Descriptive analysis of endoscopic findings in patients with a family history of colorectal cancer.

BACKGROUND: The presence of a family history implies an increased risk for developing colorectal cancer (CRC), and may require a different screening strategy. The aim of this study was to evaluate lesions found during colonoscopies of patients that had a family history of CRC. MATERIAL AND METHODS: A retrospective study was conducted that included consecutive colonoscopies performed on patients with a family history of CRC at a referral center within the period from April 2000 to January 2012. The colonoscopic findings were analyzed in relation to sex, age, and the presence or absence of symptoms. RESULTS: Data from 3,792 colonoscopies were collected. The mean age of the patients was 53.14 years (SD 12.22), and 57.4% were women. Colonoscopy was normal in 71.7% of the cases, with hyperplastic polyps being detected in 7.1%, and adenomatous polyps in 19.8% (39.4% of them were high risk). There was a 1.5% presence of adenocarcinomas in the subjects. Polyps and CRC were predominant in men (P=.001 and P=.027, respectively) and there was a linear increase with age. Symptomatic patients had a higher CRC detection rate (P<.001), but no differences were observed in relation to polyp diagnosis. CONCLUSIONS: Age and male sex increased the risk for presenting with CRC or adenomas in the group of patients with a family history of CRC, and the presence of symptoms was associated with a greater risk for presenting with CRC.

Polycystic liver in the adult (PLA) in Spain: analysis of a structured survey analyzing the experience and attitude of gastroenterologists in Spain.

BACKGROUND: Polycystic liver in the adult (PLA) is a rare disease characterized by chronic liver enlargement. OBJECTIVE: To analyse gastroenterologists´ involvement in, experience with, and attitude toward diagnosing, monitoring, andtreating patients with PLA in Spain. METHODS: Each of seven study coordinators contacted 15 specialists in their geographic area about participating in the study via an online structured survey. RESULTS: Of the 105 clinics contacted, 88 completed the questionnaire, with a mean of 3 patients being followed per practice, although 6 clinics were following more than 20 patients with PLA. Patients were being followed mainly by the Department of Hepatology (81 %) and/or the Department of Gastroenterology (33 %). The majority of patients were diagnosed (98 %) and monitored (97 %) using liver ultrasound. When diagnosed, 76 % of patients were under 50 years of age, females predominating.The primary treatment objective for the patients was symptomatic management. Pharmacotherapy was prescribed by 28 % of physicians: Somatostatin analogues, primarily, followed by mTOR inhibitors. One-third of the clinics indicated that they had patients who had undergone liver transplant and/or surgery. CONCLUSIONS: Ultrasound is the diagnosing and monitoring method of choice. Among the clinics using pharmacotherapy for symptomatic management, somatostatin analogues were the drugs of choice. These clinics´ infrequent use of invasive procedures suggests that they perceive the various invasive techniques as not very effective.

Treatment of chronic he1patitis C genotype 1 with peginterferon-alpha2a (40 kDa) plus ribavirin under routine clinical practice in Spain: early prediction of sustained virological response rate.

BACKGROUND: Sustained virological response rates of up to 52% have been obtained with peginterferon alpha2a (40 kDa) plus ribavirin in patients suffering from chronic hepatitis C genotype 1 in randomized-controlled trials. AIM: To assess early virological response and its clinical utility in predicting an sustained virological response in patients suffering from chronic hepatitis C genotype 1 in routine clinical practice in Spain. METHODS: Treatment-naïve patients received pegylated interferon alpha2a (40 kDa) 180 microg/week plus ribavirin 1000/1200 mg/day for 48 weeks, and were followed for a further 24 weeks. Overall, 475 patients received at least one dose of medication and were included in the efficacy population. RESULTS: The overall sustained virological response rate was 48%. Of those with week 12 virological data, 83% had an early virological response. The negative predictive value of an early virological response was 93%. CONCLUSION: If sustained virological response is the goal, a treatment-decision based on a 12-week evaluation during routine clinical practice is feasible.

