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Introduction: There exist a great variability in the manometric findings between patients with anal incontinence (AI) and healthy subjects. The correlation between the pressures of the anal canal and the AI is not exact by the wide rank of normal values. Objectives: Prospective study to evaluate differences in the pressures of the anal canal and in rectal sensitivity in patients with AI, chronic constipation (CC) and healthy subjects. Material and methods: Ninety four patients with AI, 36 patients with CC and 15 healthy subjects were included. The following data were obtained: age, sex, resting pressure, anal canal length (ACL), squeeze maximum pressure (SMP), squeeze pressure duration (SPD), first sensation, urge and maximum tolerated volume (MTV). Statistical study: test of Kruskal-Wallis, test of Mann-Whitney, and multinomial logistic regression test. Results: There were significant differences in the resting pressure (p < 0.001), the ACL (p < 0.001) and the SMP (p < 0.01) in the group of AI with respect to the other two groups. The volume for the first sensation was significantly lower in the healthy subjects than that in the other two groups (p < 0.05). The urge volume and the MVT were smaller in the group with AI with respect to the other groups (p < 0.001). In multivariate analysis the age, the resting pressure and the volume for the first sensation and urge increase the relative risk for AI. Conclusions: The greater age, the decrease in anal canal resting pressure and the alteration of rectal sensation increase the risk for AI.Introducción: Existe gran variabilidad en los hallazgos manométricos entre pacientes con incontinencia anal (IA) y sujetos sanos. La correlación entre las presiones del canal anal y la IA no es exacta por el amplio rango de valores normales. Objetivos: Estudio prospectivo para evaluar diferencias en las presiones del canal anal y en la sensibilidad rectal en pacientes con IA, estreñimiento crónico (EC) y sujetos sanos. Material y métodos: Noventa y cuatro pacientes con IA, 36 pacientes con EC y 15 sujetos sanos. Se obtuvieron: edad, sexo, presión de reposo, longitud del canal anal (LCA), presión de máxima contracción voluntaria (PMCV), duración de la contracción voluntaria, primera sensación, sensación de urgencia y máximo volumen tolerado (MVT). Estudio estadístico: test de Kruskal-Wallis, test de Mann-Whitney, regresión logística multinomial. Resultados: Se encontraron diferencias significativas en la edad (p < 0,001), la presión de reposo (p < 0,001), la LCA (p < 0,001) y la PMCV (p < 0,01) en el grupo de IA con respecto a los otros dos grupos. El volumen para la primera sensación fue significativamente más bajo en los sujetos sanos que en los otros dos grupos (p < 0,05). El volumen de urgencia y el MVT fueron menores en el grupo con IA con respecto a los otros dos grupos (p < 0,001). En el análisis multivariante la edad, la presión de reposo y el volumen de la primera sensación y de la urgencia aumentan el riesgo relativo de IA. Conclusiones: La mayor edad, la disminución presión basal del canal anal y la alteración del umbral sensorial rectal aumentan el riesgo de IA.

Crohn's disease (CD) is a genetically complex disease in which both genetic susceptibility and environmental factors play key roles in the development of the disorder. NOD2/CARD15 mutations are associated with CD. NOD2 encodes for a protein that is an intracellular receptor for a bacterial product (muramyl dipeptide), though the exact functional consequences of these mutations remain the subject of debate. NOD2/CARD15 mutations are associated with ileal CD, with stricturing behavior, and possibly with a more complicated course of CD. NOD2/CARD15 mutations associated with CD have demonstrated heterogeneity across ethnicities and populations throughout the world, with regional variations across Europe and Spain. However, "NOD2/CARD15 testing" is not yet ready for use in the clinical setting. One of the reasons is that we know that these genetic variants increase the risk of disease only marginally, and many healthy individuals carry the risk alleles, At present it is not recommended to screen first-degree relatives, because we do not have the ability to prevent the disease at the present time.La enfermedad de Crohn (EC) es una enfermedad compleja desde el punto de vista de la genética puesto que para el desarrollo de la enfermedad se tiene que producir una interacción entre factores genéticos y ambientales. Las mutaciones del gen NOD2/CARD15 se han asociado con la susceptibilidad a padecer la EC. El gen NOD2/CARD15 codifica una proteína que actúa como un receptor intracelular de la proteína dipeptidomuramil que se encuentran en la pared de cubierta de algunas bacterias. Actualmente se desconoce cuál es el papel exacto de estas mutaciones en el funcionamiento de la proteína NOD2/CARD15. Estas mutaciones se han asociado con la localización en intestino delgado de la enfermedad, el comportamiento fibroestenosante y con un curso más grave de la enfermedad. Las tres mutaciones asociadas con la EC presentan una distribución desigual entre las diferentes razas y áreas geográficas del mundo, con variaciones a lo largo de Europa y España. La determinación de las mutaciones del NOD2/CARD15 no se puede utilizar todavía en la práctica clínica. La principal razón es que estas variantes genéticas sólo incrementan el riesgo de una forma marginal y los podemos identificar en muchos sujetos sanos. Actualmente no se recomienda realizar estudios de despistaje en familiares de primer grado que padecen la EC porque no disponemos de ninguna medida preventiva para evitar la enfermedad.

Background and aims: more than half of patients with genotype 1 chronic hepatitis C (CHC) do not achieve a sustained viral response (SVR) to current antiviral therapy due to primary non-response, relapse or intolerance. Factors related to each of these unfavorable outcomes are different and the last two may be partially prevented. Our aim was to identify basal criteria to predict the risk of primary failure. Patients and methods: we included 251 consecutive patients (152 males) from a single centre, infected with HCV genotype 1 and not previously treated. SVR was achieved in 141 patients and primary failure in 110. Results: high vs. low viral load (> 400,000 IU/mL, OR = 6.17; 95% CI: 2.50-15.23), high serum GGT (> 60 IU/mL, OR = 4.25; 95% CI: 2.49-7.24), low serum cholesterol (< 178 mg/dL, OR = 2.93; 95% CI: 1.75-4.92) and older age (> 47 yrs., OR = 1.79; 95% CI: 1.08-2.96) were associated to the risk of primary failure in the lineal logistic regression analysis. From the 58 patients carrying all the first three negative criteria, 46 (79.3%) were primary non-responders. Conclusions: the negative basal profile identified in this study is based on easily available data and provides information about the risk of primary therapeutic failure, and may help to decide whether antiviral therapy should be offered to a single patient.

Background: few studies have reported the onset and disappearance rates of gastroesophageal reflux symptoms (GERS) in the population. Aim: to assess the occurrence and disappearance rates of GERS in Spain, and their impact on health-related quality of life (HRQL). Participants and methods: participants were selected at random from the general population of Madrid in age and sex strata. They were interviewed at home twice, 6 months apart. Heartburn, acid regurgitation and consultation were assessed with the gastroesophageal reflux questionnaire, and HRQL with the SF-36. Results: 709 individuals were included, and 451 (63.6%) were re-interviewed 6 months later. Among the 325 individuals without GERS, 9 developed weekly symptoms (2.2% [95% CI: 0.8, 3.4%]); 2 (22%) consulted because of GERS. Among the 34 subjects reporting weekly GERS initially, 26 did not report them at 6-months. Onset of GERS was associated with worsening scores in the physical summary of SF-36 (delta = -6.6 [95% CI: -11.8, -1.42]), while disappearance with an improved score (delta = -3.0 [95% CI: 0.0, 5.9]). Conclusion: despite the lower prevalence of GERS in Spain, the occurrence rate is 2.2% in 6 months; however symptoms disappeared in more than half of subjects six months later. Developing GERS was associated with reduced HRQL, and their disappearance with improvement.

