Carlos Ferre Aracil

Limited effectiveness with a 10-day bismuth-containing quadruple therapy (Pylera®) in third-line recue treatment for Helicobacter pylori infection. A real-life multicenter study

Helicobacter pylori antibiotic resistance is an increasing problem worldwide. Pylera® may be an option as salvage therapy.

Epistaxis en el paciente cirrótico: una complicación a tener en cuenta

INTRODUCTION Epistaxis in cirrhotic patients is a common issue. However, the literature published to date is very scarce. MATERIAL AND METHODS Retrospective case series of patients with cirrhosis who presented with a significant epistaxis, between 2006 and 2016. RESULTS Data were collected from 39 cirrhotic patients with a mean age of 61.4 (±14) years, 75% of which were males. The main comorbidities were hypertension (33%) and diabetes mellitus (26%). Seven (18%) patients were taking antiplatelet drugs and 3 (8%) anticoagulants. One third of patients had a previous history of epistaxis and 6 had a previous ENT pathology. The main aetiological factor of cirrhosis was alcohol in 46% of cases, with 15 (38%) patients presenting with Child A, 12 (31%) Child B and 12 (31%) Child C class. The median MELD score upon admission was 16 [12-21]. Thirty-five (97%) patients had portal hypertension. At admission, the median platelet count was 89,000 [60,000-163,000] and mean INR was 1.52 (±0.37). Clinically, epistaxis presented as haematemesis or melaena in 8 (21%) patients, simulating gastrointestinal bleeding due to swallowing of blood. In 10 (26%) patients, epistaxis was considered as the probable trigger of an episode of hepatic encephalopathy. Two patients required ICU admission due to bleeding and 8 (21%) died during hospitalisation due to causes not directly related to epistaxis. CONCLUSIONS Epistaxis is a complication to be taken into account in cirrhotic patients, as it can act as an encephalopathy trigger or simulate an episode of gastrointestinal bleeding.

Do patients with iron deficiency without anemia benefit from an endoscopic examination

Background and Aim The need for endoscopic investigation in patients with iron deficiency without anemia (ID) is not established. Methods Data from patients with ID (serum ferritin ≤20 ng/mL, normal hemoglobin) studied with upper and lower endoscopy were retrospectively analyzed. Patients evaluated for iron deficiency anemia (IDA) served as controls, matched by sex and age in a proportion 2:1. Presence, type, location and age distribution of endoscopic findings were compared. Results 109 patients (55% females; mean age 59.6 ± 13.5 years; age distribution: <50 years 27.5%, 50–69 years 43.1%, ≥70 years 29.4%) were included in group ID and 218 matched controls in group IDA. Lesions were found in a similar proportion of patients (53.2% in group ID versus 49% in group IDA, p = 0.48) irrespective of age subgroup (<50 years 53.3% vs. 40%; 50–69 years 59.5% vs. 50%; ≥70 years 43.7% vs. 56.2%; p = 0.92). Diagnostic yield of colonoscopy in subgroup <50 years was low in both groups (6.3% vs. 4.2%, p = 0.76), and was significantly higher in group IDA in age subgroup 50–69 years (17.9% vs. 44.7%, p = 0.04). Multivariate analysis only revealed a significant relationship between age (OR: 1.04, CI 95% 1.02-1.06) and male sex (OR: 2.28, CI 95% 1.18-4.39) with a positive colonoscopy. Malignancy was significantly less frequent in group ID (1.8% vs. 14.2%, p <0.05). Conclusions Prevalence of gastrointestinal lesions in patients without anemia was similar to that of patients with anemia but malignancy was eight times less frequent. Systematic endoscopic evaluation in patients with ID is therefore questionable. Copyright

Endoscopic evaluation of iron deficiency without anemia: does it have the same benefit as in patients with anemia?

Background and Aim The need for endoscopic investigation in patients with iron deficiency without anemia (ID) is not established. Methods Data from patients with ID (serum ferritin ≤20 ng/mL, normal hemoglobin) studied with upper and lower endoscopy were retrospectively analyzed. Patients evaluated for iron deficiency anemia (IDA) served as controls, matched by sex and age in a proportion 2:1. Presence, type, location and age distribution of endoscopic findings were compared. Results 109 patients (55% females; mean age 59.6 ± 13.5 years; age distribution: <50 years 27.5%, 50–69 years 43.1%, ≥70 years 29.4%) were included in group ID and 218 matched controls in group IDA. Lesions were found in a similar proportion of patients (53.2% in group ID versus 49% in group IDA, p = 0.48) irrespective of age subgroup (<50 years 53.3% vs. 40%; 50–69 years 59.5% vs. 50%; ≥70 years 43.7% vs. 56.2%; p = 0.92). Diagnostic yield of colonoscopy in subgroup <50 years was low in both groups (6.3% vs. 4.2%, p = 0.76), and was significantly higher in group IDA in age subgroup 50–69 years (17.9% vs. 44.7%, p = 0.04). Multivariate analysis only revealed a significant relationship between age (OR: 1.04, CI 95% 1.02-1.06) and male sex (OR: 2.28, CI 95% 1.18-4.39) with a positive colonoscopy. Malignancy was significantly less frequent in group ID (1.8% vs. 14.2%, p <0.05). Conclusions Prevalence of gastrointestinal lesions in patients without anemia was similar to that of patients with anemia but malignancy was eight times less frequent. Systematic endoscopic evaluation in patients with ID is therefore questionable. Copyright

