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Background The etiology and pathogenesis of inflammatory bowel disease (IBD), Crohn's disease (CD), and ulcerative colitis (UC) are complex and the mechanisms that lead to the development of these diseases remain unclear. Extracellular vesicles (EVs) are small particles covered with a cell membrane, originating from the emitting cell, excreted into the extracellular medium, and subsequently captured by receptor cells. EVs have a role in multiple diseases and they could also have a function in IBD pathogenesis. Therefore, the analysis of EVs isolated from the serum of newly diagnosed IBD patients (before starting any treatment) may represent an appropriate experimental approach to elucidate their role in IBD pathogenesis. We aimed to evaluate EVs’ composition and potential effects in the pathogenesis of IBD. Methods The protein content of EVs isolated by size exclusion chromatography from the 500 µl of serum from 100 patients with IBD (50 patients with CD and 50 patients with UC) recently diagnosed and 50 healthy controls (HC) was characterized by proteomics and their size and concentration in serum by Nanoparticle tracking analysis (NTA). The biological function of EVs and alterations in signaling pathways related to IBD were determined using Ingenuity Pathways Analysis (IPA) to analyze the OMICs results. Results A total of 1,100 proteins have been identified, of which 105 proteins were differentially expressed by patients with CD versus HC, 111 proteins by patients with UC versus HC, and 32 proteins by patients with UC versus CD. IPA analysis revealed that proteins carried in EVs are involved in the dysregulation of immune pathways such as the acute phase response (Figure 1), LXR/RXR activation pathway (Figure 2), and the complement pathway. These pathways were regulated differentially in IBD patients compared with HC, but also when the CU group was compared with the CD group (Figure 3) being upregulated nuclear receptors signaling and cytotoxicity pathways. Conclusion EVs carry proteins that can be involved in the dysregulation of the immune system in IBD; this effect would be different in UC and CD since their EVs show a differential profile. Consequently, EVs may play role in IBD pathogenesis and source of strong biomarkers candidates for diagnosis in UC and CD. Further studies on their specific function during IBD are warranted.

Background Over the last years significant advances have arisen in CD. New therapies with different mechanisms of action have been approved for the management of Crohn’s disease (CD). However, there is limited evidence on optimal positioning of agents as first-or second-line therapies due to the lack of head-to-head robust comparative data. Our aim was to establish feasible and practical recommendations for the management of patients with moderate to severe CD with the use of anti-tumour necrosis factor (TNF) drugs, with special focus on controversial areas. Methods A group of 9 expert gastroenterologists identified current relevant clinical controversies in the management of CD with anti-TNF therapies. A comprehensive literature review was performed to analyze them and a survey was launched to examine current clinical practice. This was a structured survey organized in 2 main sections that included several questions: 1) Sociodemographic and practice related questions; 2) Opinion and attitude in daily practice related to: the use of anti-TNFs, vedolizumab or ustekinumab in naïve and refractory patients, the role of HLA-DQA105, or monitoring of drug levels. An invitation to participate was emailed to a representative number of 244 IBD treating physicians all over the country. The results of the literature review and survey were discussed in a nominal group meeting, and a set of statements were proposed for a Delphi process. The participants of the survey were also invited to the Delphi. Agreement was defined if at least 70% of the participants voted ≥7 (from 1, totally disagree to 10, totally agree). For each statement, the level of evidence and grade of recommendation was established based on the Oxford Evidence Based Medicine categorization. Results A total of 14 statements were generated (table 1 depicts the statements and the results of the Delphi). All but two achieved required level of agreement. The statements cover the following areas: 1) use of first-line non-anti-TNF biologic therapy; 2) role of HLA-DQA1*05 in daily practice; 3) attitudes in primary nonresponse and loss of response to anti-TNF therapy due to immunogenicity; 4) ustekinumab or vedolizumab if a change of mechanism of action is considered; 5) anti-TNF drug levels monitoring during induction; 6) combined therapy with an immunomodulator and anti-TNF monotherapy. Conclusion This document sought to pull together the experts’ attitudes when dealing with different clinical scenarios of patients with CD on anti-TNF.

