Rafel Campo

Identification of factors that influence tolerance of upper gastrointestinal endoscopy.

OBJECTIVE Unsedated 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. METHODS Five 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. RESULTS Two 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). CONCLUSIONS The above-mentioned factors are predictive of poor tolerance, and may enable the identification of those patients who might benefit more from sedation for gastroscopy.

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

BACKGROUND Outpatient 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. METHODS Patients 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. RESULTS A 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). CONCLUSIONS Selected 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.

Hemospray treatment is effective for lower gastrointestinal bleeding

Acute lower gastrointestinal bleeding (LGIB) is diverse in origin and can be substantial, requiring urgent hemostasis. Hemospray is a promising novel hemostatic agent for upper gastrointestinal bleeding (UGIB). It has been claimed in a small series that the use of Hemospray is also feasible in LGIB. We aimed to expand our knowledge of the application of Hemospray for the treatment of LGIB in a wider range of conditions to further define the optimal patient population for this new therapeutic modality. We analyzed the outcomes of nine unselected consecutive patients with active LGIB treated with Hemospray in two major hospitals in Europe. Initial hemostasis was achieved after Hemospray application in all patients. Rebleeding occurred in two patients (22%) who were on acetyl salicylic acid and presented with spurting bleeds. These preliminary data show that Hemospray can be effective in the management of LGIB, but suggest cautious use for patients on antithrombotic therapy and spurting bleeds.

Sedación en la endoscopia digestiva. Resultados de una encuesta hospitalaria en Cataluña

INTRODUCTION: The need for sedation is increasing in digestive endoscopy units (DEU). There are no data on the use of sedation in DEU in Catalonia (Spain). OBJECTIVE: To evaluate the use of sedation in DEU in Catalonia. MATERIAL AND METHOD: A questionnaire on the practice of sedation was designed and sent to the heads of medical and nursing staff of the DEU of 63 public and private hospitals in Catalonia. Two mailings were sent with an interval of three months between each. The questionnaire included 62 items on the characteristics of the hospital and the DEU, number of explorations, frequency of sedation use, drugs employed, participation of an anesthesiologist, use of monitoring, and complications. RESULTS: Forty-four DEU (70%) corresponding to 31 public hospitals and 13 private hospitals completed the questionnaire. Evaluation of sedation patterns was based on 105,904 explorations performed in the various DEU (56,453 gastroscopies, 47,278 colonoscopies and 2,173 endoscopic retrograde cholangiopancreatographies (ERCP) in 2001. Sedation, sedation-analgesia or anesthesia was used in 17% of gastroscopies, 61% of colonoscopies and 100% of ERCP. Sedation was administered by an anesthesiologist in 7% of gastroscopies, 25% of colonoscopies and 38% of ERCP. Anesthesiologist administration was more frequent in private than in public centers (gastroscopies: 25% vs. 2%; colonoscopies: 57% vs. 9%, p < 0.001). No deaths associated with the use of sedation were reported. Eighty-nine percent of the DEU complied with standard recommendations for the practice of sedation. CONCLUSIONS: In Catalonia, the use of sedation is highly variable, depending on the endoscopic procedure and the DEU. Use of sedation in infrequent in gastroscopy, fairly widespread in colonoscopy and routine in ERCP. Anesthesiologist administration is significantly more frequent in private hospitals. Most DEU follow standard sedation practices.

microRNA profiling in duodenal ulcer disease caused by Helicobacter pylori infection in a Western population

Although the connection of microRNAs (miRNAs) to some diseases is well established, their involvement in chronic infections such as Helicobacter pylori has received less attention. The aim was to compare miRNA expression profiling in patients with duodenal ulcer (DU) due to H. pylori infection with that in infected patients without DU and in uninfected patients. The miRNA expression profile was determined by microarrays in antral mucosal samples from well-characterized dyspeptic patients (n = 46). The most significant set of miRNAs was subsequently analysed in an independent validation group of patients (n = 42). Transcripts for IL8, IL12p40, IL12p35 and IL23p19, the signalling molecules MYD88, GATA6, SOCS2 and STAT6 and H. pylori virulence factors cagA and VacA were analysed. Microarray experiments showed that 17 miRNAs were deregulated in the mucosa of H. pylori-infected patients. No significant differences were observed between normal and DU patients. PCR confirmed the up-regulation of miR-9, miR-146a, miR-155 and miR-650 and the down-regulation of miR-96 and miR-204 in the independent validation set of patients. Importantly, miR-9, miR-96, miR-146a and miR-650 expression was specific to chronic-active gastritis. H. pylori-infected patients showed higher levels of IL8 and IL12p40 mRNAs and lower levels of GATA6 and SOCS2 mRNAs. The antral mucosa of patients with non-active or chronic-active gastritis showed significantly lower levels of GATA6, MYD88, SOCS2 and STAT6 mRNAs compared with patients without gastritis. The down-regulation of these factors was not correlated with the expression of any of the validated miRNAs. The exact role of the miRNA changes observed will require further study.

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%.