Pancreatitis aguda necrótica y aparición súbita de una masa abdominal: una complicación infrecuente

Las complicaciones hemorrágicas de la pancreatitis aguda (PA) son infrecuentes y se asocian con una alta morbimortalidad. Asimismo el desequilibrio del sistema de la coagulación en la PA grave, favorece la aparición de eventos trombóticos a nivel esplácnico. Presentamos el caso de una complicación no descrita hasta la fecha que refleja este fenómeno y la complejidad del manejo de estos pacientes. Varón de 42 años, fumador y bebedor de 120 g de alcohol/ día, que ingresó en nuestro servicio por un cuadro de 48 h de evolución de dolor abdominal epigástrico y continuo, compatible con el diagnóstico de PA. En la analítica al ingreso destacaba una bilirrubina total de 2,96 mg/dl (normal: < 1,2 mg/dl), GGT 500 U/l (normal: 7-30 U/l), LDH 346 U/l (normal: 140-240 U/l), amilasa 144 U/l (normal: 42141 U/l), lipasa 355 UI/l (normal: 42-111 U/L), PCR 147 mg/l (normal: < 5 mg/l) y leucocitosis de 21.700/ l (normal: < 10.500/ l). Las transaminasas, fosfatasa alcalina, urea y hematocrito eran normales. La ecografía abdominal al ingreso no mostró hallazgos relevantes. Ante la persistencia del dolor al tercer día y el incremento de la PCR hasta 234 mg/dl, se realizó una TC abdominal en la que se objetivó una necrosis de la cabeza pancreática (2530% del parénquima) y una trombosis del 50% de la vena mesentérica superior (VMS). Se decidió iniciar tratamiento anticoagulante con heparina de bajo peso molecular a dosis de 1 mg/kg/12 h. El paciente evolucionó favorablemente hasta que en el séptimo día, de forma brusca, presentó dolor intenso en hemiabdomen inferior, deterioro del estado general y anemización hasta 5 g/dl de hemoglobina. En la exploración destacaba la aparición repentina de una masa de 8 cm de diámetro en flanco derecho. Se realizó una angio-TC urgente que constató la presencia de un hematoma de 8 × 15 × 9 cm en la pared del colon dere-

Resultados de la implementación de un programa multidisciplinar de trasplante de microbiota fecal por colonoscopia para el tratamiento de la infección recurrente por Clostridium difficile

INTRODUCTION Recurrent Clostridium difficile infection (CDI) is common and often difficult to manage. Faecal microbiota transplant (FMT) is an effective therapeutic tool in these cases, although its applicability and effectiveness in Spain is currently unknown. AIM To analyse the technical aspects, safety and effectiveness of the first consolidated FMT programme in Spain. METHODS Retrospective descriptive study of all patients with recurrent CDI treated with FMT performed by colonoscopy in a tertiary centre after the implementation of a multidisciplinary protocol between March 2015 and September 2016. RESULTS A total of 13 FMT were performed in 12 patients (11/12; 91.7% women) with a median age of 84.6 years (range: 38.2-98.2). Recurrence of CDI was the indication for FMT in all cases. Patients had suffered a median of 3 previous episodes of CDI (range: 2-6) and all had failed treatment with fidaxomicin. All procedures were performed by colonoscopy. Effectiveness with one session of FMT was 91.7% (11/12; 95% CI: 64.6 to 98.5%). In the non-responder patient, a second FMT was performed 17 days after the first procedure, with disappearance of symptoms. No side effects related to the endoscopic procedure or the FMT were recorded after a median follow-up of 6.5 months (range: 1-16 months). Two patients died during follow-up due to causes unrelated to FMT. CONCLUSION FMT by colonoscopy is an effective and safe therapeutic alternative in recurrent CDI. It is a simple procedure that should be implemented in more centres in Spain.