Background Very few studies have reported updated data on the incidence, clinical evolution and treatment of inflammatory bowel disease (IBD) in Europe. Aims i) To assess the incidence of IBD in Spain; ii) to describe the main epidemiological and clinical characteristics of patients at diagnosis and the evolution of the disease; and iii) to explore the use of drug treatments in the biological era. Methods Prospective and population-based nationwide registry. Adult patients diagnosed with IBD -Crohn’s disease (CD), ulcerative colitis (UC) or IBD unclassified (IBD-U)- during 2017 in all the 17 Spanish administrative regions were included and will be followed-up for 5 years after diagnosis. Treatment was grouped into 5 categories: mesalazine (oral or topical), steroids (intravenous, oral or topical), immunomodulators (thiopurines, methotrexate or cyclosporine), biologics (anti-TNF, vedolizumab or ustekinumab) and surgery. Results 3627 incident cases of IBD diagnosed during 2017 in 108 hospitals covering over 22 millions of adult inhabitants (about 50% of the Spanish population) comprise the study cohort (Table 1). The overall incidence (cases/100.000 person-years) was 16 for IBD, 7.5 for CD, 8 for UC, and 0.5 for IBD-U. Incidence of CD was somewhat higher in Central Spain, while that of UC was higher in Northern Spain (Asturias and Navarra) (Figure 1). About 46% of patients had CD and 50% UC. Diagnosis delay was longer in CD than in UC (5 vs. 2 months, p < 0.01). The proportion of patients with symptoms at diagnosis was higher in UC than CD (94 vs. 89%, p < 0.01). By contrast, those with CD vs. UC had higher frequency of family history of the disease (18 vs. 13%, p < 0.01), tobacco smoking (38 vs. 12%, p < 0.01) and extraintestinal manifestations (12 vs. 6%, p < 0.01). At diagnosis, 18% of CD patients had structuring or fistulising behaviour, and 69% of UC patients had extensive colitis or left-sided colitis. During a median of 12-month of follow-up, 28% of patients were hospitalised (35% of CD and 22% of UC patients, p < 0.01). A total of 2.6% CD patients progressed to a more severe phenotype, and 2% UC patients developed a more extensive involvement. The cumulative exposure to different treatments is shown in Figure 2. Conclusion The incidence of IBD in Spain is quite high and similar to that reported in Northern Europe. IBD patients require the use of substantial therapeutic resources, which are greater in CD than in UC, and much greater than previously reported. One third of patients are hospitalised in the first year after diagnosis and over 5% undergo surgery. These results highlight the high burden of IBD as well as some of the important challenges faced by clinicians and healthcare systems to manage this costly and complex disease.

Resumen Presentamos el caso de un varon de 24 anos con clinica de 2 meses de evolucion de deposiciones diarreicas con sangre y moco, asociado a tenesmo y urgencia, asi como proctalgia, dolor abdominal y cuadro de poliartralgias. Orientado inicialmente como brote de colitis ulcerosa, se pauto tratamiento con corticoides y mesalazina. Un mes mas tarde acudio a nuestra consulta por persistencia de dicha sintomatologia a pesar del tratamiento y tras una exhaustiva anamnesis el paciente confirmo relaciones anales sin proteccion, por lo que se solicitaron serologias y se repitio la colonoscopia con toma de muestras para microbiologia y anatomia patologica, que confirmaron el diagnostico de proctitis por Chlamydia trachomatis .

Resumen Presentamos el caso de un paciente varon de 34 anos, afecto de enfermedad de Crohn en tratamiento cronico con 6-mercaptopurina, a quien se diagnostico hiperplasia nodular regenerativa secundaria a este tratamiento. La sospecha clinica se realizo por alteraciones analiticas en el perfil hepatico y por signos ecograficos de hipertension portal. Finalmente, el diagnostico se confirmo mediante biopsia hepatica.

