Enric Brullet

Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: A multicenter trial

β‐Blockers and endoscopic variceal ligation (EVL) have proven to be valuable methods in the prevention of variceal rebleeding. The aim of this study was to compare the efficacy of EVL combined with nadolol versus EVL alone as secondary prophylaxis for variceal bleeding. Patients admitted for acute variceal bleeding were treated during emergency endoscopy with EVL or sclerotherapy and received somatostatin for 5 days. At that point, patients were randomized to receive EVL plus nadolol or EVL alone. EVL sessions were repeated every 10 to 12 days until the varices were eradicated. Eighty patients with cirrhosis (alcoholic origin in 66%) were included (Child‐Turcotte‐Pugh A, 15%; B, 56%; C, 29%). The median follow‐up period was 16 months (range, 1–24 months). The variceal bleeding recurrence rate was 14% in the EVL plus nadolol group and 38% in the EVL group (P = .006). Mortality was similar in both groups: five patients (11.6%) died in the combined therapy group and four patients (10.8%) died in the EVL group. There were no significant differences in the number of EVL sessions to eradicate varices: 3.2 ± 1.3 in the combined therapy group versus 3.5 ± 1.3 in the EVL alone group. The actuarial probability of variceal recurrence at 1 year was lower in the EVL plus nadolol group (54%) than in the EVL group (77%; P = .06). Adverse effects resulting from nadolol were observed in 11% of the patients. In conclusion, nadolol plus EVL reduces the incidence of variceal rebleeding compared with EVL alone. A combined treatment could lower the probability of variceal recurrence after eradication. (HEPATOLOGY 2005;41:572–578.)

Identification of factors that influence tolerance of upper gastrointestinal endoscopy.

OBJECTIVEnUnsedated gastroscopy is unpleasant for some patients. The identification of factors related to tolerance would permit the selection of patients for sedation. The aim of the present study was to identify these factors.nnnMETHODSnFive hundred and nine patients underwent diagnostic gastroscopy after the administration of topical pharyngeal anaesthesia, without sedation. Patients were grouped as to whether they had undergone prior examinations or not. Tolerance was assessed with a visual analogue scale and a questionnaire.nnnRESULTSnTwo hundred and seventy-three (54%) patients underwent gastroscopy for the first time, and 236 (46%) patients had prior experience. Patient tolerance was poor in 84 of 273 (31%) patients undergoing gastroscopy for the first time, and in 61 of 236 (26%) patients with prior experience. Logistic regression analysis identified the following variables related to poor tolerance: (a) in patients undergoing gastroscopy for the first time: presence of gag reflex (odds ratio (OR) = 3.42, 95% confidence interval (CI) 1.90-6.17), apprehension (OR = 2.57, CI 1.33-4.95), young age (OR = 0.95, CI 0.93-0.98) and high level of anxiety (OR = 1.91, CI 0.96-3.89); (b) in patients with prior experience: apprehension (OR = 4.21, CI 1.93-9.20), poor tolerance of prior examinations (OR = 4.92, CI 1.93-12.5) and female (OR = 2.23, CI 1.09-4.57).nnnCONCLUSIONSnThe above-mentioned factors are predictive of poor tolerance, and may enable the identification of those patients who might benefit more from sedation for gastroscopy.

Recomendaciones para el diagnóstico y el tratamiento de la hemorragia digestiva alta aguda no varicosa