[Large hydrostatic balloon for choledocolithiasis]. / Balón hidrostático de gran diámetro en coledocolitiasis.

AIM: To assess the efficacy and safety of hydrostatic dilatation with large balloons for the treatment of choledocolithiasis in patients with difficult or risky extraction due to stone characteristics or peripapillary anatomy. DESIGN: Prospective. PATIENTS: This study included 22 patients in whom a hydrostatic dilatation of the papilla with large balloons was performed between June 2005 and April 2006. Patients had multiple large stones, tapered distal common bile duct, peri-/intradiverticular papilla, previous sphincterotomy, or Billroth-II surgery. Esophageal, pyloric and colonic CRE dilatation balloons with diameters ranging from 12 to 20 mm (Boston Scientific Corporation) were used. RESULTS: Stone removal was achieved in a single session in all patients (100%). Most procedures (73%) did not require an extended exploration time. There were no complications. Hyperamilasemia was detected in 18% of patients. CONCLUSIONS: Hydrostatic papillary dilatation with large balloons is a simple, effective, and safe technique for the removal of difficult stones located in the distal common bile duct. It does not add to exploration time, nor increases complications, and reduces the need for lithotripsy. Further studies are needed to define the usefulness of this technique.

Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation.

BACKGROUND: Malignant gastrointestinal obstruction is a secondary complication of cancers in an advanced state. Treatment has consisted of gastrojejunostomy. However, the endoscopic placement of metallic stents has provided positive results. This study aimed to compare the efficiency of both therapeutic options. METHODS: A total of 41 patients with gastrointestinal obstruction caused by inoperable neoplasm were treated endoscopically with enteral stent (24 patients) or gastrojejunostomy (17 patients). RESULTS: In the endoscopic group (EG) 24 patients (100%) achieved efficient gastric emptying, as compared with 82.3% in the surgical group (SG). The difference was not significant. The average time for initiating oral food tolerance was 2.4 days for the EG and 5 days for the SG (p < 0.001). The average inpatient time was 7.1 days for the EG and 11.5 days for the SG (p < 0.001). Mortality at 30 days was lower in the EG (16.6%) than in the SG (29.4%) (p < 0.05). The survival time was 20 weeks for the EG and 21.6 weeks for the SG. The difference was not significant. The rate of complications was 4% in the (EG) and 17.6% in the (SG), with the difference was not significant. CONCLUSION: Endoscopic treatment of malignant gastrointestinal obstruction provides an adequate palliation of the symptoms. It is less invasive, avoids the morbidity associated with open gastrojejunostomy, and achieves a faster start to oral food and a shorter hospital stay, leading to a higher quality of life.

C282Y and H63D mutations of the haemochromatosis gene in patients with iron overload.

OBJECTIVE: To determine the relevance of C282Y and H63D mutations of HEF gene in patients with iron overload. PATIENTS AND METHODS: Patients with iron overload referred to our Liver Unit were included in the study. The association of mutations to different diagnosis and their impact on the severity of the hepatopathy were explored. Sensitivity, specificity and positive and negative predictive values of mutations for the diagnosis of haemochromatosis were determined. RESULTS: The study included 78 patients with iron overload. The control group included 21 patients of similar age and sex ratio without iron overload nor hepatopathy. Twenty three patients had haemochromatosis, 22 alcoholic liver disease and 33 other diseases unrelated to iron metabolism. Seventy three per cent of patients with haemochromatosis were homozygous for the C282Y mutation. All the C282Y homozygous subjects had also haemochromatosis. Fifty three per cent of patients with alcoholic hepatopathy had some kind of mutation. This has been also observed in 70% of patients with iron-unrelated diseases. Such percentage was significantly greater than in the control group (24% with H63D mutation). C282Y homozygosity in patients with iron overload had a sensitivity of 73.9%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 89.6%. CONCLUSIONS: In our population, as in all the Western countries, haemochromatosis is mainly associated to homozygous C282Y mutation. The high frequency of mutations in patients with iron overload and without haemochromatosis suggests the involvement of such mutations in iron overload.

