Joaquín Poza Cordón

Endoscopic management of esophageal varices

The rupture of gastric varices results in variceal hemorrhage, which is one the most lethal complications of cirrhosis. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL). The advantages of EST are that it is cheap and easy to use, and the injection catheter fits through the working channel of a diagnostic gastroscope. Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands. The following review aims to describe the utility of EBL and EST in different situations, such as acute bleeding, primary and secondary prophylaxis.

Linfogranuloma venéreo: una entidad emergente

El linfogranuloma venéreo (LGV) es una enfermedad de transmisión sexual causada por Chlamydia trachomatis. Su incidencia ha mostrado una claro ascenso en los últimos años entre la población homosexual de Europa y Estados Unidos. Debido a su reciente aparición en nuestro medio y a la inespecificidad de su clı́nica, frecuentemente se retrasa el diagnóstico, evitando un tratamiento que resulta curativo y eficaz. Presentamos el caso de un varón con infección por el virus de la inmunodeficiencia humana (VIH), que se diagnosticó de este cuadro a raı́z de un cuadro de rectorragia. Varón de 31 años de edad que consulta por rectorragia. Entre sus antecedentes destaca infección VIH en estadio A2, en tratamiento antirretroviral, con buen control de la misma. El paciente reconoce haber mantenido conductas homosexuales de riesgo y refiere que desde hace 2 semanas presenta deposiciones con sangre, acompañadas de sensación distérmica, proctalgia y tenesmo rectal. En la exploración fı́sica destaca la palpación de adenopatı́as inguinales bilaterales, de consistencia blanda, rodaderas y no dolorosas. La inspección anal refleja condilomas acuminados y, al tacto rectal, se palpa área indurada en canal anal y a punta de dedo. Se realiza colonoscopia donde se evidencia desde canal anal y hasta 15 cm de margen anal, mucosa indurada, edematosa y eritematosa con áreas ulceradas profundas y friables a la toma de biopsias (fig. 1). La anatomı́a patológica demostró un intenso infiltrado linfocitario agudo (más de 40 linfocitos por campo) con formación de abscesos y granulomas. No presentaba signos de infección por citomegalovirus, y la inmunohistoquı́mica fue negativa para herpes virus 8. La PCR a tiempo real demostró la presencia del serotipo L2b de C. trachomatis. El LGV o enfermedad de Nicolas-Favre es una enfermedad de transmisión sexual producida por los serotipos L1, L2 y L3 de C. Trachomatis. Clásicamente se ha distribuido en áreas tropicales y subtropicales de África, India y Sureste asiático. Sin embargo, a partir del 2003 se comenzaron a publicar casos aislados en Europa y Estados Unidos, con un crecimiento exponencial a partir del 2004. Las caracterı́sticas comunes de todos estos nuevos brotes son que aparece en forma de proctitis en hombres que mantienen relaciones sexuales con otros hombres y todas ellas comparten el serotipo L2b de C. trachomatis. Se han definido 3 estados de infección. El periodo de incubación del primero es de 2 – 12 dı́as y se caracteriza por úlceras genitales o una reacción inflamatoria en el sitio de inoculación. La infección secundaria aparece de 2 – 6 semanas más tarde y se relaciona con la extensión local directa hacia los ganglios linfáticos regionales, produciendo adenopatı́as inguinales y un sı́ndrome anorrectal consistente en supuración, proctalgia, estreñimiento, fiebre o tenesmo. Cuando el tratamiento no ha sido establecido o ha sido insuficiente, progresa a una situación de inflamación crónica con las complicaciones asociadas (estenosis, fı́stulas, etc.) que caracterizan al estadio tardı́o. Las pruebas dirigidas al diagnóstico definitivo son muy especı́ficas y no están disponibles en todos los centros. El cultivo es poco efectivo, porque no suele diagnosticarse durante la fase primaria y, en el estadio secundario, existe baja producción. Con respecto a las pruebas serológicas, inmunofluorescencia o ELISA, tienen el inconveniente que no diferencian los diferentes serotipos ni la infección aguda de la pasada. La amplificación mediante técnicas de reacción en cadena de la polimerasa (PCR) se ha convertido en la prueba diagnóstica principal. El empleo de PCR a tiempo real es capaz de identificar los serotipos L de C. trachomatis mediante la detección de la delección en el gen polymorphic membrane protein (pmp) H. El serotipo L2b se caracteriza por una mutación del gen omp1 que puede ser detectado mediante un análisis más reciente de PCR a tiempo real. ARTICLE IN PRESS

Sa1251 Infliximab Trough Levels and Antibodies: Relationship With Infusion Reaction, Immunomodulators and Biological Parameters

