José Luis Márquez

Thalidomide in refractory bleeding due to gastrointestinal angiodysplasias

OBJECTIVES to assess the efficacy of thalidomide in the treatment of relapsed or refractory bleeding secondary to gastrointestinal angiodysplasia. MATERIAL AND METHODS we carried out a prospective study of 12 patients with bleeding due to gastrointestinal angiodysplasia refractory to conventional therapy who were treated with thalidomide. For each patient, we considered: age, sex, underlying disease, previous therapies, dose and duration of thalidomide treatment, evolution of haemoglobin levels and adverse effects of treatment. The data obtained were analysed using descriptive statistics with SPSS v. 16. RESULTS seven men and 5 women with a mean age of 77 years were included in the present study. Five had some underlying pathology and all of them had received prior endoscopic/octreotide treatment. The dose of thalidomide administered was 200 mg/24 h and the duration of the treatment four months, with the exception of two patients in whom treatment was discontinued because of adverse side effects. Mean haemoglobin concentration before onset of treatment was 6.5 g/dL, at two months it was 11.3 g/dL and at the end of treatment 12.1 g/dL. CONCLUSIONS thalidomide is an effective treatment in gastrointestinal bleeding due to angiodysplasia, but it was withdrawn due to side effects in 16% of the patients included in our study.

Cambios en la etiología, resultados y características de los pacientes con hemorragia digestiva aguda grave a lo largo del periodo 1999-2005

Objectives: to analyze the evolution of the following variables in patients admitted to a Blood Unit for gastrointestinal bleeding throughout 1999-2005: etiology, comorbid diseases, use of NSAIDs/anticoagulants, and mortality. Material and methods: we analyzed the evolution of the following causes of GIB that required admission to the Blood Unit from 1999 to 2005: duodenal ulcer (DU), gastric ulcer (GU), portal hypertension (PHT), and others. We also analyzed changes in the percentage of patients admitted with comorbid disease, use of NSAIDs/anticoagulants, and mortality. Results: 1,611 patients with a mean age of 60.45 years (59.7-61.2) were included in this study; 76.41% were males (74.3-78.5). DU was the cause of bleeding in 22.20% of cases (20.2-24.3), GU in 18.40% of cases (16.6-20.4), and PHT in 33.60% of cases (31.3-36.0). In all, 34.5% (32.6-37.3) of patients were taking NSAIDs, 7.1% (6.0-8.6) were receiving anticoagulant therapy, 72.6% (70.4-74.8) presented with comorbid disease, and overall mortality was 6.27% (5.16-7.59). Throughout the 1999-2005 period there was an increase in the number of patients with comorbid diseases (p < 0.02), and a decrease in cases of DU (p < 0.04), without significant differences in the remaining variables. Conclusions: DU, GU and PHT account for three quarters of admissions to our Blood Unit. Over the last seven years, there has been a decrease in cases due to DU, and an increase in patients with comorbid disease; overall mortality rates have remained stable.

Transfusion requirements in patients with gastrointestinal bleeding: a study in a Blood Unit at a referral hospital

OBJECTIVES 1. To study transfusion requirements in the Department of Gastroenterology of a Tertiary Referral Hospital, and their evolution over the last seven years. 2. To analyze risk factors associated with greater erythrocyte transfusion requirements. PATIENTS AND METHODS erythrocyte transfusion requirements were compared for patients admitted to the Department of Gastroenterology at Hospital Virgen del Rocío, Seville, from 1999 to 2005. Clinical data of interest have been analyzed in order to determine factors associated with greater transfusion requirements. RESULTS 1,611 patients with a mean age of 60.45 years (59.7-61.2) were included in this study; 76.41% were males. Gastric ulcers were the cause of bleeding in 18.4% of cases (with 69% requiring transfusions); duodenal ulcers caused 22.2% of cases (with 52.9% requiring transfusions), and portal hypertension caused 33.6% of cases (with 90.2% requiring transfusions). Upper and lower gastrointestinal bleeding of unknown origin requires transfusions in 88.9 and 96.2% of cases, respectively.A multivariate logistic regression analysis showed that clinical presentations such as hematemesis (odds ratio = 3.12), hematochezia (odds ratio = 33.17), gastrointestinal hemorrhage of unknown origin (odds ratio = 6.57), and hemorrhage as a result of portal hypertension (odds ratio = 3.43) were associated with greater transfusion requirements for erythrocyte concentrates. No significant differences were observed between the percentages of patients who received transfusions from 1999 to 2005. CONCLUSIONS 1. No differences have been observed between the percentages of patients who received transfusions over the last seven years at our Department of Gastroenterology. 2. Patients presenting with hematemesis or hematochezia, in addition to those with bleeding of unknown origin or from portal hypertension, are prone to have greater transfusion requirements.

Crohn's disease and liver abscess due to Pediococcus sp.