Pyoderma gangrenosum is a serious cutaneous complication seen in approximately 1 % of patients with inflammatory bowel disease (IBD). Oral corticosteroids are the mainstay treatment, although the evidence supporting their use is weak. The purpose of this study was to investigate the characteristics of pyoderma gangrenosum associated with Crohn’s disease or ulcerative colitis and which treatments are prescribed in Spanish clinical practice. In this retrospective, observational study, the medical records from all patients with IBD and a diagnosis of pyoderma gangrenosum attended by the gastroenterology departments of 12 Spanish hospitals were reviewed. Data on patient demographics and characteristics, underlying IBD and treatment, and pyoderma gangrenosum characteristics, treatment, and outcome were collected and analyzed. The data from 67 patients were analyzed (41 [61.2 %] women, 41 [61.2 %] with Crohn’s disease, 25 [37.3 %] with ulcerative colitis, and 1 [1.5 %] with indeterminate disease). The underlying disease was in remission in approximately one-third of patients at the time of presentation of pyoderma gangrenosum. Healing was achieved in all patients (in 3 without any systemic therapy). Oral corticosteroids were taken by 51 patients (76.1 %), almost always as first-line treatment, although definitive healing was attained in 19 (28.4 %). Biologic agents such as infliximab and adalimumab were taken by 31 patients (46.3 %) at some point (first-line in 6 patients [9.0 %]), with definitive healing in 29 patients (93.5 %). Oral corticosteroid therapy remains the most common treatment for pyoderma gangrenosum associated with inflammatory bowel disease. Biologic therapies such as infliximab and adalimumab should also be considered.

Resumen Aunque la indicacion principal de ustekinumab (UST) en el momento actual es la psoriasis, su innovador mecanismo de accion aventura otras indicaciones en un futuro proximo, entre ellas, la artritis psoriasica (APs) y la enfermedad de Crohn (EC). La psoriasis y la APs son entidades donde la interaccion de elementos de restriccion genetica, junto a factores ambientales e inmunologicos juegan un papel clave para dar lugar a las manifestaciones propias de ambas enfermedades. Una de las principales vias patogenicas en estas condiciones es el eje IL-23/Th17, y existen sobradas evidencias para apoyar intervenciones farmacologicas sobre el mismo. En el momento actual, solo disponemos de un agente con capacidad de actuar sobre esta diana, UST, un anticuerpo monoclonal humano frente a la subunidad comun p40 de la IL-12 e IL-23. Aunque disponemos de cierta informacion sobre su utilidad en el tratamiento de la APs, aun precisamos de mas datos sobre su eficacia y seguridad en este campo. Por otra parte, la EC es una enfermedad inflamatoria cronica de etiologia desconocida que afecta al tubo digestivo. El tratamiento consiste en el uso de corticoides, inmunosupresores y anticuerpos anti factor de necrosis tumoral. Algunos pacientes no responden, por lo que es necesario disponer de alternativas de tratamiento, entre las que se encuentra UST. Recientemente, dos estudios fase IIb apuntan a que UST induce y mantiene la respuesta clinica en la EC, principalmente en pacientes con fracaso previo a infliximab y proteina C reactiva elevada en el momento del tratamiento. Aun quedan interrogantes por resolver, como la dosis mas eficaz o la via de administracion mas adecuada, y se precisan mas estudios para evaluar la eficacia y determinar el mejor esquema terapeutico en la EC. El presente trabajo revisa la informacion disponible hasta la fecha sobre la utilidad potencial de este nuevo agente en el tratamiento de la APs y la EC.

Background There is no information about the frequency of liver dysfunction in patients with inflammatory bowel disease (IBD) treated with immunosuppressants and infected with hepatitis B (HBV) and/or C virus (HCV). Aim To assess the influence of immunosuppressants on the course of HBV and HCV infection in IBD. Methods Patients with IBD with HBV and/or HCV infection from 19 Spanish hospitals were included. Clinical records were reviewed for the type of immunosuppressant used, treatment duration, liver function tests and viral markers before, during and after each immunosuppressant. Logistic and Cox regression analysis were used to identify predictors of outcome. Results 162 patients were included; 104 had HBV markers (25 HBsAg positive) and 74 had HCV markers (51 HCV-RNA positive), and 16 patients had markers of both infections. Liver dysfunction was observed in 9 of 25 HBsAg positive patients (36%), 6 of whom developed hepatic failure. Liver dysfunction in HCV was observed in 8 of 51 HCV-RNA positive patients (15.7%), and only one developed hepatic failure. The frequency and severity of liver dysfunction was significantly higher in HBV-infected patients than in HCV-infected patients (p=0.045 and p=0.049, respectively). Treatment with ≥2 immunosuppressants was an independent predictor of HBV reactivation (OR 8.75; 95% CI 1.16 to 65.66). The majority of patients without reactivation received only one immunosuppressant for a short period and/or prophylactic antiviral treatment. No definite HBV reactivations were found in anti-HBc positive patients lacking HBsAg. Conclusion Liver dysfunction in patients with IBD treated with immunosuppressants is more frequent and severe in those with HBV than in HCV carriers and is associated with combined immunosuppression.