Se define como hemorragia digestiva alta aquella que se origina en una lesión situada por encima del ángulo de Treitz. Clínicamente, se manifiesta en forma de hematemesis de sangre fresca o en «poso de café», de melenas, de ambas o, con menor frecuencia, como hematoquecia. La causa más frecuente de hemorragia digestiva alta no varicosa es la úlcera péptica gastroduodenal, que representa alrededor del 70% de los casos, pero también puede ser debida a lesiones agudas de la mucosa gástrica, esofagitis, síndrome de Mallory-Weiss, tumores o lesiones vasculares. La hemorragia digestiva alta no varicosa es una emergencia médica frecuente, con una incidencia anual que oscila entre 50 y 150 casos por 100.000 habitantes1. Ello representa un elevado número de ingresos anuales y un consumo muy elevado de recursos sanitarios. A pesar de los importantes avances de los últimos años, la mortalidad asociada a la hemorragia digestiva alta no varicosa todavía es elevada en algunas series (10%)2,3, aunque en estudios más recientes ha descendido hasta valores del 2%4. La reducción de la mortalidad observada en las series más recientes se debe, principalmente, al mejor conocimiento de los factores pronósticos en la hemorragia digestiva alta2,3,5-9 y, sobre todo, a la introducción y el desarrollo de diferentes técnicas de terapéutica endoscópica que ha condicionado un notable descenso de la incidencia de recidiva de la hemorragia y de la necesidad de tratamiento quirúrgico10. No obstante, existen otros factores que han contribuido a este descenso de mortalidad, y entre ellos debemos destacar el tratamiento de estos pacientes en «unidades de sangrantes». En ellas, los pacientes son atendidos por un equipo médico multidisciplinario (formado por gastroenterólogo, cirujano, endoscopista y radiólogo) y personal de enfermería especializado y altamente cualificado en el manejo de la hemorragia digestiva alta. Estas unidades también favorecen la concentración de recursos terapéuticos y la aplicación de protocolos que conducirán a un manejo más homogéneo de los pacientes. En cualquier caso, es fundamental tratar a los pacientes con hemorragia digestiva alta en centros que dispongan del personal y los recursos necesarios para tratar adecuadamente a estos pacientes. La hemorragia digestiva alta no varicosa es una entidad idónea para la confección de una guía clínica, porque tiene una elevada incidencia y ocasiona un importante consumo de recursos. A pesar de la abundante información acumulada en los últimos años sobre su pronóstico y tratamiento, todavía existe una importante heterogeneidad en el manejo de los pacientes, lo que puede ocasionar resultados clínicos diferentes. En este sentido, un estudio realizado recientemente en hospitales universitarios de nuestro país11 pone de manifiesto el diferente manejo de la hemorragia digestiva en función del servicio de ingreso del paciente (gastroenterología, cirugía o medicina interna). Si bien no se observan diferencias significativas en la mortalidad, la estancia media y el coste de la hospitalización fueron significativamente inferiores en los pacientes ingresados en el servicio de gastroenterología, que en los de cirugía o medicina interna. Estos hechos ponen de manifiesto la necesidad de una guía clínica para la hemorragia digestiva alta no varicosa, que permita homogeneizar la conducta, mejorar la calidad de la asistencia que reciben los pacientes y optimizar la utilización de recursos sanitarios. Por iniciativa de la Junta de Gobierno de la Societat Catalana de Digestologia, se constituyó un grupo de trabajo formado por 11 especialistas con amplia experiencia en el diagnóstico y el tratamiento de la hemorragia digestiva, entre los cuales había gastroenterólogos, endoscopistas y cirujanos, con el objetivo de confeccionar una guía clínica para la hemorragia digestiva alta aguda no varicosa. Cada uno de los miembros del grupo desarrolló diferentes temas de la guía, que fueron discutidos conjuntamente en las 10 reuniones de trabajo que se realizaron a lo largo de algo más de un año. Las recomendaciones que se exponen a continuación son fruto de la revisión de la mejor evidenCorrespondencia: Dr. F. Feu. Servicio de Gastroenterología. Hospital Clínic. Villarroel, 170. 08036 Barcelona. España. Correo electrónico: ffeu@clinic.ub.es

A randomized study of the safety of outpatient care for patients with bleeding peptic ulcer treated by endoscopic injection

BACKGROUNDnOutpatient management is safe for patients with non-variceal upper-GI bleeding who are at low risk of recurrent bleeding and death. However, outpatient care cannot be offered to many patients because of the presence of risk factors (severe comorbid disorders, major endoscopic stigmata of bleeding, significant hemorrhage). The present study assessed the safety of outpatient management for selected high-risk patients with bleeding peptic ulcer.nnnMETHODSnPatients hospitalized with upper-GI bleeding because of peptic ulcer with a non-bleeding vessel were eligible for inclusion in the study. Inclusion criteria were the following: ulcer size less than 15 mm, absence of hypovolemia, no associated severe disease, and appropriate family support. After endoscopic therapy (injection of epinephrine and polidocanol), patients were randomized to outpatient or hospital care. Patients remained in the emergency ward for a minimum of 6 hours before discharge, during which time omeprazole was administered intravenously. Outpatients were contacted by telephone daily during the first 3 days; a 24-hour telephone hotline was provided for any queries. For both groups, outpatient visits were scheduled at 7 to 10 and 30 days after discharge.nnnRESULTSnA total of 82 patients were included: 40 were randomized to outpatient care and 42 to hospital care. Clinical and endoscopic variables were similar in both groups. The rate of recurrent bleeding was similar in both groups (4.8% outpatient, 5% hospital). There was no morbidity or mortality in either group at 30 days. Seven patients (17%) randomized to outpatient care received blood transfusion compared with 14 (38%) in the hospital care group (p=0.06). Mean cost of care per patient was significantly lower for the outpatient vs. the hospital group (970 US dollars vs. 1595 US dollars; p < 0.001).nnnCONCLUSIONSnSelected patients with bleeding peptic ulcer can be safely managed as outpatients after endoscopic therapy. This policy conserves health care resources without compromising standards of care.