Background: hyperferritinemia is often found in patients with chronic hepatitis C (CHC) and is predictive of poorer response to antiviral therapy. Objective: to investigate changes in ferritinemia during and after antiviral therapy. Patients and methods: serum ferritin levels were measured in 262 CHC patients (163 males, mean age 48.5 years ± 10.1) before and during antiviral therapy, and six months post-treatment in all 154 patients whit undetectable serum HCV-RNA after therapy completion. Results: baseline serum ferritin was higher in patients with primary therapeutic failure than in those reaching sustained viral response (330 ± 291 ng/mL vs. 211 ± 192 ng/mL, p = 0.002). Serum ferritin transiently increased during therapy from baseline (257 ± 242 ng/mL vs. 875 ± 630 ng/mL, p < 0.001). Six months after finishing therapy, serum ferritin decreased under baseline values both in sustained responders (117 ± 102 ng/mL vs. 211± 192 ng/mL, p < 0.001) and, to a lesser extent, in relapsers (217 ± 174 ng/mL vs. 257 ± 221 ng/mL, p = 0.047). Conclusions: baseline serum ferritin may predict response to antiviral treatment in chronic hepatitis C. Combined antiviral therapy induces a marked increase in serum ferritin that falls below baseline values after sustained viral response, suggesting that the cause of hyperferritinemia in many patients is HCV infection itself rather than iron overload.Antecedentes: la hiperferritinemia es frecuente en los enfermos con hepatitis crónica C (HCC) y reduce las probabilidades de respuesta al tratamiento antiviral. Objetivo: investigar las variaciones de la ferritina sérica durante y después del tratamiento y su relación con la respuesta al mismo. Pacientes y métodos: la ferritina sérica se ha medido en 262 enfermos con HCC (163 hombres, edad media 48,5 años ± 10,1) antes y durante el tratamiento antiviral, y a los 6 meses de finalizado en los 154 enfermos con viremia indetectable al final del tratamiento. Resultados: la ferritina sérica basal era más alta en enfermos con fracaso terapéutico primario que en los que consiguieron respuesta viral sostenida (RVS) (330 ± 291 ng/ml vs. 211 ± 192 ng/ml, p = 0,002). La ferritina sérica aumentó transitoriamente durante el tratamiento (257 ± 242 ng/ml vs. 875 ± 630 ng/ml, p < 0,001). La ferritina sérica descendió a valores inferiores a los basales seis meses después de finalizado el tratamiento en los pacientes con RVS (117 ± 102 ng/ml vs. 211± 192 ng/ml, p < 0,001) y, en menor grado, en los que sufrieron recidiva viral (217 ± 174 ng/ml vs. 257 ± 221 ng/m, p = 0,047). Conclusiones: una ferritina sérica basal elevada se asocia con mayor riesgo de fracaso terapéutico en la HCC. El tratamiento antiviral induce un marcado incremento de la ferritina sérica que vuelve a valores por debajo de los basales en los enfermos que obtienen R vs. Esto sugiere que la causa de hiperferritinemia en la mayoría de los enfermos es la propia infección por VHC y no la sobrecarga de hierro.

Introducción: el adalimumab ha demostrado, en ensayos clínicos controlados con placebo y en estudios no controlados, ser efectivo en la EC luminal y fistulosa perianal. Objetivo: evaluar la eficacia y seguridad del adalimumab como tratamiento de inducción y mantenimiento en la EC. Metodología: se incluyeron 22 pacientes con EC tratados con adalimumab (16 por enfermedad luminal y 6 por enfermedad fistulosa perianal activa). Veintiún pacientes habían recibido previamente IFX. Se realizó tratamiento de inducción con 160 mg s.c. en la semana 0 y 80 mg s.c. a las 2 semanas. Los respondedores recibieron 40 mg s.c. cada 14 días como tratamiento de mantenimiento. Se valoró la respuesta a las 4 semanas de la dosis inicial, y se clasificó la respuesta como remisión, respuesta parcial o ausencia de respuesta. Resultados: tras la inducción, el 25% de los pacientes con enfermedad luminal tuvieron remisión completa y el 56,3% respuesta parcial. La respuesta clínica se mantuvo al año en el 71,6% de los pacientes, a los 18 meses en el 53,7% y a los 48 meses en el 35,8%. No se objetivaron diferencias en la respuesta entre pacientes que presentaron reacciones de hipersensibilidad o pérdida de respuesta a IFX. Todos los pacientes con enfermedad fistulosa perianal (n = 6) habían recibido previamente tratamiento con IFX. Tras la inducción un 16,7% entran en remisión y un 66,7% presentan respuesta parcial. Todos los pacientes mantienen remisión o respuesta en el tiempo con una mediana de seguimiento de 15 meses. Conclusiones: el adalimumab es un tratamiento eficaz y seguro en la inducción y mantenimiento de la respuesta en la EC luminal y fistulosa perianal. Estos resultados confirman que los hallazgos obtenidos en los ensayos clínicos controlados son reproducibles en la práctica clínica diaria.Background: adalimumab has been shown in placebo-controlled clinical trials and uncontrolled studies to be effective in luminal and perianal fistulizing CD. Objective: to evaluate the efficacy and safety of adalimumab for induction and maintenance therapy in CD. Methods: twenty-two patients with CD treated with adalimumab (16 for luminal disease and 6 for active perianal fistulizing disease) were included. Twenty-one patients had previously received IFX. All patients received induction therapy with 160 mg s.c. at week 0, and 80 mg s.c. at week 2. Responders received maintenance therapy with 40 mg s.c. every 14 days. Response was assessed at 4 weeks after the initial dose, and classified as remission, partial response, or non-response. Results: after induction, 25% of patients with luminal disease had a complete remission, and 56.3% had a partial response. Clinical response was maintained in 71.6% of patients at 1 year, in 53.7% at 18 months, and in 35.8% at 48 months. No differences in response were observed between patients with hypersensitivity reactions or loss of response to IFX. All patients with perianal fistulizing disease (n = 6) had been previously treated with IFX. After induction 16.7% entered remission, and 66.7% had a partial response. All patients maintained remission or response over time, with a median follow-up of 15 months. Conclusions: adalimumab is an effective and safe treatment for the induction and maintenance of response in luminal and perianal fistulizing CD. These results confirm that the findings obtained in controlled clinical trials are reproducible in clinical practice.

Antecedentes y objetivos: casi todos los datos sobre la eficacia del tratamiento antiviral combinado en la infección por el virus de la hepatitis C (VHC) genotipo 4, que es poco frecuente en España, se han obtenido en países del Oriente Próximo. Aportamos nuestra experiencia en pacientes tratados en España con criterios homogéneos. Pacientes y métodos: en el periodo 2001-2007 hemos tratado a 30 enfermos con hepatitis crónica por VHC genotipo 4 (20 varones) con interferón pegilado α-2b (26 casos) o α-2a (4 casos) y ribavirina en dosis ajustada al peso. En todos los casos se conoce el resultado del tratamiento y se dispone de bioquímica y datos virológicos basales, y en 24 de biopsia hepática. Hemos comparado estos resultados con los obtenidos en 355 pacientes infectados por VHC genotipo 1. Resultados: diez pacientes (33,3%) obtuvieron respuesta viral sostenida (RVS: ARN del VHC negativo en sangre a los 6 meses de finalizado el tratamiento), 12 no respondieron (fracaso viral primario), 4 recidivaron y 4 abandonaron por intolerancia. Estos resultados son muy similares a los obtenidos en el grupo de genotipo 1 (RVS: 35,1%). Conclusión: el genotipo 4 del VHC debe considerarse como tan "difícil de tratar" como el genotipo 1. La mayor eficacia del tratamiento en otras zonas geográficas (Oriente Próximo) pueden deberse a la diferente distribución de los subtipos virales existentes.Introduction: nearly all the data on the efficacy of combined antiviral therapy on chronic hepatitis C genotype 4 have been obtained in countries of Middle East. Genotype 4 is quite unusual in Spain. We report our experience in a group of Spanish patients treated with homogeneous criteria. Patients and methods: between 2001 and 2007 we have treated 30 patients with chronic hepatitis C genotype 4 (20 males) with pegylated Interferon a-2b (26 cases) or a-2a (4 cases) combined with ribavirin at a weight-adjusted dose. Results of therapy are known in all patients and liver biopsy is available in 24 cases. Results: ten patients (33.3%) obtained sustained viral response (SVR: HCV-RNA undetectable in blood 6 months after the end of therapy), 12 were primary non-responders, 4 relapsed after reaching undetectable HCV-RNA at the end of therapy and 4 interrupted the treatment due to severe adverse events. These results are very close to those obtained in 355 patients infected with HCV genotype 1. Conclusion: HCV genotype 4 should be considered as "difficult to treat". The better results of therapy in other geographical areas (Middle East) may be due to a different distribution of the subtypes of HCV genotype 4.