Antecedentes: El objetivo de este estudio fue estimar los costes directos hospitalarios asociados al manejo clinico y terapeutico de los pacientes con enfermedad de Crohn moderada y grave en la practica clinica habitual en Espana. Metodologia: Estudio descriptivo, naturalistico, retrospectivo, de caracter multicentrico y de ambito nacional. Participaron en el estudio 10 medicos gastroenterologos de 10 hospitales espanoles. La informacion para el estudio se obtuvo de una revision de historias clinicas de pacientes con enfermedad de Crohn (EC). Se elaboro un modelo de Markov para estimar el coste directo sanitario por paciente asociado al manejo clinico y terapeutico de la enfermedad de Crohn, desde la perspectiva del Sistema Nacional de Salud (SNS) en un periodo de tres anos. Se ha realizado un analisis de sensibilidad para evaluar el impacto en los resultados de cambios en las principales variables. Resultados: Se incluyo a 178 pacientes. La estimacion del coste directo sanitario asociado a la EC para un periodo de 3 anos fue de 23.168 € por paciente (7.722 € por paciente y ano). Los ingresos hospitalarios representaron un 57% del total de los costes asociados a la EC, los costes asociados al tratamiento farmacologico el 33% (27% debido a terapias biologicas (TB) y 6% por terapias convencionales). Los demas costes que incluyen visitas, pruebas e intervenciones quirurgicas representaron un 10%. La probabilidad de recibir terapia biologica fue la unica variable testada que presento un impacto significativo en el resultado final del modelo. Conclusiones: El coste directo de la EC se debe en su mayor parte a los ingresos hospitalarios y a la intensa utilizacion de recursos en los estados mas graves de la enfermedad. La utilizacion de mayores dosis de TB en la practica clinica habitual, en comparacion con las de sus fichas tecnicas, esta directamente relacionada con el aumento de los costes de la EC.

The massive star-forming region Mon R2 hosts the closest ultra-compact HII region that can be spatially resolved with current single-dish telescopes. We used the IRAM-30m telescope to carry out an unbiased spectral survey toward two important positions (namely IF and MP2), in order to studying the chemistry of deuterated molecules toward Mon R2. We found a rich chemistry of deuterated species at both positions, with detections of C2D, DCN, DNC, DCO+, D2CO, HDCO, NH2D, and N2D+ and their corresponding hydrogenated species and isotopologs. Our high spectral resolution observations allowed us to resolve three velocity components: the component at 10 km/s is detected at both positions and seems associated with the layer most exposed to the UV radiation from IRS 1; the component at 12 km/s is found toward the IF position and seems related to the molecular gas; finally, a component at 8.5 km/s is only detected toward the MP2 position, most likely related to a low-UV irradiated PDR. We derived the column density of all the species, and determined the deuterium fractions (Dfrac). The values of Dfrac are around 0.01 for all the observed species, except for HCO+ and N2H+ which have values 10 times lower. The values found in Mon R2 are well explained with pseudo-time-dependent gas-phase model in which deuteration occurs mainly via ion-molecule reactions with H2D+, CH2D+ and C2HD+. Finally, the [H13CN]/[HN13C] ratio is very high (~11) for the 10 km/s component, which also agree with our model predictions for an age of ~0.01-0.1 Myr. The deuterium chemistry is a good tool for studying star-forming regions. The low-mass star-forming regions seem well characterized with Dfrac(N2H+) or Dfrac(HCO+), but it is required a complete chemical modeling to date massive star-forming regions, because the higher gas temperature together with the rapid evolution of massive protostars., Comment: 14 pages of manuscript, 17 pages of apendix, 7 figures in the main text, accepted for publication in A&A

