José Ramón Foruny

Usefulness of penicillamine-stimulated urinary copper excretion in the diagnosis of adult Wilson's disease.

Objective. Diagnosis of Wilsons disease (WD) is reliant on liver biopsy (LB) and measurement of hepatic copper. The aim of this study was to determine the usefulness of penicillamine-stimulated urinary copper excretion (PS-UCE), a non-invasive diagnostic test, for the diagnosis of WD in adults. Material and methods. In this prospective study of patients with suspected WD, total serum copper, ceruloplasmin, basal 24-h UCE and PS-UCE levels were measured. LB with copper determination was performed in those patients with persistent hypertransaminasemia and low ceruloplasmin or basal UCE >40 µg/24 h. Diagnosis was established if the ceruloplasmin level was found to be <20 mg/dl and hepatic copper >250 µg/g. Results. A total of 115 patients were studied; LB was performed in 43, and WD was diagnosed in 6 (13.9%). Significant differences between WD and non-WD patients were found for basal UCE (WD: median 134.3 µg/24 h versus non-WD: median 19.0 µg/24 h (p<0.05)) and PS-UCE (WD: median 1284.0 µg/24 h versus non-WD: median 776.0 µg/24 h; p<0.01). In the ROC (receiver-operated curve) analysis, PS-UCE was the best discriminant between WD and non-WD (area under the curve (AUC)=0.911, best cut-off point 1057 µg/24 h, 100% sensitivity, 82.3% specificity). Conclusions. PS-UCE is probably a useful non-invasive test in the diagnosis of WD, improving the selection of patients for diagnostic liver biopsy. Patients with PS-UCE under 1057 µg/24 h only rarely will suffer from WD and are unlikely to benefit from LB.

Gastric polyps: analysis of endoscopic and histological features in our center

BACKGROUND AND OBJECTIVE the prevalence of gastric polyps in esophagogastroduodenoscopies (EGDs) ranges between 0.33 and 6.35%. The relative frequency of histological subspecies varies widely among published series. The objective is to describe the endoscopic and histological characteristics of the polypoid lesions, and to study possible associations. MATERIAL AND METHODS we retrospectively revised the EGDs done in our center in 2009. Demographic, endoscopic and histological data were gathered. We proceeded to a descriptive analysis and studied possible associations. RESULTS gastric polypoid lesions were found in 269 of the 6,307 (4.2%) reviewed EGDs, 61% were found in women. Mean age was 64.93 years (SD: ±15.23). A single polyp was found in 186 patients (69.1%), over 10 lesions appeared in 31 (11.5%). An estimated size of ≤ 3 mm was found in 108 lesions (37.2%) and greater than 10 mm in 52 cases (17.9%). Most lesions were sessile (90.8%). The location of 34.8% was the gastric antrum, 39.3% were found in the gastric body and 25.9% were in the fundus. Chronic gastritis was confirmed in 53.5% of the patients and 46.5% had received protom pump inhibitors (PPIs). Histopathological diagnosis was: hyperplastic polyps 50.9%, fundic gland polyps 7.4%, adenomas 3%, adenocarcinomas 1.9% and normal mucosa 29.7%. We found no significant association between the histopathological type of lesions and the use of proton pump inhibitor. CONCLUSIONS we found polypoid lesions in 4.2% of the EGDs. The most frequent histopathological findings were hyperplastic polyps (50.9%), followed by fundic gland polyps (7.4%), adenomas (3%), and adenocarcinomas (1.9%).

Gut eradication of VIM-1 producing ST9 Klebsiella oxytoca after fecal microbiota transplantation for diarrhea caused by a Clostridium difficile hypervirulent R027 strain

We report the fecal carriage eradication of a VIM-1-producing ST9 Klebsiella oxytoca strain in a pluripathological 84-year-old woman after fecal microbiota transplantation to control relapsing R027 hypervirulent Clostridium difficile infections. The donor was her son, in which the absence of fecal carbapenemase-producing bacteria was corroborated.

Tratamiento de pancreatitis recidivante por páncreas divisum y ansa pancreática mediante técnica de Rendez-Vous guiada por ecoendoscopia

espanolEl tratamiento endoscopico de malformaciones ductales pancreaticas causantes de pancreatitis aguda de repeticion, como el pancreas divisum o el ansa pancreatica, se basa fundamentalmente en la esfinterotomia de la papila minor. En estos casos, no obstante, la complejidad tecnica de la colangiopancreatografia endoscopica retrograda (CPRE) convencional es mayor, pudiendo resultar fallida. Presentamos el caso de un pancreas divisum completo combinado con ansa pancreatica, sintomatico, en el que, tras fracasar el acceso endoscopico convencional a la papila minor, se logra la canulacion y esfinterotomia de esta mediante tecnica de Rendez-Vous guiada ecoendoscopicamente. EnglishEndoscopic treatment of pancreatic ductal malformations causing recurrent acute pancreatitis, such as pancreas divisum or ansa pancreatica, is mainly based on the sphincterotomy of the minor papilla. However, the technical complexity of conventional endoscopic retrograde cholangiopancreatography (ERCP) is increased in patients presenting anatomical variants like these and it may be unsuccessful. We report the case of a pancreas divisum combined with ansa pancreatica and describe the cannulation and sphincterotomy of the minor papilla using an ultrasound-assisted Rendez-Vous technique.Endoscopic treatment of pancreatic ductal malformations causing recurrent acute pancreatitis, such as pancreas divisum or ansa pancreatica, is mainly based on the sphincterotomy of the minor papilla. However, the technical complexity of conventional endoscopic retrograde cholangiopancreatography (ERCP) is increased in patients presenting anatomical variants like these and it may be unsuccessful. We report the case of a pancreas divisum combined with ansa pancreatica and describe the cannulation and sphincterotomy of the minor papilla using an ultrasound-assisted Rendez-Vous technique.