Objetivo: conocer la prevalencia de la infección por Helicobacter pylori en población sana en la Comunidad de Madrid. Material y métodos: estudio transversal descriptivo en el que se realiza el diagnóstico de la infección por Helicobacter pylori mediante la prueba del test del aliento con 13C-urea. Resultados: se estudian un total de 618 sujetos. De estos, 481 son considerados evaluables con una prevalencia de infección por Helicobacter pylori del 60,3%. En esta cohorte el 36,4% eran varones y el 63,6% mujeres con una prevalencia del 60,6 y 60,1% respectivamente sin diferencias significativas. La mediana de edad de los pacientes evaluados fue de 37,5 años (rango 4-82) estableciéndose que existe una relación lineal con significación estadística entre la infección por Helicobacter pylori y la edad (χ² lineal = 33,31; p < 0,001): a mayor edad mayor probabilidad de infección. La prevalencia aumenta con la edad siendo máxima entre los 60 y 69 años (83,3% infectados). En 169 sujetos (35,1%) se conoce el nivel de estudios sin que exista relación entre este y la infección por Helicobacter pylori. Conclusión: el estudio muestra que la prevalencia de la infección por Helicobacter pylori en población sana en Madrid es elevada (60,3%), y aumenta progresivamente a lo largo de la vida para alcanzar un pico máximo en la 6ª década. No se encuentran diferencias en la muestra en función del sexo ni del nivel de estudios.Objective: to determine the prevalence of Helicobacter pylori infection in the healthy population of Madrid Autonomous Community (AC). Material and methods: a descriptive, cross-sectional study where Helicobacter pylori infection is diagnosed by means of the 13C-urea breath test. Results: a total of 618 subjects were studied. Among these, 481 were considered evaluable with a prevalence of Helicobacter pylori infection of 60.3%. In this cohort 36.4% were men and 63.6% were women, with a prevalence of 60.6 and 60.1%, respectively, and no relevant differences between both subgroups. The median age of patients was 37.5 years (range 4-82), and a statistically significant linear relationship between Helicobacter pylori infection and age (linear χ² =33.31; p < 0.001) was established -chances of infection increase with age. Prevalence increases with age and peaks at 60 to 69 years (83.3% infected). For 169 subjects (35.1%) education level was unknown, and no relationship between this level and Helicobacter pylori infection was found. Conclusions: the study shows that the prevalence of Helicobacter pylori infection in the healthy population of Madrid AC is high (60.3%), progressively increases with age, and peaks in people in their sixties. The sample showed no differences regarding sex or education level.

Objetivo: comprobar si las mutaciones del gen HFE, que pueden inducir sobrecarga hepática de hierro, guardan relación con el riesgo de desarrollar carcinoma hepatocelular (CHC) en sujetos predispuestos a sufrir este tumor. Material y métodos: se han incluido 196 pacientes (161 varones) diagnosticados de CHC. Ninguno estaba diagnosticado de hemocromatosis. El grupo control estaba constituido por 181 sujetos sanos. Todos los sujetos eran españoles de raza blanca.Las mutaciones C282Y y H63D del gen HFE se identificaron mediante reacción en cadena de polimerasa (PCR) sobre ADN genómico leucocitario utilizando enzimas de restricción específicas. Resultados (casos/controles): 1. Distribución genotípica: a) mutación C282Y: 1/0 homocigotos, 12/23 heterocigotos, 183/158 normales (p = 0,07, n.s.); y b) mutación H63D: 9/5 homocigotos, 85/52 heterocigotos, 102/124 normales (odds ratio 2,00, IC95% 1,29-3,12, p = 0,002). Cuatro casos y seis controles eran heterocigotos compuestos. 2. Frecuencias alélicas: a) mutación C282Y: normales 378/339, mutados 14/23 (p = 0,11, n.s.); b) mutación H63D: normales 289/300; mutados 103/62 (odds ratio 1,72, IC95% 1,19-2,50, p = 0,004). No se observaron diferencias en relación con el sexo, la edad o la etiología (VHC, VHB, etílica o mixta) de la hepatopatía previa. Conclusiones: la mutación C282Y no guarda relación con el riesgo de desarrollar CHC en sujetos sin hemocromatosis conocida. La posesión de la mutación H63D se asocia con un riesgo aumentado de desarrollar CHC independientemente de la etiología de la hepatopatía crónica subyacente.Aim: to disclose whether mutations in the HFE gene inducing liver iron overload are related to the risk of hepatocellular carcinoma (HCC) in otherwise predisposed patients. Patients and methods: one hundred and ninety-six patients (161 males) diagnosed with HCC and 181 healthy controls were included in the study. All subjects were white Spaniards. C282Y and H63D mutations in the HFE gene were identified in leucocyte genomic DNA using a polymerase chain reaction (PCR) and specific restriction enzymes. Results (cases/controls): 1. Genotype distribution: a) C282Y mutation: homozygotes 1/0, heterozygotes 12/23, wild type 183/158 (p = 0.07, non significant); b) H63D mutation: homozygotes 9/5, heterozygotes 85/52, wild type 102/124 (0dds ratio 2.00, 95% C.I. 1.29-3.12, p = 0.002. Four cases and 6 controls were carriers of heterozygous mixed genotypes. 2. Allele frequencies: a) C282Y mutation: wild type allele 378/339, mutated allele 14/23 (p = 0.11, non significant); b) H63D mutation: wild type allele 289/300, mutated allele 103/62 (0dds ratio 1.72, 95% C.I. 1.19-2.50, p = 0.004). Age at diagnosis, gender and etiology of the underlying liver disease do not influence these findings. Conclusion: the C282Y mutation in the HFE gene is not related to the risk of HCC in non-hemochromatosis patients. The H63D mutation is associated with a higher risk of HCC in cirrhotic patients irrespective of their underlying liver disease.

Introducción: el síndrome del intestino irritable (SII) es una patología controvertida, donde ante la escasez de evidencia científica las recomendaciones sobre su manejo clínico y su definición vienen determinadas por métodos de consenso de expertos. Objetivo: obtener la opinión de los médicos de nuestro país implicados en el manejo de pacientes con SII y conocer los puntos de acuerdo en las principales cuestiones clínicas que plantea. Material y métodos: se realizó un estudio Delphi a nivel nacional mediante dos envíos a 100 médicos de atención primaria y gastroenterólogos. El cuestionario incluía preguntas sobre el concepto, diagnóstico y tratamiento del SII, evaluando el grado de acuerdo entre los participantes. Resultados: el 55% de los encuestados completó los dos envíos. Se obtuvo acuerdo respecto a los síntomas que caracterizan al SII y los de alarma. No existió una actitud clara ante el paciente sin síntomas de alarma, pero sí acuerdo respecto a la realización de colonoscopia en su presencia. Se señaló la necesidad de realizar estudios complementarios en mayores de 40 años. En el tratamiento no encontramos una actitud uniforme, aunque parece existir una orientación diferente según el síntoma predominante. Conclusiones: los médicos participantes en el estudio demuestran a través de sus respuestas un buen conocimiento conceptual del SII, si bien las discrepancias observadas en las cuestiones sobre diagnóstico y tratamiento demuestran la complejidad y falta de uniformidad que existe en el manejo diario de este síndrome.Introduction: lack of evidence in most clinical situations regarding irritable bowel syndrome (IBS) enhances the importance of an expert's opinion, which will guide management and even the concept underlying the disease. Objective: to delve into the knowledge and degree of agreement on main clinical skills for this syndrome among physicians involved in its management. Material and method: two rounds of a Delphi survey were conducted on 100 physicians: general practitioners (GPs) and gastroenterologists. The questionnaire evaluated agreement among participants in some aspects regarding the definition, diagnosis, and treatment of IBS. Results: fifty-five percent of participants completed the two-round survey. Agreement was achieved regarding the definition of typical symptoms and red flags characterizing IBS. Although there was no consensus regarding the appropriate management of patients without alarm symptoms, the performance of a colonoscopy on any patient presenting red flags was suggested. Patients were thought to require a wider examination when older than 40. A well defined line of IBS treatment was not found, albeit most physicians tended to choose it depending on the main complaint. Conclusion: interviewed physicians showed adequate theoretical knowledge of IBS, but lack of uniformity on diagnosis and treatment approach reflects the controversial day-by-day management of this syndrome.