[Helical CT compared to ERCP in obstructive biliary pathology]. / TC helicoidal frente a CPRE en la patología biliar obstructiva.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is the examination of choice in the diagnosis of biliary tract pathology although newer, less invasive techniques with high diagnostic sensitivity should be evaluated. The aim of this study was to evaluate the diagnostic efficacy of helical computed tomography (CT) in bile duct obstruction, particularly in choledocholithiasis. PATIENTS AND METHODS: Forty-four patients with suspected bile duct obstruction were prospectively evaluated. Helical TC was carried out 12 hours before ERCP and patients were grouped according to risk of choledocholithiasis. RESULTS: Choledocholithiasis was found in 20 patients (45.4%). Helical TC identified this pathology in 17 and correctly ruled it out in 18 of 24 patients (S: 85%, E: 75%, positive predictive value 74%, negative predictive value 85.7%. Of the patients with choledocholithiasis, bile duct dilatation was found in 18. Helical TC correctly diagnosed this pathology in 16 of the 18 patients (88.8%). Helical TC correctly diagnosed one of two patients (50%) with choledocholithiasis and normal bile ducts. CONCLUSIONS: Helical TC is effective in the diagnosis of choledocholithiasis but is not sufficiently accurate to be used in the screening of this entity.

[Dilatation of the papilla of Vater in the treatment of choledocholithiasis in selected patients]. / Dilatación de la papila de Vater en el tratamiento de la coledocolitiasis en pacientes seleccionados.

OBJECTIVE: To prospectively analyze the results obtained with papillary balloon dilatation (PBD) in the treatment of common bile duct stones in patients at risk of complications if endoscopic sphincterotomy (ES) were performed. PATIENTS AND METHOD: Thirty-three patients were included between January 2001 and June 2003 (mean age 76.2 years). The criteria for PBD were: choledocholithiasis < or =10 mm in patients with peripapillary diverticula, hemostatic alterations, Billroth-II, and preservation of Oddi's sphincter. In 79% of the patients sedation was performed by an anesthetist. PBD was performed with a balloon catheter dilator with a diameter of 8 or 10 mm for 2 minutes. The efficacy and duration of the procedure as well as complications at 30 days and patient satisfaction were evaluated. RESULTS: Stone extraction was achieved in all patients (100%). The mean duration of the procedure was 26 minutes. Two patients (6%) presented mild pancreatitis. Serum amylase was elevated in 16 patients (48%): > or =3 times (post-PBD hyperamylasemia) in 11 (33%). The procedure caused no discomfort in 25/26 (96%) of the patients sedated by an anesthetist vs 2/5 patients (49%) who underwent endoscopic sedation. CONCLUSIONS: PBD is an effective and simple therapeutic option in the treatment of small common bile duct stones (< or =10 mm) and in patients at high risk. The duration of endoscopic retrograde cholangiopancreatography is not prolonged. Complications are infrequent (6%) and mild. Post-PBD hyperamylasemia is frequent and generally without clinical importance. Sedation by an anesthetist improves patient satisfaction.

[Toxic hepatitis caused by nimesulide, presentation of a new case and review of the literature]. / Hepatitis tóxica por nimesulida, presentación de un nuevo caso y revisión de la bibliografía.

Nimesulide is a potent non-steroidal anti-inflammatory drug. It is a new, selective cyclooxygenase-2 inhibitor with few adverse effects on the gastrointestinal system. We present a case of hepatotoxicity in which other possible causes of liver damage were excluded. A biochemical pattern of cholestasis was predominant. Evolution was favorable after the drug was stopped and enzymatic alterations progressively returned to normal. The cases reported to date are reviewed. The precise mechanism by which nimesulide produces liver damage is not known but it is probably caused by an idiosyncratic reaction. Because of the severity of the hepatitis described in some cases, treatment should be stopped when liver dysfunction is detected and the patients should be closely monitored.