Ultracompact (UC) HII regions constitute one of the earliest phases in the formation of a massive star and are characterized by extreme physical conditions (Go>10^5 Habing field and n>10^6 cm^-3). The UC HII Mon R2 is the closest one and therefore an excellent target to study the chemistry in these complex regions. We carried out a 3mm and 1mm spectral survey using the IRAM 30-m telescope towards three positions that represent different physical environments in Mon R2: (i) the ionization front (IF) at (0",0"); two peaks in the molecular cloud (ii) MP1 at the offset (+15",-15") and (iii) MP2 at the farther offset (0",40"). In addition, we carried out extensive modeling to explain the chemical differences between the three observed regions. We detected more than thirty different species. We detected SO+ and C4H suggesting that UV radiation plays an important role in the molecular chemistry of this region. We detected the typical PDR molecules CN, HCN, HCO, C2H, and c-C3H2. While the IF and the MP1 have a chemistry similar to that found in high UV field and dense PDRs like the Orion Bar, the MP2 is more similar to lower UV/density PDRs like the Horsehead nebula. We also detected complex molecules that are not usually found in PDRs (CH3CN, H2CO, HC3N, CH3OH and CH3C2H). Sulfur compounds CS, HCS+, C2S, H2CS, SO and SO2 and the deuterated species DCN and C2D were also identified. [DCN]/[HCN]=0.03 and [C2D]/[C2H]=0.05, are among the highest in warm regions. Our results show that the high UV/dense PDRs present a different chemistry from that of the low UV case. Abundance ratios like [CO+]/[HCO+] or [HCO]/[HCO+] are good diagnostics to differentiate between them. In Mon R2 we have the two classes of PDRs, a high UV PDR towards the IF and the adjacent molecular bar and a low-UV PDR which extends towards the north-west following the border of the cloud., 31 pages

Low thiopurine-methyl-transferase (TPMT) activity and high 6-thioguanine-nucleotide (6TGN) concentrations have been linked to therapeutic success in inflammatory bowel disease patients treated with thiopurines; however, this has not been implemented in clinical practice.To identify a therapeutic threshold value for TPMT or 6TGN concentrations, and their capability to predict treatment safety and efficacy.Prospective multicentre study including steroid-resistant/dependent patients starting thiopurines. The TPMT activity was determined at inclusion (5 U/mL required). Azathioprine metabolites [6TGN, 6-methyl-mercaptopurine ribonucleotides (6MMP), and 6TGN/6MMP and 6TGN/TPMT ratios] were periodically monitored during steroid tapering and after withdrawal for 6 months or until a new flare occurred.A total of 113 patients were analysed (62% clinical response). Areas under the receiver operating characteristic (ROC) curve (AUC) relating clinical response and metabolite levels at 2, 4 and 6 months after steroid withdrawal were less than 0.7. The AUCs relating final response and initial TPMT activity or metabolite concentrations at 2, 4, 8 and 16 weeks after starting thiopurines were less than 0.7. No cut-off point with worthwhile sensitivity/specificity was found. Eight (7%) patients developed thiopurine-related toxicity that could not be linked to TPMT activity or 6TGN levels.Our results do not support determination of TPMT activity or 6TGN concentrations to predict treatment outcome, and no useful serum metabolites threshold value to adjust the drug's dose was identified.

Herbig Ae stars (HAe) are the precursors of Vega-type systems and, therefore, crucial objects in planet formation studies. Thus far, only a few disks associated with HAe stars have been studied using millimetre interferometers. Our aim is to determine the dust evolution and the lifetime of the disks associated with Herbig Ae stars. We imaged the continuum emission at 3 mm and 1.3 mm of the Herbig Ae/Be stars BD+61154, RR Tau, VY Mon and LkHa 198 using the Plateau de Bure Interferometer (PdBI). These stars are in the upper end of the stellar mass range of the Herbig Ae stars (stellar mass greater than 3 solar masses). Our measurements were used to complete the Spectral Energy Distribution (SED). The modelling of the SED, in particular the FIR-mm part, allow us to determine the masses and dust properties of these disks. We detected the disks associated with BD+61154, RR Tau and VY Mon with disk masses of 0.35 Msun, 0.05 Msun and 0.40 Msun respectively. The disk around LkHa 198 was not detected with an upper limit to the disk mass of 0.004 Msun. We detected, however, the disks associated with the younger stellar objects LkHa 198--IR and LkHa 198-mm that are located in the vicinity of LkHa 198. The fitting of the mm part of the SED reveal that the grains in the mid-plane of the disks around BD+61154, RR Tau and VY Mon have sizes of 1--1000 microns. Therefore, grains have not grown to centimetre sizes in these disks yet. These massive (M>3 Msun) and young (about 1 Myr) HAe stars are surrounded by massive (>0.04 Msun) disks with grains of micron-millimetre sizes. Although grain growth is proceeding in these disks, their evolutionary stage is prior to the formation of planetesimals. These disks are less evolved than those detected around T Tauri and Herbig Be stars.

