Sergio Zepeda-Gómez

Managing the post-liver transplantation anastomotic biliary stricture: multiple plastic versus metal stents: a systematic review.

BACKGROUND Anastomotic biliary strictures (ABSs) are common after liver transplantation, especially with living donors. The strategy of balloon dilation and multiple plastic stents (MPSs) is effective in treating ABSs, but requires multiple ERCPs with the associated risks, cost, and patient burden. Covered self-expandable metal stents (SEMSs) have been increasingly used in this setting. However, it is not clear whether there are definite advantages of using SEMSs over MPSs. OBJECTIVE To compare the efficacy and safety of MPSs and SEMSs in ABS after orthotopic liver transplantation (OLT) and living donor liver transplantation (LDLT). DESIGN Systematic review by searching MEDLINE and EMBASE databases. PATIENTS OLT and LDLT patients. INTERVENTIONS MPSs versus SEMSs. MAIN OUTCOME MEASUREMENTS Stricture resolution and adverse event rates. RESULTS Eight studies (446 patients) using MPSs in OLT, 3 studies (120 patients) using MPSs in LDLT, and 10 studies (200 patients) using SEMSs fulfilled the inclusion and exclusion criteria. The stricture resolution rates were highest (94%-100%) when MPS duration was 12 months or longer. The stricture resolution rates with SEMSs in OLT patients were also high when stent duration was 3 months or longer (80%-95%) compared with a duration less than 3 months (53%-88%). Although the overall adverse event rates were low, the overall SEMS migration rate was significant at 16%. LIMITATIONS No randomized, controlled trials were identified; only small case series using either MPSs or SEMSs were included. CONCLUSIONS Although SEMSs appeared to be a promising option in the endoscopic management of ABSs after liver transplantation, current evidence does not suggest a clear advantage of SEMS use over MPSs for this indication.

The association of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs in peptic ulcer disease

BACKGROUND AND AIM Peptic ulcer disease (PUD) affects 10% of the world population. Helicobacter pylori infection and the use of a nonsteroidal anti-inflammatory drug (NSAID) are the principal factors associated with PUD. The aim of the present study was to evaluate a cohort of patients with PUD and determine the association between H pylori infection and NSAID use. PATIENTS AND METHODS The medical charts of patients with endoscopic diagnosis of PUD were retrospectively reviewed from September 2002 to August 2003. Patients were divided into three groups according to ulcer etiology: H pylori infection (group 1); NSAID use (group 2); and combined H pylori infection and NSAID use (group 3). RESULTS One hundred two patients were evaluated: 36 men (35.3%) and 66 women (64.7%). Forty patients had H pylori infection, 43 had used NSAIDs and 15 had combined H pylori infection and NSAID use; four patients with ulcers secondary to malignancy were excluded. The frequency of women was significantly higher in group 2 (P=0.01). The mean age of patients in group 1 was significantly lower than in the other two groups (P=0.003). PUD developed earlier in group 3 than in group 2 (5.0+/-4.7 months versus 1.4+/-2.1 months, respectively, P=0.018). Thirty-two patients (32.7%) had bleeding peptic ulcer. Group 2 had a higher risk of bleeding peptic ulcer than the other two groups (P=0.001). CONCLUSIONS The development of PUD was observed earlier in the combined H pylori and NSAID group than in patients with only NSAID use. This suggests a synergic effect between the two risks factors in the development of PUD.

HLA-DR Allele Frequencies in Mexican Mestizos with Autoimmune Liver Diseases Including Overlap Syndromes

Autoimmune liver diseases are sometimes difficult to differentiate from hepatic overlap syndromes (OS). The objective of this study was to use polymorphic genetic markers to better distinguish clinical heterogeneity in autoimmune liver disease. Since autoimmunity is the result of autoantibody production we studied HLA-DR alleles in 20 patients with autoimmune hepatitis (AIH), 16 with primary biliary cirrhosis (PBC), 10 with OS, and in 99 ethnically matched healthy individuals. Patients with OS had significantly higher alkaline phosphatase and total bilirubin levels than patients with AIH. OS patients had a higher prevalence of positive antinuclear antibodies and a higher AIH score than patients with PBC. Patients with OS also had higher total immunoglobulin levels (IgG isotype) as compared to patients with PBC. We found in PBC patients a higher gene frequency of HLA-DR4 and DR1 as compared to healthy controls (p = 0.03, OR = 2.2 and p = 0.004, OR = 4.3, respectively) and to OS patients (p = 0.01, OR = 6.8, and p = 0.004, OR = 10.0, respectively). On the other hand, the gene frequency of HLADR5 was significantly decreased in the total group of patients as compared to healthy controls suggesting a protective role of this allele for developing autoimmune liver disease.

Upper gastrointestinal dieulafoy's lesions and endoscopie treatment: first report from a mexican centre.

The aim was to evaluate the initial success, rebleeding rate, need for emergent surgery, and mortality rates of patients with Dieulafoys lesion (DL) and endoscopic treatment (ET). Patients with DL from a tertiary center were included. We included 20 patients with follow-up of 90 (60—550) days. The lesser curvature was the most common localization. Initial success, rebleeding, and emergent surgery requirement were observed in 90%, 10%, and 15%, respectively. No objective variables were related with response to ET. In conclusion, ET is secure and useful in patients with DL and it must be considered as the first-line treatment modality.

