Benito Velayos

High Levels of Proinflammatory Cytokines, but Not Markers of Tissue Injury, in Unaffected Intestinal Areas from Patients with IBD

Intestinal alterations in IBD are triggered and maintained by an overexpression of proinflammatory cytokines. Additionally, increased immune activation has been found in the adjacent intestinal areas without displaying any apparent histological alterations, however, the regulatory environment is not well established. Biopsy specimens from patients with ulcerative colitis (UC) and Crohns disease (CD), from both affected and unaffected areas, and also from a group of colonic biopsies from healthy controls, were included in our study. Cytokines and markers of mucosal damage were analyzed by real-time PCR, and some of the results confirmed by western-blot and ELISA. Levels of IFNγ, TNFα, IL-6, IL-15, IL-18, and IL-23 were increased (above healthy controls) in both affected and unaffected areas from IBD. IL-1β, IL-6, IL-12, and IL-27 were higher in affected areas compared to unaffected ones in UC but not CD. In general, a correlation was observed between mRNA levels of these cytokines and both iNOS and Granzyme B. SOCS-2 and SOCS-3 were also increased in the affected areas. In conclusion, the unaffected areas from IBD show increased levels of a restricted set of cytokines that may exert immune activating roles in these areas without being able to trigger tissue damage.

Helicobacter pylori second-line rescue therapy with levofloxacin- and bismuth-containing quadruple therapy, after failure of standard triple or non-bismuth quadruple treatments

The most commonly used second‐line Helicobacter pylori eradication regimens are bismuth‐containing quadruple therapy and levofloxacin‐containing triple therapy, both offering suboptimal results. Combining bismuth and levofloxacin may enhance the efficacy of rescue eradication regimens.

Accuracy of Urea Breath Test Performed Immediately After Emergency Endoscopy in Peptic Ulcer Bleeding

AimsThe aim of this work is to investigate the accuracy of the urea breath test (UBT) performed immediately after emergency endoscopy in peptic ulcer bleeding (PUB).MethodsUrea breath test was carried out right after emergency endoscopy in patients with PUB. The accuracy of this early UBT was compared to a delayed one after hospital discharge that was considered the gold standard. Clinical and epidemiological factors were analyzed in order to study their influence on the accuracy of the early UBT.ResultsEarly UBT was collected without any complication and good acceptance from all the 74 patients included. In 53 of the patients (71.6%), a delayed UBT was obtained. Comparing concordance between the two tests we have calculated an accuracy of 83% for the early UBT. Sensibility and specificity were 86.36 and 66%, respectively, with a positive predictive value of 92.68% and negative predictive value of 50% (Kappa index = 0.468; p = 0.0005; CI: 95%). We found no influence of epidemiological factors, clinical presentation, drugs, times to gastroscopy, Forrest classification, endoscopic therapy, hemoglobin, and urea levels over the accuracy of early UBT.ConclusionsUrea breath test carried out right after emergency endoscopy in PUB is an effective, safe, and easy-to-perform procedure. The accuracy of the test is not modified by clinical or epidemiological factors, ulcer stage, or by the type of therapy applied. However, we have found a low negative predictive value for early UBT, so a delayed test is mandatory for all negative cases.

Upper gastrointestinal findings detected by capsule endoscopy in obscure gastrointestinal bleeding

OBJECTIVE We analyzed our experience with the use of capsule endoscopy in areas that can be explored with gastroscopy to justify obscure bleeding, as well as the outcome after a new recommended gastroscopy in order to determine if a second gastroscopy before the capsule study can provide any benefit in the management of this disease. METHODS We retrospectively studied 82 patients who were explored with capsule endoscopy for obscure gastrointestinal bleeding who had undergone previously only one gastroscopy. Findings in the zones which were accessible by gastroscopy were normal, mild/known and severe/unknown. In the latter cases we recommended a second gastroscopy, and their treatment and outcome were subjected to further study. RESULTS Capsule endoscopy did not find any unknown esophageal findings. In 63% of cases, no gastric or duodenal lesions were shown; in 20%, lesions were mild or had been previously diagnosed, and in 17%, a new gastroscopy was recommended due to the discovery of an unknown condition which could be the cause of the obscure bleeding. This new information brought about a change in treatment for 78% of patients in this group, all of whom improved from their illness. Capsule endoscopy found significant intercurrent alterations in the small intestine in only 14% of cases. CONCLUSIONS The performance of a second gastroscopy, previous to capsule endoscopy, in the study of obscure gastrointestinal bleeding can offer benefits in diagnostic terms and may introduce therapeutic changes. A detailed analysis of the upper tract frames in intestinal capsule endoscopy studies is mandatory since it may provide relevant information with clinical impact on the management of these patients.

