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Non-steroidal antiinflammatory drugs (NSAIDs) are currently one of the most widely used drugs. The use of NSAIDs is associated with gastrointestinal toxicity, affecting both upper gastrointestinal tract (peptic ulcer disease) and lower gastrointestinal tract (NSAID-induced enteropathy). NSAIDs use has been associated with an increased risk of clinical relapse in inflammatory bowel disease patients. In this article, we review the upper and lower gastrointestinal toxicity of NSAIDs, with a focus on the risks and specific data of these drugs in inflammatory bowel disease patients, giving recommendations for its appropriate use in the clinical practice. Although evidence is scarce, short-term use of NSAIDs appears to be safe, and the data available suggest that selective COX-2 inhibitors are the safer option. NSAIDs should be avoided as long-term treatment or with high doses, especially in patients with active inflammation.

Non-steroidal antiinflammatory drugs (NSAIDs) are currently one of the most widely used drugs. The use of NSAIDs is associated with gastrointestinal toxicity, affecting both upper gastrointestinal tract (peptic ulcer disease) and lower gastrointestinal tract (NSAID-induced enteropathy). NSAIDs use has been associated with an increased risk of clinical relapse in inflammatory bowel disease patients. In this article, we review the upper and lower gastrointestinal toxicity of NSAIDs, with a focus on the risks and specific data of these drugs in inflammatory bowel disease patients, giving recommendations for its appropriate use in the clinical practice. Although evidence is scarce, short-term use of NSAIDs appears to be safe, and the data available suggest that selective COX-2 inhibitors are the safer option. NSAIDs should be avoided as long-term treatment or with high doses, especially in patients with active inflammation.

Background: Flexible endoscopy allows use of the vessel–tissue sealer Ligasure™ (Covidien, Massachusetts, USA) to perform diverticulotomy. Few studies have used this endoscopic approach in the uncommon disorder Zenker's diverticulum. The aim of the present study was to evaluate the effectiveness and safety of flexible endoscopy treatment assisted by Ligasure™. Methods: The single-center prospective and descriptive study included patients treated by flexible endoscopy using Ligasure™ for resection of Zenker’s diverticulum. Consecutive patients were included from March 2009 to April 2018. Patients were censored until the end of follow-up or death. Complications, symptoms before treatment, type of sedation, and number of interventions needed to resolve Zenker’s diverticulum were analyzed. Bleeding complications were considered when a case required a second endoscopy. Results: A total of 46 symptomatic patients with Zenker''s diverticulum were included in the final analysis (41.3% women, median age of 73.7 ± 11 years). The median follow-up period was 37.21 ± 28 months. Of all cases, 58.7% were considered small (< 3 cm). Solid or semi-solid food-related dysphagia was present in 55.6% of patients previously to the procedure. The technique was successful in a single procedure in 78.3% of cases. However, the success rate increased to 89.1% with a second procedure, and we had a complication rate of 4.3% with this technique. Most patients (79.66%) were managed as out-patients or with short (< 24 h) admission. Conclusion: In this large case series, treatment of Zenker''s diverticulum based on flexible endoscopy assisted by Ligasure™ was a safe and effective procedure with a high success rate in a few endoscopy sessions and low complication rate.

Most colonoscopies performed to evaluate gastrointestinal symptoms detect only non-relevant pathologies. We aimed to evaluate the diagnostic accuracy of a qualitative point-of-care (POC) test combining four biomarkers (haemoglobin, transferrin, calprotectin, and lactoferrin), a quantitative faecal immunochemical test (FIT) for haemoglobin, and a quantitative faecal calprotectin (FC) test in symptomatic patients prospectively recruited. Colorectal cancer (CRC), adenoma requiring surveillance, inflammatory bowel disease (IBD), microscopic colitis, and angiodysplasia were considered significant pathologies. A total of 571 patients were included. Significant pathology was diagnosed in 118 (20.7%), including 30 CRC cases (5.3%). The POC test yielded the highest negative predictive values: 94.8% for a significant pathology and 100% for CRC or IBD if the four markers turned negative (36.8% of the patients). Negative predictive values of FIT, FC, and its combination for diagnosis of a significant pathology were 88.4%, 87.6%, and 90.8%, respectively. Moreover, the positive predictive value using the POC test was 82.3% for significant pathology when all biomarkers tested positive (6% of the patients), with 70.6% of these patients diagnosed with CRC or IBD. The AUC of the POC test was 0.801 (95%CI 0.754-0.848) for the diagnosis of a significant pathology. Therefore, this POC faecal test allows the avoidance of unnecessary colonoscopies and prioritizes high risk symptomatic patients.