Introduction: the capsule endoscopy (CE), from his approval, has become a first line diagnostic procedure for the study of the small bowel disease. The aim of this study is to report our experience since the implantation of this technique in our hospital. Material and methods: retrospective review of the CE undertaken in Department of Endoscopy. There was gathered in every case the age, sex, motive of consultation, previous diagnostic procedures, capsule endoscopy findings and complication of the technique. One took to end a descriptive and analytical analysis. Results: there was achieved a total of 416 explorations in 388 patients. The obscure gastrointestinal bleeding was the most frequent indication (83.30%) followed by suspected Crohn's disease (7.5%). Angiodisplasia was the endoscopic lesion more frequently detected (42.2%), especially, in patients with digestive bleeding of obscure origin (OR 3.13 p < 0.001), followed by the flebectasia (10.6%) and the ulcer suspicious of Crohn’s disease (9.9%). The global diagnostic yield as for the detection of injuries was 77.34% with a case of "not defecation of the capsule' and therefore need of laparotomy. Conclusions: the capsule endoscopy is a technique consolidated and as his potential is known, his indications are extended. The obscure gastrointestinal bleeding is the most frequent indication and the angiodisplasia the most identified injury. Once known his diagnostic yield, larger studies are needed that assess the influence of capsule endoscopy on clinical outcoumes.Introducción: la cápsula endoscópica desde su aprobación se ha convertido en un procedimiento diagnóstico de primera línea para el estudio del intestino delgado. El objetivo del estudio es exponer la experiencia desde la implantación de esta técnica en nuestro hospital. Material y métodos: se hizo una revisión retrospectiva de los estudios realizados en el Servicio de Endoscopia. Se recogió en cada caso la edad, sexo, motivo de consulta, procedimientos diagnósticos previos, diagnósticos endoscópicos e incidencias inherentes a la técnica y se llevó a cabo un análisis descriptivo y analítico. Resultados: se realizaron un total de 416 exploraciones en 388 pacientes. La hemorragia digestiva de origen oscuro fue la indicación más frecuente (83,30%) seguida de la sospecha de enfermedad de Crohn (7,5%). La angiodisplasia fue la lesión endoscópica más detectada (42,2%) cuando se analizó la hemorragia digestiva oscura (OR 3.13 p < 0,001) seguida de la flebectasia (10,6%) y las úlceras sugerentes de enfermedad de Crohn (9,9%). La rentabilidad global en cuanto a la detección de lesiones fue del 77,34% con un caso de "no defecación de la cápsula' y por lo tanto de necesidad de laparotomía. Conclusiones: la cápsula endoscópica es una técnica consolidada y a medida que se conoce su potencial, se van ampliando sus indicaciones. La hemorragia digestiva de origen oscuro es la indicación más frecuente y la angiodisplasia la lesión más identificada. Una vez conocida su eficacia diagnóstica se hace necesario determinar mediante estudios a gran escala y con metodología precisa la rentabilidad clínica de la misma.

Background and objectives: interleukin-10 (IL-10) has a key role in regulating mucosal inflammation in inflammatory bowel disease. In our population of Spanish ulcerative colitis (UC) patients, we have previously demostrated that two polymorphisms (IL-10.G14 microsatellite allele and homozygous for the -1082G alelle (guanine at position -1082)) in the IL-10 gene were susceptibility markers for disease. No data exist regarding the relationship of these IL-10 polymorphims with phenotypic subpopulations in UC. Therefore, this study sought to examine the contribution of IL-10 polymorphims to phenotypical variability in UC. Material and methods: a cohort of 215 Spanish unrelated patients with UC recruited in a single center was studied. All patients were rigorously phenotyped and followed for at least 3 years (mean time: 11.8 years). The clinical phenotype was established before genotyping. Genotyping was performed using polymerase chain reaction (PCR) assays. Results: patiens with UC included 129 (60%) men and 89 (40%) women. Mean age at diagnosis was 38 years, with a range of 8-83. Disease extent included 127 (59.1%) left-side patients and 88 (40.9%) extensive patients. Neither UC phenotype variable was associated with the presence of susceptibility polymorphims (10G14 microsatellite and -1082G alelle). Conclusions: in Madrid's Spanish population of UC patients, the carrying of the ILG14 microsatellite or -1082G polymorphism in the IL-10 gene was not associated with phenotype of disease.Introducción y objetivo: el gen de la interleuquina 10 (IL-10) tiene un papel clave en la regulación de la inflamación intestinal en la enfermedad inflamatoria intestinal. Recientemente hemos descubierto que dos polimorfismos del gen de la IL-10, el microsatélite IL-10.G14 y ser homocigoto -1082G (guanina en la posición 1082 del gen promotor de la IL-10) son marcadores de susceptibilidad para padecer colitis ulcerosa (CU). No existen datos que demuestren si estos polimorfismos de la IL-10 se correlacionan con las características fenotípicas de la CU. En este trabajo se estudia la relación entre estos polimorfismos del gen de la IL-10 y las diferentes características fenotípicas de la CU. Material y métodos: se estudió una cohorte de 215 pacientes españoles no emparentados que son atendidos habitualmente en la consulta de un único centro hospitalario. Todos los pacientes fueron rigurosamente fenotipados y seguidos clínicamente durante al menos 3 años (tiempo medio de seguimiento 11,8 años). El fenotipaje se realizó antes de conocer el genotipo de los pacientes. El genotipaje se realizó según las técnicas habituales de reacción en cadena de la polimerasa. Resultados: se incluyeron 129 (60%) hombres y 89 (40%) mujeres. La edad media en el momento del diagnóstico fue de 38 años, rango (8-83). La extensión de la CU fue colitis izquierda en 127 (59,1%) pacientes y extensa en 88 (40,9%). Ninguna de la svariables fenotípicas estudiadas se asoció con la presencia o ausencia de los polimorfismos (microsatélite IL10G14 y homocigoto para el alelo -1082G) relacionados con la susceptibilidad a sufrir CU. Conclusiones: en la población española del área de Madrid, los pacientes con CU que son portadores del microsatélite IL10G14 y/o homocigotos -1082G del gen promotor de la IL-10 no se correlacionan con ninguna característica fenotípica de la enfermedad.

Treatment of perianal fistulas in Crohn's disease should be defined on an individual basis. A combined medical and surgical approach is the optimal treatment. Adequate management of perianal fistula disease is based on the presence or absence of active proctitis, anatomic location, and fistula type. Furthermore, the presence of perianal abscesses must be ruled out. This evaluation includes digital rectal examination, endoscopy, and examination under anesthesia combined with pelvic magnetic resonance imaging or anorectal endoscopy ultrasonography findings.El tratamiento de la enfermedad fistulosa perianal (EFPA) en la enfermedad de Crohn (EC) debe de ser individualizado y combinar procedimientos médicos y quirúrgicos. Los aspectos clave para un adecuado manejo de la EFPA son determinar la existencia o no de afectación rectal, las características anatómicas y tipo de fístulas, y descartar la existencia de abscesos perianales. Para lograrlo es necesaria una aproximación diagnóstica que incluya inspección y tacto rectal, endoscopia y exploración bajo anestesia combinado con resonancia magnética pélvica o ecografía anal.

