication therapy for H. pylori in the clinical course of FD. PATIENTS AND METHOD: This was a randomized, double-blind study in 93 consecutive patients diagnosed with FD and infection by H. pylori who received eradicating treatment with omeprazol, amoxicillin and clarythromicin for 7 days (group A, n = 47) vs. placebo, amoxicillin and clarythromicin for 7 days (group B, n = 46). We analyzed the clinical evolution of the disease within the following 9 months. RESULTS: Both groups of treatment were comparable concerning all the variables studied except for the consumption of alcohol, with a greater prevalence in group A, yet no patient consumed more than 40 g per day. The average age of patients was 42 (18-65). Eradication of H. pylori occurred in 65.9% of patients in group A and 4.3% of patients in group B. 40% of all patients included in the study had improved symptoms. In 60.6% of patients whose infection was eradicated, their symptoms improved, as opposed to 25% of patients whose infection was not eradicated (p = 0.001). Among patients whose symptoms improved following eradication, 70% had had an FD duration of less than 3 years and in 30% FD had lasted for more than 3 years (p < 0.05). CONCLUSIONS: The eradication of H. pylori in patients with short-lasting FD may lead to a significant clinical benefit, especially in those whose duration of symptoms is below 3 years.

Exocrine pancreatic insufficiency and chronic pancreatitis in chronic alcoholic liver disease: coincidence or shared toxicity?

OBJECTIVES: The aims of this study were to determine the prevalence of exocrine pancreatic insufficiency (EPI) and chronic pancreatitis (CP) in patients with chronic alcoholic liver disease and to analyze the possible associated factors. METHODS: This is an analytical observational study of cases and controls for a sample of patients with chronic alcoholic and nonalcoholic liver disease. Exocrine pancreatic insufficiency was diagnosed using the C mixed-triglyceride breath test. Patients with abdominal pain underwent endoscopic ultrasonography for CP evaluation using the Wiersema criteria. RESULTS: A total of 154 patients were included, 129 with alcoholic liver disease (83 with cirrhosis) and 25 with nonalcoholic liver disease. Exocrine pancreatic insufficiency was found in 55.2% versus 16.7% (P < 0.001), 70% of patients without cirrhosis compared with 46.2% of patients with cirrhosis had pancreatic insufficiency (P = 0.017), and 82.7% of patients with alcoholic liver disease and abdominal pain had CP (P < 0.001). Exocrine pancreatic insufficiency was associated with the male sex, alcohol intake, abdominal pain, degree of liver failure, and the absence of portal hypertension. Chronic pancreatitis was correlated with age younger than 55 years and abdominal pain. CONCLUSIONS: Patients with alcoholic liver disease had a high prevalence of EPI and CP; this prevalence was even higher in patients who have not yet developed cirrhosis with liver failure or portal hypertension.