Manuel Rodríguez-Téllez

Proton-pump inhibitors adverse effects: a review of the evidence and position statement by the Sociedad Española de Patología Digestiva.

INTRODUCTION In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest. OBJECTIVE The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use. MATERIAL AND METHODS A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients. RESULTS Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis. CONCLUSIONS PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.

Previously unknown stricture due to radiation therapy diagnosed by capsule endoscopy

Radiation enteritis is a complex clinical entity secondary to the affectation of intestinal epithelial cells as a result of radiation in the management of pelvic malignancies that may occasionally cause intestinal strictures. We present the case of a 60 year-old woman who had been diagnosed ten years before with endometrial adenocarcinoma, and who underwent hysterectomy with double adnexectomy and subsequent radiation therapy. The patient consulted for abdominal pain and ferropenic anemia of several years standing, and had negative results following radiographic and endoscopic conventional techniques, reason why she was subjected to a capsule endoscopy study that revealed the presence of an ulcerated ileal stricture, which caused the asymptomatic retention of the capsule within the ileum. A laparotomy was subsequently performed--the strictured segment was resected and the capsule retrieved. The histologic examination of the resected segment confirmed the capsule endoscopy-raised suspicion of radiation enteritis. This case shows the role capsule endoscopy may play in the diagnosis of this condition.

Utilidad de la cápsula endoscópica en gastroenterología pediátrica

La capsula endoscopica es un nuevo metodo de diagnostico no invasivo que permite visualizar de forma nitida posibles lesiones en el intestino delgado. Su tamano es pequeno y porta una bateria y una videocamara que permite tomar dos fotos por segundo del interior del tubo digestivo. Esta indicada en casos de hemorragia digestiva de causa no clara y en el diagnostico de enfermedad inflamatoria intestinal, entre otros. Hasta la fecha se ha utilizado principalmente en adultos. Creemos que en la edad pediatrica puede tener un papel muy importante, por tratarse de una prueba no invasiva, porque permite el diagnostico de procesos intestinales, y asi evitar la realizacion de numerosas pruebas diagnosticas inutiles. Aportamos el caso de una paciente en edad pediatrica con alta sospecha de enfermedad de Crohn no confirmada mediante las tecnicas endoscopicas habituales. La capsula muestra lesiones intestinales compatibles con esta enfermedad. Tras tratamiento corticoideo la paciente mejora clinicamente y con una evolucion favorable de su proceso.

Es útil la cápsula endoscópica en niños con dolor abdominal crónico

Chronic abdominal pain is highly prevalent in school-aged children and is one of the most frequent disorders in our environment. The aim of the present study was to evaluate the usefulness of capsule endoscopy (CE) in patients with chronic abdominal pain. Sixteen patients (nine boys and seven girls), aged between 5 and 16 years old, with chronic abdominal pain for at least 12 months were studied. In all patients the results of hemograms, biochemical investigations, urine sediment test, Helicobacter pylori breath test and celiac serology were normal. In all children, gastroscopy, small bowel follow-through, abdominal ultrasound and colonoscopy were normal. All patients received CE by mouth. In 43.75 % of the patients studied (7/16), the capsule showed evidence of nodular lymphoid hyperplasia, mainly located in the ileum. In one girl, oxyuriasis was observed in the cecum and in another girl aphthous lesions were observed in the ileum. These lesions suggested small bowel Crohns disease. CE mainly showed images compatible with nodular lymphoid hyperplasia, with unknown clinical significance. Consequently, we conclude that CE does not provide useful information in patients with abdominal pain without other symptoms.