INTRODUCCIÓNLa bacteria Helicobacter pylori infecta aproximadamente a la mitad de la población mundial, y puede producir patología como dispepsia, úlcera gástrica y/o duodenal y cáncer gástrico, principales indicaciones de tratamiento. Existen métodos diagnósticos invasivos (basados en la gastroscopia) como es la histología, y otros métodos no invasivos como son el test de urea en aire espirado o la detección de antígeno en heces. El tratamiento se basa en un inhibidor de la bomba de protones (IBP) asociado a 2 o 3 antibióticos, tomados de 7 a 14 días. El aumento en la resistencia bacteriana en las últimas décadas ha conducido a un cambio constante en las recomendaciones terapéuticas por parte de los comités de expertos para poder mantener cifras aceptables de eficacia o incluso mejorarla. En Aragón apenas hay estudios recientes sobre eficacia y resistencia bacteriana, y el conocimiento de éstos a nivel local permite la elección del tratamiento más adecuado.OBJETIVOSDeterminar la eficacia de los distintos tratamientos en nuestra área sanitaria. Describir el manejo clínico de los pacientes infectados y analizar su adecuación a guías clínicas. Analizar la asociación e influencia de distintas variables sociodemográficas y clínicas sobre la eficacia. Evaluar la capacidad diagnóstica de distintos métodos diagnósticos y su concordancia. Evaluar las tasas de resistencia antibiótica.MÉTODOSSe realizó un estudio descriptivo retrospectivo de pacientes diagnosticados de infección por Helicobacter pylori y tratados por primera vez entre 2010 y 2019, ambos incluidos, en dos centros de Aragón (Hospital clínico universitario Lozano Blesa de Zaragoza y Hospital general Obispo Polanco de Teruel), que recogió la práctica clínica diaria: síntomas, métodos diagnósticos, tratamientos prescritos y su eficacia. Se hizo análisis descriptivo y estudio de asociación entre eficacia y otras variables con el estadístico Chi Cuadrado, y se obtuvo la influencia de dichas variables sobre la eficacia mediante Odds ratio tras análisis de regresión logística. Por otro lado, se realizó un estudio prospectivo de análisis de muestras obtenidas mediante gastroscopia para evaluar concordancia entre distintos métodos diagnósticos (mediante kappa de Cohen) y realizar antibiograma para evaluación de las resistencias.RESULTADOSSe evaluaron 1730 pacientes con una edad media de 50,5 años. El 59,8% fueron mujeres y el 58% menores de 55 años. La gastroscopia fue el método diagnóstico más utilizado (70,1%), seguido del test de aliento (28,8%).Los pacientes recibieron entre 1 y 5 líneas de tratamiento, aplicándose un total de 2260 tratamientos, el 58% de ellos indicados por dispepsia y el 16% por úlcera. A principios de la década se usaron más las pautas triples como ICA (IBP+claritromicina+amoxicilina) o ICL (IBP+claritromicina+levofloxacino) en alérgicos a penicilina, pero a partir de 2014 aumentó el uso de terapias cuádruples como ICAM (IBP+claritromicina+amoxicilina+metronidazol), y a partir de 2016 comenzó el uso de IPylera® (IBP+Pylera® (unicápsula 3en1 que contiene subcitrato de bismuto+metronidazol+tetraciclina).La eficacia global por intención de tratar tras una primera línea de tratamiento fue del 69,8%, siendo mayor con las terapias cuádruples ICAM e IPylera®, que alcanzaron el 84,5% al optimizar su prescripción (aumentando la duración del tratamiento y utilizando IBPs de nueva generación). La eficacia también fue mayor al utilizar tratamientos recomendados en las guías clínicas, si bien la adecuación de los tratamientos de primera línea a las guías en pacientes no alérgicos fue del 76,4%, usándose en ocasiones tratamientos no recomendados y tratando patologías sin indicación de tratamiento (como rosácea o corioretinopatía). No hubo diferencias de eficacia entre los dos centros ni entre los dos grupos de edad establecidos, salvo con la terapia ILA (IBP+levofloxacino+amoxicilina), que fue tanto en primera como en segunda línea más eficaz en menores de 55 años que en pacientes superando esa edad. La eficacia fue un 5% mayor en hombres que en mujeres no alérgicos a penicilina (p=0,021).La terapia de segunda línea más utilizada en no alérgicos a penicilina fue la triple con levofloxacino ILA hasta 2016 cuando comenzó a usarse IPylera®, con eficacia mayor del 70%. La edad influyó en la eficacia, siendo un 14% más alta en los pacientes menores de 55 años (p=0,006).Un 2,5% de los pacientes abandonaron en algún momento el seguimiento clínico, teniendo más probabilidad los hombres, los menores de 55 años, y los diagnosticados mediante test de aliento.En el segundo bloque, la parte prospectiva del estudio, se incluyeron finalmente a 66 pacientes. Los test diagnósticos con mayor concordancia y sensibilidad fueron la reacción en cadena de la polimerasa (PCR) de tejido gástrico y la histología. El cultivo tuvo una sensibilidad menor al 70% debido a sobrecrecimiento bacteriano. La resistencia primaria a claritromicina fue del 11,1% y a metronidazol del 44,4%, aunque un 31,7% de los casos presentaron sensibilidad a todos los antibióticos.CONCLUSIONESEl manejo de la infección es heterogéneo entre centros, y en ocasiones discrepante con las recomendaciones de las sociedades científicas. La mayor eficacia en nuestra muestra se ha alcanzado con ICAM y con IPylera®, confirmando así su alta eficacia en nuestro medio, si bien la eficacia de los tratamientos en práctica clínica real aún no alcanza el 90%. El uso de terapias triples debería abandonarse por influir negativamente en la eficacia. El tratamiento con la triple terapia de levofloxacino ha sido menos eficaz en mayores de 55 años que en menores, por lo que desaconsejamos su uso en este grupo de pacientes, al menos en primera y segunda línea de tratamiento. Debería prescribirse siguiendo las recomendaciones de las guías en cuanto a fármacos y duración para obtener mayor eficacia. La resistencia bacteriana antibiótica ha aumentado en la última década..