We present interferometric observations of the CN 1-0 (113.491 GHz), N2H+ 1-0 (93.173 GHz), H(41)a (92.034 GHz), CH3CN (91.987 GHz), CS 3-2 (146.969 GHz), c-C3H2 3-2 (145.089 GHz), H2CO 2-1 (145.603 GHz) and HC3N 16-15 (145.601 GHz) lines towards M82, carried out with the IRAM Plateau de Bure Interferometer (PdBI). PDR chemical modelling is used to interpret these observations. Our results show that the abundances of N2H+, CS and H13 CO+ remain quite constant across the galaxy confirming that these species are excellent tracers of the dense molecular gas. On the contrary, the abundance of CN increases by a factor of 3 in the inner x2 bar orbits. The [CN]/[N2 H+ ] ratio is well correlated with the H(41)a emission at all spatial scales down to 100 pc. Chemical modelling shows that the variations in the [CN]/[N2H+] ratio can be explained as the consequence of differences in the local intestellar UV field and in the average cloud sizes within the nucleus of the galaxy. Our high-spatial resolution imaging of the starburst galaxy M 82 shows that the star formation activity has a strong impact on the chemistry of the molecular gas. In particular, the entire nucleus behaves as a giant photon-dominated region (PDR) whose chemistry is determined by the local UV flux. The detection of N2H+ shows the existence of a population of clouds with Av >20 mag all across the galaxy plane. These clouds constitute the molecular gas reservoir for the formation of new stars and, although distributed all along the nucleus, the highest concentration occurs in the outer x1 bar orbits (R = 280 pc)., 19 pages, 14 figures

Identification of patients with hereditary nonpolyposis colorectal cancer (HNPCC) can allow colorectal cancer (CRC) prevention through colonoscopy and polypectomies. The purpose of this study was to report the clinical characteristics of HNPCC families in our registry.HNPCC was identified using the Amsterdam criteria. Familial clustering of CRC and extracolonic cancers were investigated in families. Individuals at risk were offered annual colonoscopy, starting from the age of 25 years.Twelve HNPCC families were identified. There were 46 cases of CRC in 38 patients. The mean age at diagnosis of CRC was 45.4 +/- 12.7 years (range 25-73 years). In patients with documented disease, right-sided tumors predominated. Eleven patients with extracolonic cancer were identified (six tumors located in the endometrium). Of 43 at-risk individuals, 29 accepted surveillance.Our data confirm the importance of the family history in identifying HNPCC. This study confirms previously described characteristics in HNPCC, namely, early age at onset of CRC, right-sided predominance, multiple synchronous and metachronous neoplasms, and increased extracolonic cancers. This is the first study of clinical data in a Spanish HNPCC registry.

Scarce data are available in Europe on the cost of treatment for ulcerative colitis (UC).To assess the cost of illness of moderate-to-severe UC in two scenarios: traditional treatment versus alternative treatment incorporating granulocyte, monocyte adsorption - apheresis (GMA-Apheresis; Adacolumn). To determine the relative cost-effectiveness of both options in steroid-dependent patients.One-year cost-of-illness and cost-effectiveness analysis from the third-payer perspective using a decision tree model was carried out. Probabilities of each event were derived from the literature and an expert panel. Direct medical costs were obtained from official sources (euro2004). Effectiveness was measured by the proportion of patients achieving clinical remission.The average annual cost per patient treated with traditional treatment was estimated to be euro6740; with GMA-Apheresis, the cost was estimated to be euro6959. In steroid-dependent patients, the average annual cost was euro6059 and euro11,436, respectively. The proportion of patients achieving clinical remission with GMA-Apheresis was 22.5% higher. As second- and third-line therapy, a new course of corticosteroids and surgery was avoided in 18.5 and 4% of patients, respectively.Incorporating GMA-Apheresis (Adacolumn) in the therapeutic management of moderate-to-severe UC patients is cost-effective and implies savings related to the reduction of adverse effects derived from corticosteroid use and to the decreased number of surgical interventions.