Estudio multicéntrico de seguridad en endoscopia bariátrica

INTRODUCTION Bariatric endoscopy includes a series of specific techniques focused on the management of obese patients. As a quality criterion, safety as expressed by a minimal incidence of serious complications is required in addition to efficacy. METHODS A descriptive, retrospective, multicenter review of the experience recorded at seven hospitals included in the Grupo Español de Endoscopia Bariátrica (GETTEMO) in order to document the incidence, cause, and resolution (including legal consequences) of serious complications reported for each bariatric technique, and according to endoscopist expertise. RESULTS In all, 6,771 bariatric endoscopic procedures were collected, wherein 57 serious complications (0.84%) were identified. Balloons: Orbera®-Medsil®, 5/5,589; Spatz2® (older model): 44/225; Heliosphere®: 1/70; Obalon®: 0/107. Sutures: POSE®, 5/679; sleeve gastroplasty with Apollo® system: 0/55. Prostheses: Endobarrier®: 2/46. All complications were resolved with medical/endoscopic management except for five cases (0.07%) that required surgery. A single lawsuit occurred (esophageal perforation with Spatz2® balloon), which had a favorable outcome. There was no mortality, and apparently no differences were found according to endoscopist expertise level. CONCLUSIONS In our multicenter experience, bariatric endoscopy may be considered as a safe procedure (0.84% of serious complications in all). However, some devices may induce a higher proportion of complications, such as 19.55% for Spatz2® balloons (already replaced) or 4.34% for Endobarrier® sleeves (at the upper limit of accepted safety), although our experience with the latter is limited. All complications were resolved with conservative medical management, and only exceptionally required surgery (0.07%). No technique-related mortality was seen, and only one lawsuit occurred. Further evolutionary studies are required on the novel endoscopic techniques presently emerging to authenticate our results.

Long-term follow-up of patients with chronic hepatitis C treated with α-interferon and ribavirin antiviral therapy: clinical and fibrosis impact of treatment response.

Background and goals The slow progression of chronic hepatitis C (CHC) infection requires long observation periods to detect clinical changes. We compare the incidence of clinical events, hepatocellular carcinoma (HCC), overall mortality, liver-related mortality, and fibrosis progression between patients with a sustained virological response (SVR) and nonresponders (NR) after a 13-year follow-up period. Study One hundred and eighty-two CHC patients, who received interferon and ribavirin treatment between 1996 and 2000, were included. Clinical events were evaluated during follow-up. At the end of follow-up, transient elastography was used to assess fibrosis progression. Results Of the 182 patients, 46.7% (n=85) achieved an SVR. Twenty-seven patients developed hepatic decompensation (one SVR) and 15 developed HCC (three SVR). Twenty-nine patients died (eight SVR). Twelve of the 29 deaths were liver related (two SVR). Independent factors associated with hepatic decompensation were NR to treatment [hazard ratio (HR)=23.35; 95% confidence interval (CI): 2.90–189.25; P=0.003], advanced fibrosis at baseline (HR=9.11; 95% CI: 4.13–20.09), and treatment delay after diagnosis (HR=1.02; 95% CI: 1.00–1.03; P=0.012). Only the latter two were associated with HCC development and liver-related mortality. An assessment of liver fibrosis was performed on 125 patients (66 SVR). Fibrosis values were significantly lower in SVR patients, showing less progression to advanced stages of fibrosis [SVR: 6.6 (2.8); 95% CI: 5.8–7.3] than NR [NR: 14.0 (11.1); 95% CI: 11.1–16.9; P<0.001]. Conclusion In patients with CHC, SVR is durable and reduces clinical events. The risk of HCC development is lower, but not eliminated. Sustained responders showed fibrosis stabilization or improved fibrosis values.

Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions

This document summarizes the contents of the Clinical Guidelines for the Endoscopic Mucosal Resection of Non-Pedunculated Colorectal Lesions that was developed by the working group of the Spanish Society of Digestive Endoscopy (GSEED of Endoscopic Resection). This document presents recommendations for the endoscopic management of superficial colorectal neoplastic lesions.