Alianza para la Prevención del Cáncer de Colon en España: un compromiso cívico con la sociedad

Colorectal cancer (CRC) is the most common malignant tumor in Spain, when men and women are considered together, and the second leading cause of cancer death. Every week in Spain over 500 cases of CRC are diagnosed, and nearly 260 people die from the disease. Epidemiologic estimations for the coming years show a significant increase in the number of annual cases. CRC is a perfectly preventable tumor and can be cured in 90% of cases if detected in the early stages. Population-based screening programs have been shown to reduce the incidence of CRC and mortality from the disease. Unless early detection programs are established in Spain, it is estimated that in the coming years, 1 out of 20 men and 1 out of 30 women will develop CRC before the age of 75. The Alliance for the Prevention of Colorectal Cancer in Spain is an independent and non-profit organization created in 2008 that integrates patients associations, altruistic non-governmental organizations and scientific societies. Its main objective is to raise awareness and disseminate information on the social and healthcare importance of CRC in Spain and to promote screening measures, early detection and prevention programs. Health professionals, scientific societies, healthcare institutions and civil society should be sensitized to this highly important health problem that requires the participation of all sectors of society. The early detection of CRC is an issue that affects the whole of society and therefore it is imperative for all sectors to work together.

Limited usefulness of a seven-day twice-a-day quadruple therapy

Objective To test the usefulness of a twice‐a‐day, simplified quadruple therapy to cure Helicobacter pylori infection. Design Helicobacter pylori‐positive ulcer patients were treated with omeprazole 20 mg twice a day (b.d.), amoxicillin 1 g b.d., tinidazole 500 mg b.d. and bismuth subcitrate 240 mg b.d. for 7 days in an experimental, noncomparative pilot study. Setting The gastroenterology unit of a county hospital. Participants Forty‐four consecutive patients with peptic ulcer disease and H. pylori infection. Measurements Cure was tested by either endoscopy or breath test after 2 months, and by urea breath test 6 months after therapy. Results One patient was lost to follow‐up. Of the remaining 43, 37 were cured at the first control, giving an intention‐to‐treat cure rate of 84.1% (95% CI 69‐93%) and a per protocol cure rate of 86% (95% CI 71‐94%). Thirty‐three cured patients agreed to return for a six‐month breath test. All but one were cured (long‐term per protocol cure rate 82.1%; 95% CI 66‐92%). Conclusions This particular quadruple therapy is well tolerated and easy to comply with. However, cure rates did not reach 90%.

Four-day, twice daily, quadruple therapy with amoxicillin, clarithromycin, tinidazole and omeprazole to cure Helicobacter pylori infection: a pilot study.

Background. The best regimen for the treatment of Helicobacter pylori infection has yet to be defined. Four‐day quadruple therapy with tetracycline, metronidazole, bismuth, and a proton pump inhibitor has been shown to obtain a very high cure rate. However, the fact that it must be taken four times daily may interfere with compliance. The objective of the study was to test the efficacy and tolerability of a new 4‐day therapy with 4 drugs taken every 12 hours to cure H. pylori infection.

Efficacy of low and standard midazolam doses for gastroscopy. A randomized, double-blind study