Divertículo de Meckel y tumor estromal gastrointestinal: una curiosa asociación

Meckels diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract. Bleeding from Meckels diverticulum is the most common clinical presentation, especially in childhood. In adults, manifestations include a broad spectrum of symptoms ranging from an incidental finding in surgery, iron deficiency anemia of unknown etiology, and acute abdomen due to mechanical complications of the diverticulum. Neoplastic transformation has been reported, but gastrointestinal stromal tumors are exceptional in this location. We report a case of gastrointestinal stromal tumor in Meckels diverticulum, complicated by perforation.Meckels diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract. Bleeding from Meckels diverticulum is the most common clinical presentation, especially in childhood. In adults, manifestations include a broad spectrum of symptoms ranging from an incidental finding in surgery, iron deficiency anemia of unknown etiology, and acute abdomen due to mechanical complications of the diverticulum. Neoplastic transformation has been reported, but gastrointestinal stromal tumors are exceptional in this location. We report a case of gastrointestinal stromal tumor in Meckels diverticulum, complicated by perforation.

Natural history of irritable bowel syndrome

Chronic diarrhea and functional abdominal pain (FAP) in childhood could be an early manifestation of adult irritable bowel syndrome (IBS). The aim of this study was to investigate the presence of chronic functional digestive symptoms in childhood, interviewing adult patients diagnosed with IBS, in an attempt to establish a relationship between them.

Choledocho-renal fistula in locally advanced cholangiocarcinoma

as complications of cholangiocarcinoma. We report a new kind of biliary fistula as a result of cholangiocarcinoma. A 56-year-old man underwent ERCP because of progressive jaundice. He had no urinary or other symptoms. His only relevant medical history was a cholecystectomy performed one year before because of acute cholecystitis; operatory cholangiography was normal. Cannulation revealed a normal pancreatogram. Intrahepatic ducts were markedly dilated, with an irregular tapering in the middle of the common bile duct with a malignant in appearance (Fig. 1). A few seconds afterwards, the radiological image showed the right renal pelvis and ureter filled with the non-absorptive contrast (iohexol) we used. A sphincterotomy was performed, and samples for citology were obtained with a brush. Then, a 8.5 French and a 10-cm wire-guided stent was placed through the stricture (Fig. 2). The left renal system worked properly and was never filled with contrast. Further films confirmed this finding. Jaundice improved. Computerized tomography and urine tests showed no alterations. A cytologic diagnosis of cholangiocarcinoma was made. The patient went under expected curative surgery. The tumor, with a 3-cm-long fistulous tract towards the right kidney, was confirmed and then removed by surgery. Carcinomatous cells were found in the excised biliary tract, and in the tissue around it. Although biliary tumors usually grow slowly and seldom involve adjacent organs, they may sometimes, through circular size increases, affect neighboring tissues by compression, infiltration or fistulation. These are usually end stages, and treatment is usually endoscopic with biliary stents (5). Surgical treatment can be useful in selected cases. 1130-0108/2005/97/10/750-751 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS Copyright

Fístulas ileocólicas tras radioterapia por carcinoma de endometrio

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Atmospheric pressure does not influence acute diverticular disease