El uso de endoscopios atravesando cavidades endoluminales, es habitual para el diagnóstico y tratamiento de enfermedades gastrointestinales. En los últimos años, gracias al avance de la Inteligencia Artificial han surgido nuevos colonoscopios que han permitido un gran avance en el diagnóstico y tratamiento endoscópico. Sin embargo, estos instrumentos carecen de capacidad para realizar una cartografía en tiempo real de las cavidades por donde navegan, y de su ubicación respecto de esa cartografía. El seguimiento y mapeo real de estructuras se basa en la tecnología v-SLAM, sin embargo, esta tecnología está diseñada para mapear estructuras rígidas, no deformables. El objetivo principal de nuestro trabajo de investigación será rediseñar esta tecnología v-SLAM para cavidades no rígidas y deformables como el tracto gastrointestinal.El resultado de este trabajo será un nuevo paradigma de investigación que denominaremos EndoMapper y que permitirá abordar la localización y el mapeo en tiempo real de cavidades del cuerpo humano, utilizando solo el video de un endoscopio monocular estándar.Nuestra metodología de investigación incluirá la explotación masiva de las imágenes obtenidas a partir de endoscopias que se realizan rutinariamente en Servicio de Endoscopias del Hospital Clínico Lozano Blesa de Zaragoza. Por una parte, estas grabaciones permitirán la inclusión de técnicas de aprendizaje profundo (Deep Learning) en EndoMapper y por otra parte para la validación experimental de los resultados obtenidos.