EVALUACION PROSPECTIVA DE LA INFLUENCIA DEL ESPECIALISTA EN FORMACION EN EL ÉXITO Y LA TASA DE COMPLICACIONES DE LA CPRE

Introduccion: Se ha sugerido que la intervencion de medicos especialistas en formacion en la CPRE (intento de canulacion por residente: ICPR) podria asociarse con menor eficacia y mas complicaciones. Objetivo: Evaluar prospectivamente si el ICPR influye en los resultados de la CPRE (exito en la canulacion, exito terapeutico, complicaciones). Material y Metodo:Analisis: base de datos prospectiva(03/12 – 06/16). Informacion: Resultados: Analisis descriptivo: Analisis comparativo: Univariado(AUV)/Multivariado(AMV). Conclusiones:

Do we use more NGT than needed

We have read with great interest the study published by Iwasaki et al. [1] in this journal, as well as the editorial by Denis M. McCarthy published in the same issue [2]. There are some methodological aspects we would like to point out. First, it is a unicentric and retrospective study. Second, although investigators describe clinical presentations in table 1, patients with suspicion of UGIB are not clearly defined. Third, a selection bias might originate from the study population (patients in which NGT was used). Fourth, ‘‘coffee ground’’ material, an important result of lavage (23 % of patients with this presentation had high risk lesions at endoscopy [1]), was surprisingly excluded from the analysis. Fifth, time to endoscopy and how its results were used in the analysis are not uniform. After all, we realize that the main decisions that clearly affect the outcomes are left up to clinicians: placement of NGT (selecting the study population) and urgent endoscopy decision (which is part of their conclusion). An important aspect of the new proposed score is the HR/SPB ratio for which we recommend Denis M. McCarthy0s editorial reading [2]. The 1.4 cut-off obtained in COR-curve for the score shows sensitivity, specificity, and PPV values of 65.5, 65.2, and 45.2 %, respectively [1]. We agree that those values are not good enough, considering that the aim of this combined score is to select UGIB patients who may benefit from urgent endoscopy [2]. The best obtained value was NPV (81.8 %), which might be used to discard patients with active UGIB, but we also think that this result is of little interest, as 12 % of patients reaching that cut-off value could have UGIB, which is potentially lethal, but it can be effectively treated by urgent endoscopy. Additionally, we would like to comment on NGT use as recommended by the authors. Comparing with our clinical experience, NGT is clearly overused, as it was placed in 54 % of patients admitted with UGIB [1]. NGT utility is in doubt, and there are no established criteria to use it. Neither relevant clinical guidelines nor international reviews clearly state in which patients an NGT should be placed, leaving that decision to individual medical criteria [3–7]. A negative NGT result does not rule out high risk lesions or active bleeding. In fact, in this study 50 % of active duodenal bleeding had a negative lavage [1]. It is important to remember that negative false rate of NGT is around 15 % [4, 5]. As a result, the fluid recorded from an NGT is not an accurate representation of what is happening inside the stomach. NGT placement is technically easy and usually done without difficulty. But in our experience, it is sometimes challenging, and as patients report, the procedure is much more unpleasant than non-sedated endoscopy. Some articles have pointed at this issue [8, 9], commenting that NGT placement is more painful than an abscess incision and drainage, fracture reduction, or urethral catheterization. In this study [1], in 68 % of patients in which an NGT was placed, a non positive-fluid was recorded, therefore rendering it a useless procedure. Any on-call physician who is required to evaluate a suspected UGIB needs patient information, and NGT record is one of them. Nowadays many gastroenterologists still like to know this information [8, 9], but NGT has many drawbacks (problems of placement, unknown situation into the stomach, interpretation of its content). Moreover, J. Martinez-Gonzalez (&) M. Aicart-Ramos J. R. Foruny A. Lopez San Roman A. Albillos Servicio de Gastroenterologia, Hospital Universitario Ramon y Cajal, IRYCIS, Universidad de Alcala, Madrid, Spain e-mail: martinez.gonzalez.javier@gmail.com

Tumor rectal de crecimiento lateral tipo no granular resecado mediante disección endoscópica submucosa pura: un tratamiento inusual para una lesión atípica

Consulta de Alto Riesgo de Cancer Colorrectal. Unidad de Endoscopia. Department of Gastroenterology. Hospital Universitario Ramon y Cajal. Madrid. Universidad de Alcala, IRYCIS. Madrid, Spain. Endoscopy Division. National Cancer Center Hospital. Tokyo, Japan. Department of Gastroenterology. Fujita Health University University School of Medicine. Aichi, Japan. Department of Gastroenterology. Hospital Virgen de la Arrixaca. Murcia, Spain. Department of Pathology. Hospital Universitario Ramon y Cajal. Madrid. Universidad de Alcala, IRYCIS. Madrid, Spain. Departmento of General and Digestive Surgery. Hospital Universitario Ramon y Cajal. Madrid. Universidad de Alcala, IRYCIS. Madrid, Spain PICTURES IN DIGESTIVE PATHOLOGY