Objective: to describe our experience with granulocyte apheresis to induce remission in patients with active Crohn's disease refractory to conventional treatment. We summarize the results previously obtained with this technique. Conclusions: granulocyte apheresis is a safe and well tolerated therapeutic modality that can be a valid therapeutic alternative in the induction of remission in inflammatory bowel disease, although controlled clinical trials must be conducted to define long-term efficacy, as well as to establish “optimal patient” selection, re-treatment interval, and number of sessions.Objetivo: describir nuestra experiencia con la granulocitoaféresis para inducir la remisión en pacientes con enfermedad de Crohn activa refractarios al tratamiento convencional. Realizamos un resumen de los resultados previos obtenidos con esta técnica. Conclusiones: la granulocitoaféresis es una modalidad terapéutica segura y bien tolerada que puede ser una alternativa terapéutica válida en la inducción de la remisión en la enfermedad inflamatoria intestinal, siendo necesaria la realización de ensayos clínicos controlados para poder definir su eficacia a largo plazo, la selección del "paciente óptimo", intervalos de retratamiento y número de sesiones.

The hyperferritinemia-cataract syndrome, inherited as a Mendelian dominant trait, is due to mutations in the 5’ non-coding region of the ferritin light chain gene that modifies the shape of the IRE (iron responsive element) region, which loses its normal function of regulating the synthesis of ferritin light chains. Excess of light chains results in complexes that accumulate into the lens giving rise to early cataracts. We present a Spanish family with seven affected members through three generations. A genetic study reveals a substitution of a single base (C?T) at position 33 in the IRE sequence in the index case and in one affected brother, whereas a non-affected sister shows the normal sequence. The hyperferritinemia-cataract syndrome was identified in 1995 and is still poorly understood. Clinicians should suspect it when treating any subject with early cataracts, even more if they are familial, or in patients with very high levels of ferritinemia without evidence of iron overload. There are no known consequences of the syndrome other than cataracts, and its proper diagnosis carries a favorable prognosis and eliminates the risk of unnecessary phlebotomies.El síndrome de hiperferritinemia y cataratas es un trastorno autosómico dominante debido a mutaciones en la región 5’ no codificante del gen de la cadena ligera de ferritina, localizado en 19q.3-q13,4. Como consecuencia se altera la morfología de la region IRE (iron responsive element) que pierde su capacidad normal de regular la síntesis de cadenas ligeras de ferritina, las cuales se sintetizan en exceso y forman complejos que se acumulan en el cristalino, dando lugar a cataratas precoces. Se presenta una familia española con 7 miembros afectados en tres generaciones. El estudio genético pone de manifiesto un cambio de una sola base C?T en posición 33 del IRE en el caso index y un hermano, mientras que otra hermana no afecta del síndrome no mostraba mutaciones. Este síndrome se identificó en 1995 y aún es poco conocido. La sospecha clínica debe surgir ante sujetos con cataratas precoces, especialmente si son de tipo familiar, o en personas con cifras elevadas de ferritina sin causa aparente y sin signos de sobrecarga de hierro. El trastorno no parece tener otras consecuencias que las cataratas y su identificación permite establecer un pronóstico favorable y evitar sangrías terapéuticas innecesarias.

Ethanol abuse is the most prevalent cause of liver cirrhosis in Spain. Genetic polymorphisms affect the activity of the enzymes involved in ethanol metabolism and in processing the toxic by-products generated in the liver. N-acetyltransferase 2 (NAT2) is a polymorphic phase 2 enzyme not involved in these processes, but recent data suggest that the most prevalent slow acetylator genotype protects against the risk of advanced alcoholic liver disease (ALD). We have identified six single nucleotide polymorphisms (SNP) at the NAT2 gene locus in order to disclose whether such an association exists.Genomic DNA from 95 ALD patients (15 with superimposed hepatocellular carcinoma (HCC)) and from 258 healthy individuals was analysed for SNPs at the coding region of the NAT2 gene by means of allele-specific polymerase chain reaction.There are no differences in the relative frequencies of the eight identified NAT2 alleles (including the wild-type allele) nor in the distribution of predicted phenotypes (54% of slow acetylators in each group). Twelve patients with HCC (80%) were slow acetylators (P0.05).There is no relationship between the NAT2 genotype and the risk of ALD. Slow acetylator genotype may predispose to the development of HCC in severe ALD patients not infected by the hepatitis C virus.

Introduction: There exist a great variability in the manometric findings between patients with anal incontinence (AI) and healthy subjects. The correlation between the pressures of the anal canal and the AI is not exact by the wide rank of normal values. Objectives: Prospective study to evaluate differences in the pressures of the anal canal and in rectal sensitivity in patients with AI, chronic constipation (CC) and healthy subjects. Material and methods: Ninety four patients with AI, 36 patients with CC and 15 healthy subjects were included. The following data were obtained: age, sex, resting pressure, anal canal length (ACL), squeeze maximum pressure (SMP), squeeze pressure duration (SPD), first sensation, urge and maximum tolerated volume (MTV). Statistical study: test of Kruskal-Wallis, test of Mann-Whitney, and multinomial logistic regression test. Results: There were significant differences in the resting pressure (p < 0.001), the ACL (p < 0.001) and the SMP (p < 0.01) in the group of AI with respect to the other two groups. The volume for the first sensation was significantly lower in the healthy subjects than that in the other two groups (p < 0.05). The urge volume and the MVT were smaller in the group with AI with respect to the other groups (p < 0.001). In multivariate analysis the age, the resting pressure and the volume for the first sensation and urge increase the relative risk for AI. Conclusions: The greater age, the decrease in anal canal resting pressure and the alteration of rectal sensation increase the risk for AI.

adalimumab has been shown in placebo-controlled clinical trials and uncontrolled studies to be effective in luminal and perianal fistulizing CD.to evaluate the efficacy and safety of adalimumab for induction and maintenance therapy in CD.twenty-two patients with CD treated with adalimumab (16 for luminal disease and 6 for active perianal fistulizing disease) were included. Twenty-one patients had previously received IFX. All patients received induction therapy with 160 mg s.c. at week 0, and 80 mg s.c. at week 2. Responders received maintenance therapy with 40 mg s.c. every 14 days. Response was assessed at 4 weeks after the initial dose, and classified as remission, partial response, or non-response.after induction, 25% of patients with luminal disease had a complete remission, and 56.3% had a partial response. Clinical response was maintained in 71.6% of patients at 1 year, in 53.7% at 18 months, and in 35.8% at 48 months. No differences in response were observed between patients with hypersensitivity reactions or loss of response to IFX.All patients with perianal fistulizing disease (n = 6) had been previously treated with IFX. After induction 16.7% entered remission, and 66.7% had a partial response. All patients maintained remission or response over time, with a median follow-up of 15 months.adalimumab is an effective and safe treatment for the induction and maintenance of response in luminal and perianal fistulizing CD. These results confirm that the findings obtained in controlled clinical trials are reproducible in clinical practice.

nearly all the data on the efficacy of combined antiviral therapy on chronic hepatitis C genotype 4 have been obtained in countries of Middle East. Genotype 4 is quite unusual in Spain. We report our experience in a group of Spanish patients treated with homogeneous criteria.between 2001 and 2007 we have treated 30 patients with chronic hepatitis C genotype 4 (20 males) with pegylated Interferon alpha-2b (26 cases) or alpha-2a (4 cases) combined with ribavirin at a weight-adjusted dose. Results of therapy are known in all patients and liver biopsy is available in 24 cases.ten patients (33.3%) obtained sustained viral response (SVR: HCV-RNA undetectable in blood 6 months after the end of therapy), 12 were primary non-responders, 4 relapsed after reaching undetectable HCV-RNA at the end of therapy and 4 interrupted the treatment due to severe adverse events. These results are very close to those obtained in 355 patients infected with HCV genotype 1.HCV genotype 4 should be considered as "difficult to treat". The better results of therapy in other geographical areas (Middle East) may be due to a different distribution of the subtypes of HCV genotype 4.