Introducción: La doble antiagregación plaquetaria (DAP) ha demostrado disminuir la incidencia de eventos cardiovasculares tras síndrome coronario agudo. Clásicamente se ha basado en ácido acetil salicílico (AAS) y clopidogrel, pero la variabilidad individual en la respuesta a clopidogrel ha favorecido el desarrollo de nuevos antiagregantes (NA), prasugrel y ticagrelor, que han demostrado ser más eficaces. Sin embargo, en los estudios de registro los NA se han asociado con un incremento del riesgo hemorrágico global, lo cuál ha limitado su uso a pacientes muy seleccionados y con menos comorbilidades y, por lo tanto, no utilizándolos en los pacientes con mayor riesgo que son los que más se beneficiarían. Destaca una gran variabilidad en el diseño y resultados de los estudios que pretenden evaluar el riesgo hemorrágico asociado a estos fármacos y no existe ningún estudio que compare el riesgo específico de hemorragia gastrointestinal (GI) de la DAP basada en los NA con respecto a clopidogrel. Hipótesis: la DAP basada en NA incrementa el riesgo de sangrado GI con respecto a clopidogrel, tras angioplastia coronaria percutáneaObjetivos: Primario: determinar y comparar la frecuencia de eventos GI mayores y menores durante 12 meses tras angioplastia coronaria en pacientes con DAP basada en prasugrel, ticagrelor o clopidogrel. Secundarios: comparar características demográficas entre grupos de tratamiento. Analizar tipo de hemorragia GI y origen. Determinar actitud con respecto a DAP tras evento GI. Analizar la utilización de inhibidores de la bomba de protones (IBP)Metodología: estudio de cohortes retrospectivo en el que se incluyeron pacientes que iniciaron DAP tras una angioplastia coronaria percutánea entre el 1 de enero de 2015 y el 31 de diciembre de 2016. A través de la historia clínica electrónica se recogieron datos demográficos y la aparición de eventos de interés: evento GI mayor (hemorragia GI), evento GI menor (anemia y/o ferropenia), eventos isquémicos, otros eventos hemorrágicos no GI y muerte. El seguimiento finalizó a los 12 meses de inicio del tratamiento, ante la aparición de un evento GI mayor, cuando la DAP se interrumpió de forma definitiva o si el paciente falleció.Resultados: Se incluyeron 1327 pacientes, 54% iniciaron DAP basada en clopidogrel y 45,9% basada en NA. En el grupo de pacientes tratados con AAS y clopidogrel hubo significativamente menor proporción de varones (73,5% vs 80,7%; p = 0,002), pacientes de mayor edad (edad media 71,4 vs 61,5; p < 0,001), así como más comorbilidad (media del índice de Charlson 4,2 vs 1,9; p Conclusión: Más de uno de cada cuatro pacientes tratados con DAP presenta un evento GI en el seguimiento, sin diferencias en la incidencia según pauta de tratamiento (DAP basada en NA vs clopidogrel), por lo que en base al riesgo GI la indicación de NA podría extenderse a población menos seleccionada

The risk for gastrointestinal bleeding from dual antiplatelet therapy (DAPT) with new antiplatelets (prasugrel/ticagrelor) compared to clopidogrel is unclear. Aim: To determine the risk and type of major (gastrointestinal bleeding requiring hospitalization) and minor (anemia and iron deficiency) gastrointestinal events with different types of DAPT. Methods: Retrospective observational cohort study of patients who started DAPT after percutaneous coronary intervention. Follow-up was censored after 12 months of DAPT, when a major gastrointestinal event occurred, or when DAPT was discontinued. Results: Among 1,327 patients (54.03% were treated with clopidogrel-based DAPT, 38.13% with ticagrelor-based DAPT, and 7.84% with prasugrel-based DAPT), 29.5% had at least one gastrointestinal event. Patients taking clopidogrel-DAPT were older, with more comorbidities, and higher gastrointestinal risk compared to those taking other DAPT regimens. Adjusted hazard ratios (HRs) showed no between-group differences in the risk for major (clopidogrel vs. new antiplatelets: HR 0.996, 95% confidence interval 0.497&ndash, 1.996) and minor (HR 0.920, 0.712&ndash, 1.189) gastrointestinal events. Most patients received proton pump inhibitors while on DAPT (93.3%) and after withdrawal (83.2%). Conclusion: Prasugrel- or ticagrelor-based DAPT was not associated with increased gastrointestinal bleeding risk when compared to clopidogrel-DAPT. New antiplatelets do not necessarily need to be restricted to patients with low gastrointestinal risk.