Palliative treatment of malignant obstruction of gastric outlet using an endoscopically placed enteral Wallstent.

Surgical gastrojejunostomy is the standard treatment for malignant gastric outlet obstruction, although it is associated with significant morbidity and mortality. The aim of this study was to evaluate the efficacy and feasibility of a newly designed expandable metal stent (Wallstent Enteral) to treat malignant gastric outlet obstruction. Six patients (five women, one man; mean age 76 years) underwent stenting. Stents 20-22 mm in diameter and 60-90 mm in length were deployed through a duodenoscope channel under endoscopic and fluoroscopic control, without previous stricture dilation. In all six cases the stent was adequately positioned and food intake was possible in the next 24 h. The mean time for hospital discharge was 2.5 days (1-5 days), without complications related to the procedure. Five patients died in the follow-up from progression of their cancer and one remains alive; none had recurrent obstruction. The median survival time was 9 weeks (95% CI: 3-15 weeks). In conclusion, endoscopic self-expandable stent (Wallstent Enteral) placement is safe and effective palliation for malignant gastric outlet obstruction and appears to be a therapeutic alternative to surgical gastrojejunostomy.

Antipyrine clearance and metabolite formation in primary biliary cirrhosis.

The disposition of antipyrine is altered and may be a prognostic factor in the presence of various types of hepatic dysfunction. The object of the present study was to investigate whether antipyrine clearance and metabolite formation are useful to detect altered metabolic function in primary biliary cirrhosis. Saliva clearance of antipyrine and the formation clearance of antipyrine metabolites (hydroxymethylantipyrine, HMA; norantipyrine, NORA; and 4-hydroxyantipyrine, OHA) were investigated in a group of 34 women with biopsy-proven PBC (mean age 60 years; range 39-87 years) and in 15 healthy control women (mean age 62 years; range 46-78 years). Parameters of antipyrine clearance of patients in stage I and II were similar to those observed in healthy subjects. When compared to patients in stage I, patients in advanced stages showed a reduction in antipyrine clearance (-29% and -44% in stages III and IV, respectively) and increases in antipyrine half-life (+24% and +75% in stages III and IV, respectively). The reduction in antipyrine clearance was due to a reduction in the formation of all three antipyrine metabolites, with the formation clearance of both HMA and NORA decreasing to a slightly greater extent than that of OHA. Antipyrine clearance correlated significantly with serum bilirubin (P < 0.017) and the Mayo risk score (P < 0.001). Logistic regression analysis indicated that antipyrine clearance was an independent predictor of the histological stage of the disease (P < 0.001). Antipyrine clearance and metabolite formation is a sensitive parameter for assessing hepatic metabolic function in primary biliary cirrhosis.

Impairment of metabolic function in chronic hepatitis C is related to factors associated with resistance to therapy.