Prevalence of symptomatic gastroesophageal reflux disease (GERD) in severe obstructive sleep apnea (OSA)

The pathogenetic relationship underlying the high prevalence of gastroesophageal reflux disease (GERD) in patients with obstructive sleep apnea (OSA) remains unclear. Objective: 1.To investigate the GER in patients with severe OSA and to corroborate variations in the pH-metry register using auto-CPAP. 2.To test symptoms of GERD at baseline and after beginning treatment for OSA. METHOD: Prospective study with 22 severe OSA patients to study GERD by endoscopic placement of a record of continuous wireless pH monitoring(BravoTM capsule, up to 96 hours recording). After placing the capsule, nocturnal polysomnography study was done and then the auto-CPAP treatment began. Symptoms of GERD were assessed using specific questionnaires (GSRS and QOLARD),filled prior to placement of the capsule, at 96 hours and at a month. RESULTS: 77.2 % were man and obese (63.6%). The incidence of GERD was 65%. After starting auto-CPAP, we observed a significant improvement of parameters associated with the GER in 48 hours, with normalization of pH monitoring in 61.5 % of cases, although without reaching statistical significance. Significant symptomatic changes in the score of the questionnaires at baseline, at 96 hours and at a month after initiation of treatment with auto-CPAP were found. There were with a baseline score for GSRS>2.5 in 40.9% of cases and with the QOLARD CONCLUSIONS: We found a high prevalence of symptomatic GERD in patients with severe OSA. There are significant improvement in symptoms of GERD and tendency to normalization of pathological GER after initiation of treatment with CPAP. These findings could justify the active pursuit of GERD in patients with severe OSA.

Su1149 Two-Week, High-Dose Proton Pump Inhibitor, Moxifloxacin Triple H. pylori Therapy After Failure of Standard Triple or Non-Bismuth Quadruple Treatments

who underwent the gastroscopy were enrolled. Gastric atrophy was classified based on Kimura-Takemotos classification of gastric atrophy. Gastric biopsy specimens were obtained for rapid urease test (RUT). Patients with a negative result of RUT and not having atrophic gastritis were diagnosed to be uninfected with H. pylori. Patients with positive results of RUT and having endoscopic gastric atrophy were diagnosed infected with H. pylori. Others were excluded from analyses. Serum anti-H. pylori IgG antibody was measured using the DB-13-04 and the existing kit, E-plate® (Eiken Chemical, CO.,LTD., Tokyo, Japan). Results: Sensitivity, specificity and validity of DB-13-04 were 94.4%, 90.0% and 94.2%, while those of the existing kit were 88.3%, 100.0% and 88.9%. When stratified based on gastric atrophy, in patients with advanced gastric atrophy (e.g., grade O-III), the sensitivity of the DB-1304 was 70.0% (14/20), which was significantly higher than that with the existing kit (55.0%, 11/20) ( P < 0.05, McNemar test) (Fig). Conclusion: As whole, the sensitivity, specificity and validity of DB-13-04 were equal or superior to those of the existing kit widely used in Japan. However, the sensitivity of DB-13-04 in patients with severe atrophic gastritis was significantly superior to that of the existing kit. Therefore, we expect that the DB-13-04 will greatly contribute to the decrease of the falsely sero-negative results in patients with severe atrophic gastritis.

Endoscopia transnasal en paciente con penfigoide cicatricial

A 32-year-old male referring asthmatic bronchitis, corticoid-associated cicatricial pemphigoid, osteoporosis secondary to the use of corticoids and steroid cataracts, is sent to our Unit due to persistent oropharyngeal dysphagia. Conventional endoscopy is programmed in two different days and, subsequent to the failure of the procedure, oral approach is carried out in a vain attempt with a 5.9 mm endoscope. Transnasal route is then considered (Fig. 1), resulting successful as multiple ulcerous lesions and fibrous portions of the hypopharynx can be observed, which are hardly overcome. No other lesions were observed along the esophagic or gastric mucosa as well as the second duodenal portion. A posterior pharynx biopsy revealed the presence of subepidermal split, vesiculobullous mucosa with subepitelial hemorrhage and granulation tissue in the submucous (Fig. 2).