To determine the prevalence of Helicobacter pylori infection in the healthy population of Madrid Autonomous Community (AC).A descriptive, cross-sectional study where Helicobacter pylori infection is diagnosed by means of the 13C-urea breath test.A total of 618 subjects were studied. Among these, 481 were considered evaluable with a prevalence of Helicobacter pylori infection of 60.3%. In this cohort 36.4% were men and 63.6% were women, with a prevalence of 60.6 and 60.1%, respectively, and no relevant differences between both subgroups. The median age of patients was 37.5 years (range 4-82), and a statistically significant linear relationship between Helicobacter pylori infection and age (linear chi2 =33.31; p0.001) was established -chances of infection increase with age. Prevalence increases with age and peaks at 60 to 69 years (83.3% infected). For 169 subjects (35.1%) education level was unknown, and no relationship between this level and Helicobacter pylori infection was found.The study shows that the prevalence of Helicobacter pylori infection in the healthy population of Madrid AC is high (60.3%), progressively increases with age, and peaks in people in their sixties. The sample showed no differences regarding sex or education level.

To disclose whether mutations in the HFE gene inducing liver iron overload are related to the risk of hepatocellular carcinoma (HCC) in otherwise predisposed patients.One hundred and ninety-six patients (161 males) diagnosed with HCC and 181 healthy controls were included in the study. All subjects were white Spaniards.C282Y and H63D mutations in the HFE gene were identified in leucocyte genomic DNA using a polymerase chain reaction (PCR) and specific restriction enzymes. RESULTS (CASES/CONTROLS): 1. Genotype distribution: a) C282Y mutation: homozygotes 1/0, heterozygotes 12/23, wild type 183/158 (p = 0.07, non significant); b) H63D mutation: homozygotes 9/5, heterozygotes 85/52, wild type 102/124 (0dds ratio 2.00, 95% C.I. 1.29-3.12, p = 0.002. Four cases and 6 controls were carriers of heterozygous mixed genotypes. 2. Allele frequencies: a) C282Y mutation: wild type allele 378/339, mutated allele 14/23 (p = 0.11, non significant); b) H63D mutation: wild type allele 289/300, mutated allele 103/62 (0dds ratio 1.72, 95% C.I. 1.19-2.50, p = 0.004). Age at diagnosis, gender and etiology of the underlying liver disease do not influence these findings.The C282Y mutation in the HFE gene is not related to the risk of HCC in non-hemochromatosis patients. The H63D mutation is associated with a higher risk of HCC in cirrhotic patients irrespective of their underlying liver disease.

lack of evidence in most clinical situations regarding irritable bowel syndrome (IBS) enhances the importance of an expert s opinion, which will guide management and even the concept underlying the disease.to delve into the knowledge and degree of agreement on main clinical skills for this syndrome among physicians involved in its management.two rounds of a Delphi survey were conducted on 100 physicians: general practitioners (GPs) and gastroenterologists. The questionnaire evaluated agreement among participants in some aspects regarding the definition, diagnosis, and treatment of IBS.fifty-five percent of participants completed the two-round survey. Agreement was achieved regarding the definition of typical symptoms and red flags characterizing IBS. Although there was no consensus regarding the appropriate management of patients without alarm symptoms, the performance of a colonoscopy on any patient presenting red flags was suggested. Patients were thought to require a wider examination when older than 40. A well defined line of IBS treatment was not found, albeit most physicians tended to choose it depending on the main complaint.interviewed physicians showed adequate theoretical knowledge of IBS, but lack of uniformity on diagnosis and treatment approach reflects the controversial day-by-day management of this syndrome.

Evolution of bowel habit in irritable bowel syndrome (IBS) is not well known.To evaluate the change over time of bowel habit in IBS patients followed-up during 1 year.Five hundred and seventeen patients with IBS were prospectively included in an observational study with five evaluations over a 1-year period. Symptoms were recorded daily in diary cards during four 4-week periods along the study. Bristol Stool Scale (BSS) was used to define bowel habit.Four-hundred patients completed the study. Rome II showed low-moderate agreement (42%) with BSS to define bowel habit. Frequency of constipation and diarrhoea showed little changes throughout the study. Over 50% of the patients had the same bowel habit when each diary was compared with the next one. A third of patients maintained the same habit throughout the study. Most changes occurred from/to mixed or unsubtyped IBS. Only 14% of cases changed from constipation to diarrhoea or vice versa. This change was associated to female gender (OR: 2.65).The frequency of constipation and diarrhoea remains relatively stable over time. Changes in IBS subtypes are common, but changes between constipation and diarrhoea are rare. Alternating IBS is more frequent in women.

To compare the effect of effervescent ranitidine, almagate (magnesium carbonate-aluminium hydroxide) and placebo on gastric pH, in fasting and postprandial conditions.Twelve healthy volunteers underwent a gastro-oesophageal pH monitoring on three different occasions after the administration of each of the following randomly allocated treatments: almagate, effervescent ranitidine and placebo. Treatment effects were assessed in fasting and postprandial conditions. Onset and duration of alkalinization, percentage of time with pH4 and median gastric pH after treatments were calculated in both periods.Onset of action of effervescent ranitidine was similar to almagate in fasting [median 1.2 min (IQR: 0.6-12.7) vs. 2.9 min (0.4-227.6)] and postprandial conditions [1.4 min (0.5-4.9) vs. 4.1 min (1.3-63.8)] and both were significantly faster than placebo [fasting 211.1 min (2.7-240); postprandial 240 min (175.6-240)]. The duration of action of effervescent ranitidine was statistically significant longer than almagate in fasting [235 min (105.2-239.4) vs. 19.4 min (6.7-38.8)] and postprandial conditions [171.8 min (133.2-239.5) vs. 61.3 min (44.7-91.9)]. Effervescent ranitidine was more effective than almagate in increasing the percentage of time with a pH4 both in fasting (73.9% vs. 7.3%) and postprandial (59.1% vs. 21.3%).Effervescent ranitidine shows an effect on gastric pH as fast as almagate but provides a duration of alkalinization longer than almagate, in both fasting and postprandial conditions.

To study whether any relationship exists between the C282Y and H63D mutations of the HFE gene, iron liver content, and the severity of histological damage in patients with hepatitis C virus (HCV)-induced chronic hepatitis.In 72 patients diagnosed with HCV-chronic infection, naïve for antiviral therapy, and undergoing liver biopsy, the Knodell index was established, a morphometric evaluation of hepatic hemosiderin deposits was performed by using a semiautomatic method of image analysis, and mutations of the HFE gene were identified through a polymerase chain reaction on leukocyte genomic DNA by using specific restriction enzymes. The control group for the distribution of HFE genetic variants was composed of 181 healthy individuals with the same ethnic and geographical (white Spaniards) origin.(Cases/controls): 1. Genotype distribution: a) mutation C282Y: no homozygotes, 6/23 heterozygotes, 66/158 without the mutation (not significant, n.s.); b) mutation H63D: 2/5 homozygotes, 26/52 heterozygotes, 44/124 without the mutation (n.s.). compound heterozygotes 2/6. 2. Allele frequencies: a) mutation C282Y: 0.042/0.064 (n.s.); b) mutation H63D: 0.208/0.171 (n.s.). Four C282Y heterozygous patients had stainable liver iron (p=0.015 vs patients without mutations). Sixty-six patients were not carriers of the C282Y mutation; among them, 26.9% of 26 carriers and 15% of 40 non-carriers of the H63D mutation had liver stainable iron (n.s.). Knodell index score, gender, age at diagnosis, mode of transmission, and serum and liver iron values were not related to the HFE genotype.our results suggest that the C282Y mutation, but not the H63D mutation, of the HFE gene is frequently associated with stainable iron in the liver in HCV-related chronic hepatitis. The HFE genotype is not related to the histological severity of the disease.