Cardiovascular disease is the most important cause of morbidity and mortality in the world and low-dose aspirin is considered the cornerstone of the cardiovascular disease prevention. However, low-dose aspirin use is associated with gastrointestinal adverse effects in the whole gastrointestinal tract. In this setting, co-therapy with a proton pump inhibitor is the most accepted strategy to reduce aspirin related upper gastrointestinal damage. In addition, some adverse effects have been described with proton pump inhibitors long term use. Areas covered: Low-dose aspirin related beneficial and adverse effects in cardiovascular system and gastrointestinal tract are reviewed. In addition, this manuscript summarizes current data on upper gastrointestinal damage prevention and adverse events with proton pump inhibition. Finally, we discuss the benefit/risk ratio of proton pump inhibitor use in patients at risk of gastrointestinal damage taking low-dose aspirin. Expert commentary: Nowadays, with the current available evidence, the combination of low-dose aspirin with proton pump inhibitor is the most effective therapy for cardiovascular prevention in patients at high gastrointestinal risk. However, further studies are needed to discover new effective strategies with less related adverse events.

19 pags., 7 figs., 2 tabs. -- This article belongs to the Special Issue Gastrointestinal Cancers and Personalized Medicine, Background: Current efforts in the identification of new biomarkers are directed towards an accurate differentiation between benign and premalignant cysts. Thermal Liquid Biopsy (TLB) has been previously applied to inflammatory and tumor diseases and could offer an interesting point of view in this type of pathology. Methods: In this work, twenty patients (12 males and 8 females, average ages 62) diagnosed with a pancreatic cyst benign (10) and premalignant (10) cyst lesions were recruited, and biological samples were obtained during the endoscopic ultrasonography procedure. Results: Proteomic content of cyst liquid samples was studied and several common proteins in the different groups were identified. TLB cyst liquid profiles reflected protein content. Also, TLB serum score was able to discriminate between healthy and cysts patients (71% sensitivity and 98% specificity) and between benign and premalignant cysts (75% sensitivity and 67% specificity). Conclusions: TLB analysis of plasmatic serum sample, a quick, simple and non-invasive technique that can be easily implemented, reports valuable information on the observed pancreatic lesion. These preliminary results set the basis for a larger study to refine TLB serum score and move closer to the clinical application of TLB providing useful information to the gastroenterologist during patient diagnosis., This research was funded by the Spanish Ministry of Economy and Competitiveness and European ERDF Funds (MCIU/AEI/FEDER, EU) (BFU2016-78232-P to A.V.C.); Projects funded by Instituto de Salud Carlos III and co-funded by European Union (ESF, ”Investing in your future”): “PI15/00663 (FIS project to O.A)”, “PI18/00349 (FIS project to O.A. and Contract to LC)”, “FI19/00146 (PFIS contract for SHD)”, “CPII13/00017 (Miguel Servet Program to OA)”; Diputación General de Aragón (Protein Targets and Bioactive Compounds Group E45_17R to A.V.C. and Digestive Pathology Group B25_17R to O.A.); and the Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd).

La inmunoterapia es una herramienta cada vez más utilizada en el campo de la oncología. Conviene conocerla debido a sus crecientes usos, entre los que se incluye el tratamiento de tumores del aparato digestivo (hepatocarcinoma1, adenocarcinoma colorrectal con alta inestabilidad en microsatelites2) así como por las reacciones adversas que con elevada frecuencia afectan al tubo digestivo. Presentamos el caso de un varón de 74 años, con antecedentes personales de enfermedad pulmonar obstructiva crónica (EPOC) y melanoma con metástasis pulmonares. Debido a estas patologías tomaba de manera habitual inhaladores de salbutamol y había estado en tratamiento con nivolumab, suspendido hacía cuatro meses tras conseguir una respuesta radiológica completa de las metástasis pulmonares. El paciente refería cuadro diarreico de un mes de evolución, consistente en tres a cuadro deposiciones (Bristol 5-6) sin productos patológicos, que afectaban el descanso nocturno, asociaban molestias centroabdominales intermitentes y pérdida de peso de unos 3-4 kg. No había ingerido alimentos crudos, antibióticos o nuevas medicaciones. Tampoco había convivientes con la misma sintomatología ni había realizado viajes al extranjero. Negaba cualquier otra sintomatología y antecedentes familiares de interés. La exploración física era anodina a excepción de unas ligeras molestias a la palpación profunda en mesogastrio...