Endoscopic balloon catheter dilation for treatment of primary cricopharyngeal dysfunction.

Primary cricopharyngeal dysfunction (PCD) is a disorder of unknown etiology that is an increasingly recognized and potentially reversible cause of oropharyngeal dysphagia (1). It is characterized by failed or partial sphincter relaxation, lack of pharyngoesophageal coordination, or a reduction in the muscular compliance of the upper esophageal sphincter (UES) (2, 3). It has a low prevalence and affects mainly elderly people. The most frequent symptoms are dysphagia, choking during meals, aspiration, and immediate expectoration of an offending bolus. Diagnosis can be made by videofluoroscopy or by contrast radiographic studies; these may show a typical cricopharyngeal bar that is a prominent posterior indentation at the level of the UES (4). Manometric studies may not show uniform characteristics and these can include normal or increased resting UES pressure with incomplete relaxation and loss of pharyngoesophageal coordination (5). Treatment is started after secondary causes of oropharyngeal dysphagia are excluded and symptoms can be relieved by cricopharyngeal myotomy in most patients (6). Recently, the use of botulinum toxin injection and endoscopic balloon catheter dilation has been reported to be safe and effective for the treatment of cricopharyngeal dysphagia (7–10). Here we describe the results of treatment with balloon dilation and follow-up in a patient with PCD.

Oral challenge with a methionine load in patients with inflammatory bowel disease: a better test to identify hyperhomocysteinemia.

Background: Patients with inflammatory bowel disease have an increased risk of thrombosis. Hyperhomocysteinemia is one of the factors that have been related to thromboembolic complications. Patients with hyperhomocysteinemia and normal fasting homocysteine levels can be identified with an oral methionine load. We studied homocysteine levels in patients with IBD during fasting and after methionine load to determine the true prevalence of hyperhomocysteinemia and its relation with thrombotic events. Methods: Prospective analysis of homocysteine levels in consecutive patients with IBD during fasting and 6–8 hours after an oral methionine load. Levels of folate and vitamin B12 were also determined. History of thrombotic events were recorded. Results: Eighty‐two patients with IBD, 56 with UC and 26 with CD were included. Eighteen patients (22%) had hyperhomocysteinemia during fasting. Mean levels of homocysteine after methionine load were 20.4 ± 18.1 &mgr;mol/l (range, 1–79.7 &mgr;mol/l), and 43 patients (52%) had hyperhomocysteinemia (≥20 &mgr;mol/l) after methionine load. Six patients (7.3%) had history of thrombosis. The homocysteine levels during fasting and after methionine load were significantly higher in patients with thrombotic events than in patients without thrombosis (15.5 ± 3.7 &mgr;mol/l vs. 6.6 ± 6.5 &mgr;mol/l; P = 0.002; 44.5 ± 20.9 &mgr;mol/l vs. 18.4 ± 16.5 &mgr;mol/l; P < 0.001, respectively). Conclusions: There is a higher prevalence of hyperhomocysteinemia in IBD patients than previously thought, this can be identified with an oral challenge of a methionine load. Hyperhomocysteinemia increases the risk of thromboembolic complications in patients with IBD.

Endoscopic diagnosis of a goblet cell carcinoid tumour of the appendix

Primary malignancies of the appendix are rare. Of these, less than 5% are goblet cell carcinoid (GCC) tumours. The majority of GCC present with findings of acute appendicitis or advanced peritoneal spread. We describe a rare presentation of GCC as subtle mucosal abnormality of the appendiceal orifice seen on colonoscopy performed for iron-deficiency anaemia. Biopsies were interpreted as adenocarcinoma; however, final surgical pathology confirmed GCC of the appendix with caecal involvement. The patient recovered well from surgery, anaemia resolved and follow-up did not show metastatic disease.

Impacto de la resección endoscópica de la mucosa en la reclasificación histológica y tratamiento de displasia en esófago de Barrett

Introduction and aims. In selected patients, endoscopic mucosal resection (EMR) is a valuable tool for diagnosis and treatment of Barretts esophagus (BE). Currently, there is few available information regarding the reclassification of histological diagnosis in BE associated focal lesions. The aim was to evaluate the reclassification of histological diagnosis post-EMR, in patients with BE with biopsy proven dysplasia. Material and methods. This is a retrospective and descriptive study. We included patients with BE from January 2002-december 2013, in whom EMR was performed and had a previous biopsy with either low grade dysplasia (LGD), high grade dysplasia (HGD) or intramucosal carcinoma (IMC).EMR was performed by either the cap technique or by using the multi-band ligator technique. Results. We analyzed 41 specimens obtained in 19 EMR procedures performed in 11 patients. When pre and post-EMR diagnosis were evaluated, there was a reclassification in histological diagnosis in 7 of 11 (63%) patients (downstaging occurred in 5 and upstaging occurred in 2 patients). The global follow-up time was 45 (3-95) months. Nine patients (81.8%) received endoscopic eradication therapy without recurrence in the follow up. There were no procedure related complications. Conclusions. EMR conditions a significant change in histological diagnosis in BE with dysplasia patients.