The inflammatory bowel disease is accompanied by cutaneous manifestations in approximately 10% of the cases. Neutrophilic dermatoses are located on the dermis and/or epidermis and are characterised on histological examination by the presence of an infiltrate that consists largely of neutrophils. The prototype of neutrophilic dematoses is Sweetacute;s syndrome; which is rarely associated with Crohńs disease.A 63 year old woman was admitted to hospital with pyrexia, abdominal pain, episcleritis and skin lesions. She presented erythematous lesions on trunk, legs and arms, with tendency towards formation of plaques, nodules and vesicular pustular lesions. Both the colonoscopy and colonic biopsies confirmed the diagnosis of colonic Crohńs disease. Cutaneous biopsies re-vealed an infiltrate consisting mainly of neutrophils. These biopsies, together with clinical details led to the diagnosis of Sweetacute;s syndrome. A methylprednisolone treatment rapidly improved the skin lesions and clinical symptoms. The different clinical forms of neutrophilic dermatosis are an extra intestinal manifestation of Crohńs disease, and are some-times found concurrently in the same patient, which would indicate a common pathogenesis with different clinical presentations (spectrum of neutrophilic dermatoses).

To produce and validate for telephone use in Spain a cross-cultural adaptation of the gastroesophageal reflux questionnaire (GERQ) developed by Locke et al.The Spanish version of the questionnaire was developed through translation, assessment of comprehensibility, back translation, and appraisal of applicability. Subsequently, reproducibility was measured by a test-retest procedure in 125 patients, and concurrent validity was evaluated by comparing self-reported questionnaire data against a gastroenterologist's findings from clinical interviews with 50 patients.The Spanish version showed itself to be easily understandable and widely applicable. Reproducibility for the two cardinal symptoms of gastroesophageal reflux disease (heartburn and acid regurgitation) as measured by the kappa index (95% confidence interval), was 0.85 (0.73-0.97) and 0.81 (0.70-0.92), respectively. With respect to the process of concurrent validation, kappa values (95% confidence interval) for heartburn and acid regurgitation were 0.85 (0.68-1) and 0.91 (0.79-1), respectively. Median kappa for all questions on the questionnaire was 0.75 (range: 0.42 a 1) in the reproducibility analysis and 0.83 (range: 0.44 a 1) in the concurrent validity analysis.The reproducibility and concurrent validity of the Spanish version of the GERQ is excellent and comparable to that of the original English version.

The aim of this study is to report our experience with infliximab and analyse prognostic factors for response in Crohn's disease (CD).Consecutive patients were prospectively enrolled in the study when referred for infliximab infusion. Data collected included indication for infusion, patient epidemiological characteristics, Vienna classification, previous surgery, previous medications and extra-intestinal manifestations. Adverse events and clinical response were tabulated separately for patients with luminal or fistulous Crohn's disease.28 patients were treated (7 with inflammatory and 21 with fistulizing disease). Patients received a total of 116 infusions of infliximab: 57.1% (4 of 7) of patients with luminal disease had complete response within a median of 17.5 days (range 15-28 days), and 62% (13 of 21) of patients with fistulizing disease had complete response within a median of 9 days (range 6-51 days). All patients (5) without relapse received concomitant treatment with immune modifiers. The group of patients with previous resection or perianal fistula repair had complete response more frequently p = 0.03 (OR = 30; IC 95% = 1.47-119.8).Infliximab is safe and beneficial in clinical practice for Crohn's disease. The re-treatment regimen of infliximab is effective in maintaining clinical response. Immunosuppressant therapy may have a role in the duration of maintained clinical remission in patients with fistulizing disease. In patients with perianal fistulizing disease infliximab treatment is more effective when previous resection or fistula repair is present.

To evaluate the prevalence of rectal hypersensitivity in our irritable bowel syndrome (IBS) patients, the relationship of hypersensitivity to rectal distensibility and the differences in sensitivity among clinical subgroups of IBS.18 healthy subjects and 56 IBS patients (Rome-II criteria; 22 diarrhea-predominant, 15 constipation-predominant and 19 alternating). Rectal sensitivity and distensibility were studied by isobaric phasic distension of a poliethilene bag with a barostat.IBS patients showed a lower threshold for discomfort, pain and maximum tolerate distension, without any differences in rectal distensibility. 64% of IBS patients were hypersensitive. 89% of patients with alternating IBS were hypersensitive while only 68% and 26% of patients with diarrhea-predominant IBS and constipation-predominant IBS, respectively, were. There were no differences in rectal distensibility between hypersensitive and normosensitive patients.64% of our IBS patients show rectal hypersensitivity, apparently not related to rectal distensibility. Hypersensitivity is mostly found in alternating IBS patients, and rare in constipation-predominant IBS.

A Spanish Consensus Conference had been arranged by the Spanish Club for the Study of Helicobacter pylori to encourage the use of eradication regimens in appropriate indications. The aim of our study was to assess whether the publication of these recommendations in November 1999 induced a change on the indications of eradication in the referring primary care district.Patients who had undergone Helicobacter pylori eradication therapy indicated by a gastroenterologist and referred to perform the 13C-labelled marked urea breath test were evaluated. Indications of eradication therapy were analysed and divided in: a) use of Conference recommended procedures (duodenal or gastric ulcer, erosive duodenitis, gastric MALT lymphoma and after resection of gastric adenocarcinoma); and b) other procedures not included in the recommendations (the rest). Indications established during former and latter years of publication of the Club's recommendations were compared.A total of 659 established eradications in 1999 against 537 in 2000, were studied. Regarding established eradications in 1999, 418 out of 659 (63%) followed the recommendations made by the Spanish Club, while 241 (37%) did not. In 2000, the proportion of eradication therapy administered using the recommendations made by the Spanish Club was similar to previous year: 338 (63%) followed the recommendations, against 199 (37%) that did not (p = not significant). In both years, considering those indications not recommended, patients either with superficial chronic gastritis with or without dyspepsia or with gastrooesophageal reflux disease were the main disorders to indicate eradication therapy.The recommendations of the Spanish Helicobacter pylori Study Club have not triggered a significant change after their publication on the indications for Helicobacter pylori eradication therapy in the setting studied.

To evaluate any differences in rectal distension perception between healthy subjects and patients with irritable bowel syndrome (IBS) according to an isobaric distension protocol (progressive or phasic).10 healthy subjects and 41 patients with IBS (Rome II criteria). Rectal distension was performed using a barostat connected to a 500 mL bag, and a progressive distension protocol (continuous distension at a rate of 0.36 mmHg/sec) was compared to phasic distension protocol (distensions for 60 sec with 4 mmHg increases separated by 0 mmHg pressures during 60 sec). Perception was evaluated using three descriptive scales of 7 categories each for perception type, intensity, and affectivity. Perception thresholds were assessed.No significant differences in any perception thresholds were found between control subjects and IBS patients using a progressive distension protocol. Differences in the perception of inconvenient distension and maximum tolerable distension were encountered with the phasic distension protocol. Uncomfortable distension thresholds below those of controls were found in 48.8% of patients with IBS when a phasic distension protocol was used, versus only 9.7% with a progressive protocol.Hypersensitivity in patients with IBS is mainly seen with the use of phasic distension isobaric protocols for affective negative perceptions.

Usually, cytomegalovirus infection dosen't cause symptoms in immunocompetents patients although sometimes can. In alcoholic and cirrhotic subjects can cause several and fatal infections. We describe a case of disseminated cytomegalovirus infection in an alcoholic patient with excellent response to ganciclovir.