Aim To evaluate the efficacy and safety of two different doses of intravenous midazolam (35 and 70 &mgr;g/kg) compared to placebo in patients undergoing gastroscopy. Patients and methods Sixty patients scheduled for diagnostic gastroscopy were selected according to factors previously reported to affect tolerance (Eur J Gastroenterol Hepatol 1999; 11:201‐204) and were randomly assigned to receive premedication with midazolam 35 &mgr;g/kg iv, midazolam 70 &mgr;g/kg iv or placebo iv. Oxygen saturation was continuously monitored during the procedure. Patients tolerance, time to discharge and post‐sedative inconvenience were evaluated using visual analogue scales and a questionnaire. Results Patients receiving either dose of midazolam showed better tolerance of gastroscopy than those receiving the placebo. Fewer patients receiving 70 or 35 &mgr;g/kg of midazolam were reluctant to undergo a further gastroscopy compared to those receiving the placebo (2, 1 and 9 patients respectively, P = 0.01). Compared to patients receiving midazolam 70 &mgr;g/kg, those receiving midazolam 35 &mgr;g/kg were discharged earlier (29.3 ± 14.4 versus 43.1 ± 12.4 min respectively, P < 0.001), experienced less post‐sedative inconvenience (8 versus 15 patients slept for > 1 h at home respectively, P = 0.02), and suffered fewer clinically relevant desaturation episodes (< 90%) (0 versus 5 patients respectively, P = 0.04). Conclusions Low doses of intravenous midazolam (35 &mgr;g/kg) are adequate and safe when sedation is indicated for gastroscopy. Eur J Gastroenterol Hepatol 12:187‐190

Evaluación de un nuevo test rápido para la detección de Helicobacter pylori en heces

Fundamento El objetivo del presente estudio fue evaluar la fiabilidad diagnostica y reproducibilidadde una nueva prueba rapida inmunocromatografica (Stick H. pyl, Operon SA, Zaragoza),que utiliza anticuerpos monoclonales para la deteccion de antigeno de Helicobacter pylori enheces, y compararla con la prueba actualmente comercializada (HpSA, EIA, Premier PlatinumHpSA, Meridian Diagnosis Inc, Cincinnati, Ohio). Metodo Se incluyo a 71 pacientes sometidos a endoscopia para estudio de sintomas dispepticos.Se practicaron biopsias para CLO-test e histologia antral. Se considero infectados por Helicobacterpylori a aquellos pacientes que presentaban histologia y CLO-test positivos, y no infectadosa aquellos con ambos tests negativos. En heces se realizaron 2 determinaciones seriadasde antigeno de Helicobacter pylori mediante HpSA y 4 determinaciones consecutivas con StickH. pyl. Se calcularon la sensibilidad, la especificidad y los valores predictivos positivo y negativo.La concordancia entre determinaciones se evaluo mediante el estadistico kappa. Resultados De los 68 pacientes evaluables, 48 presentaban infeccion por Helicobacter pylori.La sensibilidad, la especificidad y los valores predictivos positivo y negativo en las distintas determinacionesoscilaron entre 89-96%, 60-70%, 85-88% y 74-87% respectivamente paraStick H. pyl frente al 70-75%, 60-85%, 85-92% y 55-80% para HpSA. Los indices de concordanciavariaron entre 0,82 y 0,93 para Stick H. pyl frente a 0,57 para HpSA. Conclusiones Stick H. pyl en heces presenta excelentes sensibilidad y reproducibilidad para eldiagnostico de la infeccion por Helicobacter pylori. Su fiabilidad es superior a la de HpSA.

Validation of phone interview for follow-up in clinical trials on dyspepsia : evaluation of the Glasgow Dyspepsia Severity Score and a Likert-scale symptoms test

Objective To validate two widely used dyspepsia scores performed by phone interview. Design Spanish translations of the Glasgow Dyspepsia Severity Score and a Likert‐scale symptomatic test were evaluated. Responsiveness to the treatment, validity of the tests, and reproducibility of tests performed by phone interview were assessed. Setting Gastroenterology and endoscopy unit of a county hospital. Participants Group I consisted of 16 ulcer patients undergoing Helicobacter pylori eradication; Group II consisted of 29 healthy volunteers; and Group III consisted of 95 patients undergoing upper endoscopy. Measurements Glasgow Severity Dyspepsia Score and Likert test. Results Both tests showed adequate improvement (responsiveness) after H. pylori eradication. With regard to validity, the Glasgow and Likert test were significantly higher in 95 patients undergoing endoscopy than in 29 healthy controls. Analysis of reproducibility showed that intraobserver variation was low on both the Glasgow and Likert scores. No differences were found between consecutive tests regardless of whether both were performed by phone (24 patients) or one by phone and the other by clinical interview (40 patients). Interobserver variation analysis showed that the Glasgow test remained highly reproducible even when performed by different observers using different methods (clinical interview 8.83, phone 8.44, P = 0.12). By contrast, Likert‐scale tests showed significant differences between observers for all symptoms except abdominal pain. Conclusions (1) The Glasgow score is highly reproducible even when performed by different observers and using different methods. (2) By contrast, Likert tests show greater variability. To be reproducible in different conditions, they need to be performed by the same observer. Eur J Gastroenterol Hepatol 12:949‐953