INFECCION FULMINANTE POR HERPES VARICELA ZOSTER EN PACIENTE CON ENFERMEDAD DE CROHN EN TRATAMIENTO CON AZATIOPRINA

Paciente de 27 años con EC ileocólica, afectación perianal grave y manifestaciones extraintestinales (eritema nudoso y poliartritis). A los 3 años del diagnóstico se inició tratamiento con azatioprina (dosis de 2,5 mg/kg/día) por corticodependencia y persistencia de la enfermedad perianal. Evolución favorable con resolución progresiva de las lesiones perianales y síntomas articulares, y con controles analíticos periódicos en los que mantiene cifras de 3.000 y 5.000 leucocitos. Dos años después acude a urgencias por fiebre y disnea progresiva. A la exploración se constata una erupción cutánea vesiculosa generalizada, fiebre de 40 °C, taquipnea y aspecto de gravedad. La radiografía de tórax mostraba un infiltrado intersticial difuso bilateral, y analíticamente destacaba una cifra de 5.300 leucocitos (3.500 neutrófilos), marcada hipoxemia (pO2, 35 mmHg) y signos de fracaso multiorgánico, especialmente hepatorrenal. En los días previos se constataba contacto con un familiar afectado de varicela. Con la orientación diagnóstica de neumonía varicelosa y varicela diseminada se inició aciclovir intravenoso a dosis de 10 mg/kg/8 h y medidas de soporte vital, ingresando en la unidad de cuidados intensivos. La paciente falleció a las pocas horas por fallo multiorgánico, sin ser posible realizar estudio necrópsico por la negativa de la familia.

Evaluación de un test rápido (ImmunoCard STAT! HpSA) para la detección de Helicobacter pylori en heces

Introduccion La utilizacion de una tecnica diagnostica rapida puede ser extremadamente util para el tratamiento de las enfermedades relacionadas con la infeccion por Helicobacter pylori. Recientemente se ha comercializado una prueba rapida inmunocromatografica en heces (ImmunoCard STAT! HpSA, Meridian Diagnosis Inc., Cincinnati, Ohio, EE.UU.) para la deteccion de H. pylori. El objetivo del estudio fue evaluar la fiabilidad diagnostica y reproducibilidad de ImmunoCard STAT! HpSA en pacientes dispepticos. Pacientes y metodos Se incluyo a 63 pacientes sometidos a endoscopia para estudio de sintomas dispepticos en los que se practicaron biopsias para CLO-test e histologia antral. Se consideraron infectados por H. pylori los pacientes que presentaban ambos tests positivos, y no infectados, los que dieron negativo en los dos. En heces se realizaron dos determinaciones seriadas de antigeno de H. pylori mediante ImmunoCard STAT! HpSA. Se calcularon la sensibilidad, la especificidad y los valores predictivos positivo y negativo de la tecnica. La concordancia entre las dos determinaciones se evaluo mediante el estadistico Kappa. Resultados De los 63 pacientes, 46 presentaron infeccion por H. pylori , 12 fueron negativos y tres se consideraron indeterminados. La sensibilidad, la especificidad y los valores predictivos positivo y negativo de las distintas determinaciones de ImmunoCard STAT! HpSA fueron del 89-91, el 86-93, el 96-98 y el 72-75%, respectivamente. El indice de concordancia entre determinaciones fue de 0,845. Conclusion ImmunoCard STAT! HpSA muestra una buena sensibilidad y reproducibilidad; por tanto, puede ser de gran utilidad en el tratamiento de las afecciones relacionadas con la infeccion por H. pylori.

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.

The fecal hemoglobin concentration, age and sex test score: Development and external validation of a simple prediction tool for colorectal cancer detection in symptomatic patients

Prediction models for colorectal cancer (CRC) detection in symptomatic patients, based on easily obtainable variables such as fecal haemoglobin concentration (f‐Hb), age and sex, may simplify CRC diagnosis. We developed, and then externally validated, a multivariable prediction model, the FAST Score, with data from five diagnostic test accuracy studies that evaluated quantitative fecal immunochemical tests in symptomatic patients referred for colonoscopy. The diagnostic accuracy of the Score in derivation and validation cohorts was compared statistically with the area under the curve (AUC) and the Chi‐square test. 1,572 and 3,976 patients were examined in these cohorts, respectively. For CRC, the odds ratio (OR) of the variables included in the Score were: age (years): 1.03 (95% confidence intervals (CI): 1.02–1.05), male sex: 1.6 (95% CI: 1.1–2.3) and f‐Hb (0–<20 µg Hb/g feces): 2.0 (95% CI: 0.7–5.5), (20‐<200 µg Hb/g): 16.8 (95% CI: 6.6–42.0), ≥200 µg Hb/g: 65.7 (95% CI: 26.3–164.1). The AUC for CRC detection was 0.88 (95% CI: 0.85–0.90) in the derivation and 0.91 (95% CI: 0.90–093; p = 0.005) in the validation cohort. At the two Score thresholds with 90% (4.50) and 99% (2.12) sensitivity for CRC, the Score had equivalent sensitivity, although the specificity was higher in the validation cohort (p < 0.001). Accordingly, the validation cohort was divided into three groups: high (21.4% of the cohort, positive predictive value—PPV: 21.7%), intermediate (59.8%, PPV: 0.9%) and low (18.8%, PPV: 0.0%) risk for CRC. The FAST Score is an easy to calculate prediction tool, highly accurate for CRC detection in symptomatic patients.