Presentamos el caso de una paciente, mujer, de 67 años, sin antecedentes de interés ni hábitos tóxicos. Ingresó al Servicio de Aparato Digestivo por un cuadro clínico de dolor epigástrico de seis días de evolución, por el que ya había consultado en Urgencias cinco días antes, siendo dada de alta a domicilio por la normalidad de las pruebas complementarias (analítica, ecografía abdominal) y el buen control del dolor con analgesia. En esta ocasión, en la analítica presentaba una leve elevación de enzimas hepáticas (AST 64 U/L, ALT 104 U/L, GGT 143 U/L, fosfatasa alcalina 187 U/L) y elevación de reactantes de fase aguda (proteína C reactiva > 350 mg/L, fibrinógeno 1.000 mg/dL), la ecografía abdominal fue nuevamente normal. Durante el ingreso se consiguió un buen control del dolor, permaneciendo la paciente con buen estado general y para completar el estudio, se solicitó una tomografía computarizada (TC) abdominal que se realizó al cuarto día de ingreso. En dicha prueba, se objetivó una colección intraabdominal con un nivel hidroaéreo, de gran tamaño (12 x 14 cm) en contacto con lóbulo hepático izquierdo y antro gástrico (figs. 1A-1B)...

Helicobacter pylori (Hp) infection is the main cause of peptic ulcer and gastric cancer. Hp eradication rates have fallen due to increasing bacterial resistance to currently used broad-spectrum antimicrobials. We have designed, synthesized, and tested redox variants of nitroethylene- and 7-nitrobenzoxadiazole-based inhibitors of the essential Hp protein flavodoxin. Derivatives of the 7-nitrobenzoxadiazole lead, carrying reduced forms of the nitro group and/or oxidized forms of a sulfur atom, display high therapeutic indexes against several reference Hp strains. These inhibitors are effective against metronidazole-, clarithromycin-, and rifampicin-resistant Hp clinical isolates. Their toxicity for mice after oral administration is low, and, when administered individually at single daily doses for 8 days in a mice model of Hp infection, they decrease significantly Hp gastric colonization rates and are able to eradicate the infection in up to 60% of the mice. These flavodoxin inhibitors constitute a novel family of Hp-specific antimicrobials that may help fight the constant increase of Hp antimicrobial-resistant strains., J.S. was supported by grant BFU2016-78232-P (MINECO, Spain) and E45_17R (Gobierno de Aragón, Spain). A.L. was supported by grant PI11/02578 (MICINN, Spain). S.S. and A.M. are recipients of predoctoral fellowships from the Aragonese and Spanish Governments, respectively.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most numerous category of drugs sharing the same mechanism of action and therapeutic activities (anti-inflammatory, analgesic and anti-pyretic). Despite having similar efficacy for pain relieve, the different available NSAIDs show variability in its safety profile. The risk of gastrointestinal and cardiovascular complications varies depending on the dose of NSAID and also the presence of different risk factors. It is necessary, therefore, an individualized case assessment before establishing the indication of the best NSAID for each patient, taking account of the best gastroprotection strategy. Improved prescription and enhanced treatment adherence are central objectives to reduce NSAID-related complications. A recent consensus of the Spanish Association of Gastroenterology and the Spanish societies of Cardiology and Rheumatology intends to promote the rational use of NSAIDs according to new recent studies. This review provides additional aspects to facilitate the optimal decision-making process in the routine use of these drugs in clinical practice.

Resumen Los antiinflamatorios no esteroideos (AINE) configuran la familia mas numerosa de farmacos que comparten los mismos mecanismos de accion y actividades terapeuticas (antiinflamatoria, analgesica y antipiretica). A pesar de tener una eficacia similar para controlar el dolor, los diferentes AINE disponibles presentan variabilidad en su perfil de seguridad. El riesgo de complicaciones gastrointestinales y cardiovasculares varia en funcion del AINE y de la dosis que utilicemos, ademas de la presencia de factores de riesgo. Es necesaria una evaluacion individualizada de cada caso antes de sentar tanto la indicacion del AINE «ideal» como la estrategia de prevencion gastrointestinal si fuera necesaria. Una correcta prescripcion y una adecuada adherencia al tratamiento gastroprotector son los objetivos que hay que plantearse para conseguir reducir las complicaciones secundarias al tratamiento con AINE. Recientemente se han publicado unas recomendaciones de prescripcion adecuada fruto de la colaboracion de la Asociacion Espanola de Gastroenterologia y las sociedades espanolas de Reumatologia y Cardiologia que tiene por objeto impulsar un uso racional de los AINE en funcion de los ultimos estudios publicados. Esta revision completa aspectos adicionales necesarios para facilitar la toma de decisiones optima en el uso habitual de estos farmacos en la practica clinica diaria.