Dear Editor: Increased intraluminal pressure has been suggested as a pathogenic factor for diverticular disease [1]; moreover, we believe that studies on this issue are needed and have been scarce in recent years. In the 1960s, Arfwidsson et al. showed higher luminal pressures in patients with sigmoid diverticula [2]. Painter N.S. confirmed this and showed that the basal pressure of the sigmoid colon is a few millimetres of mercury above atmospheric pressure [3, 4]. So, as changes in internal pressure of the colon are related to diverticular disease and the basal pressure of the colon is related to atmospheric pressure, we thought that changes in atmospheric pressure could have an influence on the pathophysiology of diverticular disease of the colon. The question if atmospheric events can have an influence on some acute or chronic diseases has been previously raised, especially in rheumatology. We thought that atmospheric pressure could have an influence on the development of acute diverticular disease by raising intra-diverticular pressure in days with higher atmospheric pressure; increasing by this means potentially damaging pathogenic mechanisms such as barotrauma, mucosal abrasion and bacterial translocation through the compromised wall of the colon diverticula. In order to prove this hypothesis, we collected in a prospective way the value in millibars of atmospheric pressure of every day of 2012 and the daily trends provided by the meteorological agency of our city. Then, we studied all the patients with acute diverticulitis that attended the emergency department of our hospital, a tertiary centre with a referral population of three hundred thousand people. The diagnosis was made according to the Guidelines of the European Association for Endoscopic Surgeons, and all of the patients had a computed tomography performed as it is recommended [1]. The average barometric pressure was 1,018.9 mbars (range, 1,000–1,040 mbars); it was rising in 45 days, falling in 99 days and steady in 221 days. There were 68 days in which a diagnosis of diverticulitis was made (77 patients, 34 male; mean age, 65.5 years; range, 22–90 years). The patients had relevant cardiovascular risk factors in 45.5 % of the cases, ischemic cardiomyopathy in 18.2 %, neurological disease in 9 %, chronic renal failure in 6.5 %, endocrinopathy in 6.5 %, neoplasms in 5.2 % and pneumopathy in 3.9 %. Diverticulitis occurred in the sigmoid colon in 87 % of the cases (13 % in the descending colon). Medical therapy was prescribed in 87 % of the patients, and surgery was needed in the remaining 13 %, with an average hospital stay of 8.4 days (range, 1–29 days). Our data did not reveal a statistically significant difference between the days with high or low barometric pressure in terms of diverticulitis diagnosis (p=0.135). We also did not find any relation between diverticulitis and barometric trends (p=0.851). B. Velayos (*) : L. Fernández-Salazar : L. Olmo : J. M. Hernández-González Department of Gastroenterology, University Hospital of Valladolid, Av Ramón y Cajal 3, 47005 Valladolid, Spain e-mail: benitovelayos@hotmail.com

Radiation enteritidis diagnosed by wireless capsule endoscopy

A 55 year-old patient was attended at our institution due to epigastric pain. She had suffered an apendicectomy in her childhood and an endometrial carcinoma treated with surgery and radiotherapy 10 years ago. She had been attended at emergency room on several occasions for nausea, bilious vomiting, and abdominal pain. No abnormalities were seen either on her analyses or in her abdominal X-ray. Along these years (20082011), two upper gastrointestinal endoscopies, one colonoscopy with ileoscopy, an abdominal CT scan, a nuclear magnetic cholangioresonance and a small bowel barium enema were performed, which yielded no pathological findings. Only abdominal CT scan finally identified thickened bowel loops and free fluid suggesting radiation enteritis. So, wireless capsule endoscopy was indicated. This study showed angiectasias, severe villous edema and diffuse lymphangiectasias with mucosal denudation (Fig. 1). There were at least 3 strictures in the proximal small bowel (Fig. 2 A and B). The capsule remained stationary for almost two hours in one of them. After 7 hours recording, it had not reach the cecum, but it was retrieved 24 hours later spontaneously. Chronic radiation enteritidis was diagnosed on the basis of the clinical and capsule findings. We added pentoxifylline and decided to follow up. Surgery will be indicated if symptoms become severe or more frequent. Radiation enteritidis diagnosed by wireless capsule endoscopy