To the Editor: We report a 27-year-old woman diagnosed with Crohn’s disease (CD) 15 years ago after surgical resection of an inflammatory tumor of the ileum and sigmoid, and performance of a double ileocolonic and colorectal anastomosis. A recurrence in preanastomotic ileum despite treatment with mesalazine was noted; after a new flare-up of activity 4 years ago, azathioprine was added. The patient was admitted to our center with fever (38 C) and cough as the only associated symptoms. The physical examination showed no abnormalities. Laboratory tests showed an elevation of erythrocyte sedimentation rate (ESR) (104 mm/h) and C-reactive protein (CRP) (144 mg/L) and other inflammatory reactants (fibrinogen and ferritin). Chest x-ray was normal and abdominal ultrasound showed a heterogeneous mass of 10 cm in hepatic segments VI–VII, suggesting an abscess. Percutaneous drainage was performed, extracting 60 cc of purulent content and inserting a drainage catheter. Abdominal computed tomography (CT) scan confirmed these findings, detecting in addition inflammation in the distal ileum with stenosis of ileocolonic anastomosis and probable fistulous tracts, with right pleural effusion. Azathioprine was suspended and empirical antibiotic therapy with intravenous piperacillin-tazobactam was established, maintaining the patient without fever. The blood culture was negative, but the drainage culture showed the existence of Pediococcus sp., sensitive to cefotaxime and penicillin and resistant to clindamycin, erythromycin, and vancomycin. After 14 days of treatment with piperacillin-tazobactam, with extraordinary clinical and radiological evolution, when drainage had ceased and after verifying the practical disappearance of the abscess, the catheter was removed and therapy was modified to amoxicillin-clavulanate until 1 month of treatment had been completed. The patient remained asymptomatic from the standpoint of CD all the time. Paradoxically, after improvement of the abscess an episode of progressive dyspnea presented, secondary to an increase in pleural effusion, which required evacuative thoracentesis. The analysis revealed sterile inflammatory pleural fluid. After clinical and radiological improvement, the patient continued to be monitored at her reference center. To our knowledge this is the second case of hepatic abscess caused by a germ of the genus Pediococcus, and the first in a patient with CD. The presence of other germs of the family Lactobacillaceae is equally exceptional, with seven published cases and only one in CD. The association between CD and liver abscess is uncommon, most authors considering them to originate through a hematogenous route when an increase in mucosal permeability exists toward the portal system, even though it may sometimes be secondary to acute cholangitis caused by biliary pathology associated with inflammatory bowel disease (IBD) or by enterobiliary fistulae. This is reported generally in males, of younger age than in the general population (biliary origin), with long-term and active CD—although it has been reported an early stage. Among associated risk factors, intraabdominal abscesses, fistulizing disease, malnutrition, and treatment with steroids and metronidazole have been reported, without reporting a relationship with immunosuppressant therapy. According to some authors, prior resection of the small intestine favors the development of liver abscess, perhaps due to the increase in intestinal permeability. Abscesses in IBD are usually monomicrobial, Streptococcus milleri being the most frequent germ. The pathogenic power of Pediococcus, present in the oral and intestinal flora, is uncertain but the fact that it was the only germ isolated in our patient supports its being treated as the causal agent. However, although a potential benefit of lactobacillus in CD has been postulated, a recent meta-analysis notes that its use in maintaining the remission of CD may even have a negative effect on the disease. In short, Lactobacilli, which have a low pathogenic power, are a potential cause of problems when some circumstances conditioned upon the behavior of the CD and the currently available medical-surgical therapies act in combination.

Linfoma intestinal y paniculitis mesentérica: complicaciones de una enfermedad celíaca no diagnosticada

Resumen La enfermedad celiaca se produce por la ingesta de gluten en ninos y adultos geneticamente susceptibles, y es la intolerancia alimentaria grave mas comun en los paises occidentales. La eliminacion del gluten presente en la dieta es obligatoria en estos pacientes, ya que la mayoria de las complicaciones que pueden presentarse son mas frecuentes en caso de incumplir el tratamiento. El desarrollo de neoplasias constituye la complicacion mas grave de la celiaquia (el mas frecuente es el linfoma de celulas T asociado a enteropatia), pero se han descrito otras, como la yeyunoileitis ulcerativa, y manifestaciones extrain-testinales, como la hepatitis cronica, la enfermedad pulmonar fibrosante, el sindromes de epilepsia, etc. Presentamos el caso de un varon de 53 anos de edad con sindrome diarreico de muy larga evolucion, en el que no se sospecho una enfermedad celiaca y se complico con un linfoma intestinal de celulas T asociado a enteropatia y una paniculitis mesenterica.

Inhibidores de la bomba de protones por vía intravenosa en la hemorragia por úlcera péptica: ¿es necesaria la supresión ácida máxima para disminuir el resangrado?

OBJECTIVE: To compare two regimens of pantoprazole administered intravenously in patients with ulcerative gastrointestinal bleeding (UGB), and a high risk of presenting with persitent or recurrent hemorrhage. MATERIAL AND METHOD: Patients were randomized into two groups: group 0--treatment with a 80 mg bolus of pantoprazole administered intravenously, followed by continuous infusion of 8 mg/h for 72 hours; group 1--treatment with 40 mg of pantoprazole administered intravenously on a daily basis. The percentage of hemorrhagic persistence/recurrence in both groups was analyzed, as were transfusion requirements, need for surgery, and mortality resulting from the hemorrhagic episode. RESULTS: There were 20 patients in group 0 and 21 in group 1. No differences were found between groups in terms of gender, age, smoking habits, use of NSAIDs, presence of hemodynamic instability or stigmata in ulcer crater (Forrest Ia: 5 vs. 14.3%, p = 0.322; Forrest Ib: 30 vs. 33.3%, p = 0.819; Forrest IIa: 60 vs. 50.1%, p = 0.753). In group 0, 90% of patients received endoscopic treatment, versus 100% in group 1, p = 0.232. In group 0, 50% of patients had a transfusion, as compared to 52.4% in group 1, p = 0.879. In group 0, 2 patients (10.5%) presented with recurrent hemorrhage, versus 3 patients (14.3%) in group 1. Surgery was required by 1 person from each group, and 1 patient in group 0 died. CONCLUSIONS: Maximum acid inhibition with a bolus and then a continuous infusion of pantoprazole does not yield better results than treatment with conventional doses in acute hemorrhagic episodes.