Background: Adalimumab (ADA), a monoclonal antibody against TNFα is effective therapy for inflammatory bowel diseases (IBD: ulcerative colitis (UC) and Crohns disease (CD)). Loss of response to ADA may be the consequence of increased ADA clearance (CL), resulting in short half-life (t1/2) and decreased troughs. Studies evaluating ADA pharmacokinetics (PK) in IBD are scarce. Aim: To generate a preliminary PK model for ADA and to investigate factors affecting ADA PK variability in IBD. Methods: IBD patients were prospectively recruited; ADA serum concentrations as well as antibodies toward ADA (ATA) were measured by ELISA (Immundiagnostik AG) during therapeutic drug monitoring (TDM). Demographic, clinical and laboratory data were recorded. ADA data were evaluated using population modeling (NonmemVersion 7.2 Icon Development). Standard PKmodel building approaches and performance evaluations were used. The absorption rate constant (Ka) was fixed to 0.02 hr-1 (consistent with the product label). Apparent CL/bioavailability (F), volume of distribution and between-patient variability for CL/F were estimated. Results: ADA concentrations (n=87) from 63 patients (CD:56, UC:7) were evaluated. Baseline (mean ± SD) demographics were: weight 60.5±23.9 kg, age 36.4±12.1 years, males: 33, BMI 21.0±7.8 kg/cm2, CRP 19.7±28.4 mg/L, albumin 4.0±0.54 g/dL. Positive ATA at first sampling were present in 9 patients, and further developed in 2. Moderate/severe disease activity was detected in 17/2 subjects, respectively. ADA as second line treatment was given to 37/63 (58.7%) patients. Dosage at sampling was 40/2 mg/weeks for 54 (85.7%), and 80/2 for 7 (11.1%) subjects. PK data were best described using a one compartment model with linear elimination. Parameter precision was good ( 0.05. Typical (ATA negative, weight 70 kg, ALB 4 g/dL) CL/F was 0.0124 L/hr. ATA formation was associated with a nearly 5 fold increase in ADA CL/F. Conclusions: ADA CL/F is significantly influenced by patient factors. ATA, concomitant use of antibiotics and corticosteroids, higher ADA doses and ADA as second line of therapy increase CL/F. The highly variable t1/2 suggests that interval shortening rather than increased doses may ensure higher exposure and increased troughs. The high between-patient variability suggests that additional factors affect troughs and that individualized, PK-guided rather than fixed dosing, may improve IBD patient outcomes.

Chilaiditi syndrome complicated by a sigmoid volvulus and hepatic displacement

Chilaiditis sign is an anatomical alteration consisting of the transposition of the small intestine or colon between the liver and diaphragm that is asymptomatic and is usually an accidental radiological finding. The onset of Chilaiditi syndrome is accompanied by clinical symptoms and is even rarer. Moreover, the combination of sigmoid volvulus and Chilaiditi syndrome is extremely rare, with only 17 previous published cases, one of which occurred in a female patient.

CARTA AL DIRECTOREnfermedad de Whipple: ¿podemos hacer un diagnóstico por técnicas de PCR?Can Whipple's disease be diagnosed through PCR techniques?

1. Brullet E, Guevara MC, Campo R, Falcó J, Puig J, Presa A, et al. Massive rectal bleeding following transrectal ultrasound-guided prostate biopsy. Endoscopy. 2000;32:792–5. 2. Djavan B, Waldert M, Zlotta A, Dobronski P, Seitz C, Remzi M, et al. Safety and morbidity of first and repeat transrectal ultrasound guided prostate needle biopsies: Results of a prospective European prostate cancer detection study. J Urol. 2001;166:856–9. 3. Brewsler SF, Rooney N, Kabala J, Feneley RC. Fatal anaerobic infection following transrectal biopsy of a rare prostatic tumor. Br J Urol. 1993;72:977–8. 4. Rodrı́guez LV, Terris MK. Risks and complications of transrectal ultrasound guided prostate needle biopsy. A prospective study and review of the literature. J Urol. 1998;160:2115–20. 5. Gonen M, Resim S. Simplified treatment of massive rectal bleeding following prostate needle biopsy. Int J Urol. 2004;11:570–2. 6. Wachsberg RH. Transrectal color Doppler sonographically guided compression to treat active extravasation after transrectal prostate biopsy. AJR. 2004;183:1706–7. 7. Strate LL, O‘Leary MP, Carr-Locke DL. Endoscopic treatment of massive rectal bleeding following prostate needle biopsy. Endoscopy. 2001;33:981–4. 8. Kimmey T, Kozarek R, Wiessman R. Sigmoidoscopic evaluation and treatment of hemorrhage after prostate biopsy. Am J Gastroenterol. 1999;94:2675–7. 9. Braun KP, May M, Helke C, Horchke B, Ernst H. Endoscopic therapy of a massive rectal bleeding after prostate biopsy. Int Urol Nephrol. 2007;39:1125–9.

Enfermedad de Whipple: ¿podemos hacer un diagnóstico por técnicas de PCR?

1. Brullet E, Guevara MC, Campo R, Falcó J, Puig J, Presa A, et al. Massive rectal bleeding following transrectal ultrasound-guided prostate biopsy. Endoscopy. 2000;32:792–5. 2. Djavan B, Waldert M, Zlotta A, Dobronski P, Seitz C, Remzi M, et al. Safety and morbidity of first and repeat transrectal ultrasound guided prostate needle biopsies: Results of a prospective European prostate cancer detection study. J Urol. 2001;166:856–9. 3. Brewsler SF, Rooney N, Kabala J, Feneley RC. Fatal anaerobic infection following transrectal biopsy of a rare prostatic tumor. Br J Urol. 1993;72:977–8. 4. Rodrı́guez LV, Terris MK. Risks and complications of transrectal ultrasound guided prostate needle biopsy. A prospective study and review of the literature. J Urol. 1998;160:2115–20. 5. Gonen M, Resim S. Simplified treatment of massive rectal bleeding following prostate needle biopsy. Int J Urol. 2004;11:570–2. 6. Wachsberg RH. Transrectal color Doppler sonographically guided compression to treat active extravasation after transrectal prostate biopsy. AJR. 2004;183:1706–7. 7. Strate LL, O‘Leary MP, Carr-Locke DL. Endoscopic treatment of massive rectal bleeding following prostate needle biopsy. Endoscopy. 2001;33:981–4. 8. Kimmey T, Kozarek R, Wiessman R. Sigmoidoscopic evaluation and treatment of hemorrhage after prostate biopsy. Am J Gastroenterol. 1999;94:2675–7. 9. Braun KP, May M, Helke C, Horchke B, Ernst H. Endoscopic therapy of a massive rectal bleeding after prostate biopsy. Int Urol Nephrol. 2007;39:1125–9.