OBJECTIVE: Liver disease causes a loss of hepatic function, and remission is associated with improved functional hepatic mass. The object of the present study was to investigate whether liver metabolic function assessed by antipyrine clearance is related to other disease characteristics influencing response to therapy in chronic hepatitis C. METHODS: Patients (n = 96) received three different treatment regimens: one group received interferon alfa-2b for 48 wk; in a second group with maintained positive hepatitis C virus (HCV) RNA after 12 wk, interferon was combined for 36 wk with oral ribavirin; and patients who were relapsers or nonresponders to a previous therapy with interferon alone received interferon alfa-2b plus ribavirin for 48 wk. RESULTS: Twenty-five patients (26%) showed sustained normalization of ALT levels and negative HCV RNA 6 months after therapy. The response was more likely to be sustained in patients with a genotype other than 1 (52.0% vs 15.5% in patients with genotype 1, p < 0.001), and the percentage of sustained responders was higher among patients who demonstrated negativity of HCV RNA at the end of 4 wk of treatment (64% vs 13% without negativity, p < 0.001). Sustained response was associated with significantly lower baseline serum ferritin (-46%, p < 0.01) and duration of infection (-33%, p < 0.01). Baseline antipyrine clearance was higher in sustained responders than in nonresponders (+19%, p < 0.05) and lower in genotype 1 patients than in those with a genotype other than 1 (-24%, p < 0.05). Antipyrine clearance increased by 12% at the end of the 48-wk course of treatment among sustained responders (+34% vs nonresponders, p < 0.001) and still remained elevated at the end of the follow-up (+35% vs nonresponders, p < 0.001). CONCLUSION: In summary, the present study shows that liver oxidative metabolism is related to antiviral response rates and suggests that much of the effect is explained by viral genotype.

Comparative study of the efficacy of an induction dose of interferon-alpha2b with ribavirin compared with standard combined treatment in naive patients with chronic hepatitis C.

The efficacy and secondary effects of an induction dose of interferon-alpha2b (IFN-alpha2b) with ribavirin compared with standard combined treatment in naive patients with chronic hepatitis C infection were compared. A prospective study was undertaken between March 1998 and November 2001 in which 84 Spanish hospitals took part. Six hundred and fourteen naive patients (age range 18-65 years) diagnosed with chronic hepatitis C virus (HCV) infection and without cirrhosis or co-infection by other viruses, were included. Patients were divided into two groups. Group A (n = 304) received induction treatment with a daily dose of 5 MU of IFN-alpha2b for 4 weeks, followed by 5 MU three times a week with ribavirin (1000-1200 mg/day, according to weight) until completing 1 year of treatment. Group B (n = 310) received the standard dose of IFN-alpha2b of 3 MU three times per week for 48 weeks together with ribavirin (1000-1200 mg/day, according to weight). Both groups were completely comparable according to age, gender, body weight, transaminase levels, genotype, viral load and hepatic inflammatory activity (Knodell Index). No control group was included for ethical reasons. Pegylated interferon was not available at the time of the study. Serum baseline samples were collected for the determination of genotype. Samples were also collected at baseline, weeks 4, 12, 24, 48 and 72, in order to detect and quantify HCV-RNA. The efficacy of treatment was evaluated by means of sustained viral response (SVR) characterized by persistent negativity of HCV-RNA at the end of the follow-up period. At week 4, the response to treatment was greater in group A (49.6%) compared with group B (34.5%) (P = 0.0002), and was maintained until week 12 (64.1% compared with 55.8% respectively) (P = 0.03). These differences disappeared at week 24, when group A (69%) was compared with group B (65%) (NS). At week 48, the response rate for group A was 50.6% compared with group B 47.4% (NS), and at week 72, the SVR in group A was 46% compared with 40.3% for group B (NS). The global SVR was 43.1%. On analysing the response to treatment according to genotype and viral load, we found that the induction treatment was slightly superior in patients with genotype 1 and an elevated viral load (>2 x 10(6) copies/ml). They achieved a SVR in group A of 39.1% compared with 25.5% in group B (P < 0.05). However, this slight improvement obtained in group A, was achieved at the expense of a greater percentage of dropouts compared with group B (6.4% vs 2.2%, P < 0.01); a greater rate of side effects (58.5 vs 36.7%, P < 0.05) and also a greater percentage of neutropenia (3.1% vs 0.9%, P < 0.05). The induction treatment presented a better initial response, but this was not maintained at the end of treatment, and did not improve the results obtained with the standard treatment. Although the patients with genotype 1 and elevated viral load had a better response with the induction treatment, this was accompanied by a greater percentage of dropouts and secondary effects. It would be interesting to repeat this type of study in the future, using pegylated interferon.