Background Patients with gastrointestinal bleeding during anticoagulant and/or antiplatelet therapy represent a clinical challenge. Aim To determine the risk/rates of rebleeding, vascular events and death in patients treated with antiplatelet or anticoagulant agents who developed major gastrointestinal bleeding METHODS: This was an observational cohort study of patients who developed gastrointestinal bleeding while on antiplatelet and/or anticoagulant therapy. Drug use information was collected prospectively during bleeding events. Cox proportional hazards models were used to evaluate rebleeding, vascular events and death. Results Among 871 patients (mean age 78.9 ± 8.6 years), 38.9% used an anticoagulant, 52.5% used an antiplatelet and 8.6% used both; 93.1% interrupted treatment after gastrointestinal bleeding and 80.5% restarted therapy within 7.6 ± 36.4 days; 38.7% had upper gastrointestinal bleeds, 46.7% lower gastrointestinal bleeds and 14.6% gastrointestinal bleeds of unknown origin. Median follow-up was 24.9 months (IQR: 7.0-38.0). Resumption of both therapies was associated with a higher risk of rebleeding, lower risk of ischaemic events or death and a similar risk for upper and lower gastrointestinal events. Resumption of therapy ≤ 7 days after bleeding showed a similar pattern with no differences in death. Rebleeding rates were higher in anticoagulant vs antiplatelet patients (138.0 vs 99.0 events per 1000 patient-years), and the bleeding location was identical in 61.8% of cases. Conclusions Resumption of anticoagulant or antiplatelet therapy after a gastrointestinal bleeding event was associated with a lower risk of vascular events and death and a higher rebleeding risk. The benefits of early reinstitution of anticoagulant/antiplatelet therapy outweigh the gastrointestinal-related risks.

No abstract available Keywords: Dyspepsia; Helicobacter pylori; Peptic ulcer; Stomach diseases.

T1 colorectal polyps with at least 1 risk factor for metastasis to lymph node should be treated surgically and are considered endoscopically unresectable. Optical analysis, based on the Narrow-Band Imaging International Colorectal Endoscopic (NICE) classification system, is used to identify neoplasias with invasion of the submucosa that require endoscopic treatment. We assessed the accuracy of the NICE classification, along with other morphologic characteristics, in identifying invasive polyps that are endoscopically unresectable (have at least 1 risk factor for metastasis to lymph node).We performed a multicenter, prospective study of data collected by 58 endoscopists, from 1634 consecutive patients (examining 2123 lesions) at 17 university and community hospitals in Spain from July 2014 through June 2016. All consecutive lesions10 mm assessed with narrow-band imaging were included. The primary end point was the accuracy of the NICE classification for identifying lesions with deep invasion, using findings from histology analysis as the reference standard. Conditional inference trees were fitted for the analysis of diagnostic accuracy.Of the 2123 lesions analyzed, 89 (4.2%) had features of deep invasion and 91 (4.3%) were endoscopically unresectable. The NICE classification system identified lesions with deep invasion with 58.4% sensitivity (95% CI, 47.5-68.8), 96.4% specificity (95% CI, 95.5-97.2), a positive-predictive value of 41.6% (95% CI, 32.9-50.8), and a negative-predictive value of 98.1% (95% CI, 97.5-98.7). A conditional inference tree that included all variables found the NICE classification to most accurately identify lesions with deep invasion (P.001). However, pedunculated morphology (P.007), ulceration (P = .026), depressed areas (P.001), or nodular mixed type (P.001) affected accuracy of identification. Results were comparable for identifying lesions that were endoscopically unresectable.In an analysis of 2123 colon lesions10 mm, we found the NICE classification and morphologic features identify those with deep lesions with96% specificity-even in non-expert hands and without magnification. ClinicalTrials.gov number NCT02328066.