To assess long-term outcome for patients with chest pain in our environment, to estimate direct resource use, and to evaluate the influence of patient views regarding pain origin on outcome.All patients referred to our Department between 1994 and 1998 to undergo pH-metry as a result of chest pain were identified. Those detected were subjected to a structured direct interview on the telephone.104 patients with a follow-up period (since pH-metry) of 3.76 years were evaluated. Thirty nine percent of patients were free from pain (37.5%), and one had died from a seemingly unrelated cause (1%), whereas the rest still suffered from pain. The mean number of visits per patient during the last year was 2.83 to their general practitioner, 1.04 to an specialist, and 0.99 to an Emergency Unit; hospitalisations were 0.26, and ICU admissions 0.09. Patients who trusted medical diagnoses showed better outcomes than those who did not trust or understand them, in association with lower resource use, particularly Emergency Unit use.Patients with chest pain had a favourable life prognosis, but 60% still suffer from pain after nearly 4 years of follow-up, which entails a relevant use of health-care resources. Trust in medical diagnosis seemingly influences outcome, and the use of diagnostic procedures to determine pain origin is thus likely beneficial for patient.

La infección por citomegalovirus en pacientes inmunocompetentes suele ser asintomática. Los pacientes inmunodeprimidos pueden presentar cuadros severos con mala respuesta al tratamiento. Presentamos el caso de un paciente alcohólico con infección diseminada por citomegalovirus con excelente respuesta al tratamiento con ganciclovir.

The last few years have witnessed radical changes in medical practices due to scientific and technological developments, the population's demands, the evolution of the economy, the optimisation of resources, the Media, not forgetting the major ethical, legal and political aspects, which have changed considerably in just a few years. Basic training, specialised training and ongoing training must allow doctors to assume many of these changes, although in general in should be they who are willing to put such changes into practice. Education and training should be modified to make it easier and faster to assume these changes. Medicine is no longer what it used to be: instead of being limited, knowledge is now boundless, instead of working alone, doctors now work in teams, instead of only the doctor having the information, patients now have it too. There has been a move from the ethics of welfare to the ethics Of autonomy, from problem-free spending to cost containment, from the demand for relief to the demand for treatment and healing, from a call for health to a call for quality of health, from non-judicialisation, and so on and so forth. All these factors have clearly affected the structure of medicine, and it is not surprising that nowadays there is more talk about the prestige of medicine that the prestige of the doctor, as occurred not so many years ago. There is really no substitute for individual attitudes to this situation. The article contains certain considerations about how current changes are affecting doctor's attitudes and the need not only to accept the change but also to lead it. The competitive doctor of today must meet a broad spectrum of requirements, ranging from initiative and flexibility to technological know-how-and capacity. Nowadays society is moving towards a situation in which it not only demands and expects these conditions from its leaders but also from all doctors. Patients have an increasingly higher level of education and, as such, are becoming more demanding because they have tools with which to compare and demand more from doctors.

Cutaneous Electrogastrography (EGGc) is a technique used for recording the Gastric Electrical Activity by means of electrodes placed on the abdominal skin. The aim of the present study was to determine normal values in healthy volunteers as well as the influence of factors such as age, gender, Body Mass Index (BMI) and echographic location of the gastric antrum.An abdominal echography was initially performed in 35 of the 44 healthy volunteers in order to locate the gastric antrum and to place along its axis the skin electrodes, whereas in the other 9, the electrodes were placed according to anatomical references. Afterwards, the echography was also performed in those 9 volunteers in order to have all the 44 baseline echographic records. In every case, a record of ambulatory EGGc over 60 minutes was obtained, along with other record over the same period after eating a standard meal. The analysis of data was conducted through visual inspection and combined computer analysis.Eighty per cent of the study subjects showed a dominant frequency ranging from 2 to 4 cpm during both periods. After the meal, the parameters showed a characteristic variation. A significant difference was found when comparing subjects under 40 years of age versus subjects between 40 and 60 years of age in terms of preprandial dominant frequency instability coefficient (DFIC) (p = 0.002) and bradygastria (p = 0.03). Subjects with BMI25 kg/m2 showed preprandially a smaller dominant power instability coefficient (DPIC) (p = 0.035) and a greater Dominant Power (DP) (p = 0.045). In subjects without echographic control, DFIC (p = 0.001), bradygastria (p = 0.016) and tachygastria (p = 0.02) were more frequent, with a shorter period of normogastria (p = 0.001) during the postprandial period.Normogastria is the predominant rhythm in healthy people, although brief dysarrhythmias can be recorded that do not have any pathological meaning. Age and BMI, but not sex, seem to influence the Gastric Electrical Activity. The percentage of gastric dysarrhythmias decreases when the electrodes are placed along the longitudinal axis of the gastric antrum through echographic control.

Cutaneous electrogastrography (cEGG) is a technique used for recording gastric electrical activity through electrodes placed on the abdominal skin. Given its increasing use for different pathologies, we decided to study its reliability (or reproducibility), that had never been appropriately assessed before.Ambulatory cutaneous electrogastrogram was recorded after US location of the gastric antrum in 26 healthy volunteers with ages ranging from 20 to 60 years. cEGG was recorded during 60 minutes in fasting state and 60 minutes after a standard meal and it was repeated in a different day but under the same conditions.ANOVA analysis showed significant individual differences regarding dominant frequency (DF) (p = 0.19) and power ratio (PR) (p = 0.11), and before and after the meal, except for DF (p = 0.12), dominant power (DP) (p = 0.59) and bradygastria (p = 0.09). No significant differences were found related to the day of the recording. The intra-observer agreement index showed a good agreement in the DF and the percentage of normogastria (0.91).Currently, DF and normogastria percentage are the most reliable variables for the non-invasive study of gastric electric activity.

Hemochromatosis is a disorder of parenchymal iron overload. The diagnosis is based upon clinical manifestations, laboratory findings and iron concentration in liver. Magnetic resonance imaging (MRI) shows a decrease in liver signal intensity. Its role has not been already defined. Nonetheless, ratio of liver to muscle proton density (LMPD) shows a significant correlation with hepatic iron. One patient with a long-standing cirrhosis with data of hemochromatosis whose coagulation study did not allow to perform a liver biopsy was diagnosed with this method. Hepatic iron concentration was calculated based upon: microgram/g of hepatic iron = (-5.174* LMPD) + 9.932. MRI can be useful in the evaluation of hemochromatosis among patients who refuse or have contraindication to liver biopsy.

although the etiology of ulcerative colitis disease remains an enigma, the importance of the major histocompatibility complex genes has been described, as in many other autoimmune diseases.we investigated the contribution of HLA-DRB1, DQA1 and DQB1 genes (HLA region) in patients with pancolitis.we studied a total of 89 patients diagnosed as having ulcerative colitis (34 pancolitis and 55 left colitis) and 275 healthy control subjects. Complete information on sex, age, family history, age of onset, localization, complications, surgery and treatment was obtained from all patients. DNA was extracted from peripheral blood leukocytes and all individuals were HLA-DRB1 genotyped.there was an association between pancolitis and the presence of DR4-Val86 (p = 0.009; OR = 3.3) and DRB1*0103 (p = 0.02; OR = 5.1) alleles. In patients with left colitis an association with DRB1*1501 (p = 0.03; OR = 1.9) and DRB1*0103 alleles (p = 0.03; OR = 3.8) was observed. We conclude that a strong association between DR4-Val86 and pancolitis exists.

We report the case of a previously well 89-years-old-healthy man who presented at least four episodes of intermittent obstructive jaundice during the eight months prior to admission in our Hospital. Studies revealed a duodenal diverticulum arising near of the ampulla of Vater. We believed the diverticulum was responsible for the intermittent obstructive jaundice and we performed a choledochoduodenostomy. He had no postoperative complications and was discharged from the hospital asymptomatic. This case documents an uncommon presentation of this disease generally asymptomatic with intermittent obstructive jaundice episodes.