Helicobacter pylori (H. pylori) infection and NSAID/low-dose aspirin (ASA) use are associated with peptic ulcer disease. The risk of peptic ulcer bleeding (PUB) associated with the interaction of these factors remains unclear. The objective of this study was to determine the risk of PUB associated with the interaction between H. pylori infection and current nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose ASA use.This was a case-control study of consecutive patients hospitalized because of PUB. Controls were matched by age, sex, and month of admission. H. pylori infection status was determined in all cases and controls by serology. Drug use was determined by structured questionnaire. Adjusted relative risk (RR) associated with different factors, and the interaction between NSAID/ASA and H. pylori infection was estimated by logistic regression analysis.The study included 666 cases of PUB and 666 controls; 74.3% cases and 54.8% controls (RR: 2.6; 95% confidence interval (CI): 2.0-3.3) tested positive for H. pylori infection; 34.5% of cases had current NSAID use compared with 13.4% of controls (RR: 4.0; 95% CI: 3.0-5.4). Respective proportions for low-dose ASA use were 15.8 and 12%, respectively (RR: 1.9; 95% CI: 1.3-2.7). The RR of PUB for concomitant NSAID use and H. pylori infection suggested an additive effect (RR: 8.0; 95% CI: 5.0-12.8), whereas no interaction was observed with ASA use (RR: 3.5; 95% CI: 2.0-6.1).NSAID, low-dose ASA use, and H. pylori infection are three independent risk factors for the development of PUB, but there were differences in the interaction effect between low-dose ASA (no interaction) or NSAID (addition) use and H. pylori infection, which may have implications for clinical practice in prevention strategies.

Nonsteroidal anti-inflammatory drug (NSAID) treatment will be necessary as part of our therapeutic armamentarium for many years to come. Therefore, safe prescription is mandatory in order to prevent adverse events. In the last two decades, new strategies and new drugs have been developed to reduce NSAID-associated upper gastrointestinal (GI) adverse events. Although the implementation of guidelines into clinical practice takes time, several studies have shown a recent and profound decrease in hospitalizations due to upper GI complications, which has been linked to widespread use of proton pump inhibitors (PPIs), better NSAID prescription, and decreased prevalence of Helicobacter pylori infection. This is encouraging. Safe NSAID prescription should be straightforward since the most relevant aspects are clinical in nature. Before issuing any prescription, three key questions should be considered: 1) Is NSAID treatment necessary for this patient? 2) What cardiovascular (CV) and GI risk factors does this patient have? 3) What is the most suitable NSAID for this patient? GI and CV risk are easy to estimate, and we know that these risks are not the same for all NSAIDs. Selective cyclooxygenase (COX)-2 inhibitors, like celecoxib at usual doses, carry the lowest GI risk and are the best option in patients with moderate/high GI risk without high CV risk. Gastroprotective therapy (PPI as the drug of choice) should be considered if a non-selective NSAID is prescribed. For those at the highest risk, a combination of PPI plus a coxib is the best option. Also, eradication of H. pylori infection in patients with previous peptic ulcer or in NSAID-naive users must be considered. Naproxen is the best option in patients with high CV risk and low/moderate GI risk. Patients taking aspirin represent a real challenge for treatment, since interaction with frequently prescribed NSAIDs (e.g. ibuprofen/naproxen) may alter its antiplatelet effect, representing a potential clinical problem. Switching treatment (e.g. taking aspirin before NSAID dosing) may not be an alternative since interaction may persist, especially when taking enteric-coated aspirin. Changing NSAID treatment to diclofenac/celecoxib/etoricoxib may also not be an option in patients with high or previous CV event history. Under these circumstances, careful prescription should be considered at the individual patient level. When dyspepsia develops in an NSAID user, PPI co-therapy plus reduction of the NSAID dose or a change in the type of NSAID are valid alternatives, but clinical experience shows that, for some patients, stopping NSAID therapy may be the only option. After a bleeding episode, most patients can be managed with alternative therapy to NSAIDs, but if needed, a coxib plus a PPI and H. pylori eradication is a safe alternative.