The role of lactose malabsorption in ulcerative colitis is controversial. The aim of this study was to compare the prevalence of lactose malabsorption in a group of ulcerative colitis patients and a control group and to modify lactose consumption in view of the results.Lactose malabsorption was studied using the hydrogen breath test in 52 patients with ulcerative colitis and 34 controls after ingestion of 25 g of lactose. A questionnaire on ingestion of milk products was also administered.Of the 52 patients with ulcerative colitis, 13 (25%) presented lactose malabsorption compared with 11 of the 34 (32%) controls (p = 0.45). Twenty-four patients (46%) had been advised to completely eliminate lactose from their diets. Twenty-seven of the 39 patients without malabsorption had reduced or eliminated lactose consumption after being diagnosed with ulcerative colitis.No significant differences in the prevalence of lactose malabsorption was found between patients with ulcerative colitis and controls. We believe that systematic elimination of lactose from the diets of these patients is erroneous. In our environment, we recommend the hydrogen breath test only in patients with symptoms of lactose intolerance.

We present the results of a retrospective study of endoscopic management (with flexible endoscopy) in 501 patients admitted for suspected ingestion of a foreign body between 1977 and 1997. The mean age of the patients was 55.73 19.38. Foreign bodies were found in the esophagus in 322 patients (64.3%) and endoscopic removal was successful in 307 (95.35%). More experienced endoscopists, with more than 45 cases, had a higher success rate (98.1%) than did less experienced endoscopists (87.9%) (p0.01). The most frequent type of foreign body in our series was meat bolus (32.8%). Underlying disease was found in 38.9%, and peptic stenosis was the most frequent. The only severe complication found was esophageal perforation in one patient (0.3%). Emergency flexible endoscopy is the most effective method for managing patients admitted for suspected ingestion of a foreign body and for the removal of foreign bodies located in the esophagus.

Tropical chronic pancreatitis is a form of idiopathic chronic pancreatitis that has not previously been described in Spain. Typically it is related to dietary factors and malnutrition, although genetic factors may also play a significant role in the development of the disease. We report a case of chronic tropical pancreatitis in a 27-year-old woman from the Dominican Republic domiciled in Spain since 1992. The patient was admitted to our hospital for acute pancreatitis that fulfilled the diagnostic criteria (clinical and radiological) for chronic tropical pancreatitis. This case has led us to review this uncommon entity. Because of the increasing number of immigrants from tropical countries, chronic tropical pancreatitis will probably need to be taken into account in the differential diagnosis of chronic pancreatitis in our patients.

We present a case of non-Hodgkin's lymphoma of B cells in a patient with cirrhosis by hepatitis C virus. Our patient presented scarce symptomatology related with non-Hodgkin's lymphoma. A notable hyperbilirrubinaemia with hypoalbuminaemia were the only features that allowed us to suspect the diagnosis. The diagnostic was proved by necroscopic study. There are several factors involved in the etiology of non-Hodgkin's lymphoma, including infectious agents. Recent Italian studies have suggested an association between C virus infection and non-Hodgkin's lymphoma. We have carried out a bibliographical revision of this association to conclude that important geographical differencies must be pointed out.

A case of celiac disease of the adult is herein described in a patient with a history of orthotopic liver transplantation because of cirrhosis due to hepatitis C virus. The patient presented with a decrease in the levels of cyclosporinemia, diarrhea and an increase in transaminases. This is an infrequent form of presentation leading to differential diagnosis with a complication related to the liver disease.

Acute hemorrhage from pancreatic pseudoaneurysm is the most rapidly fatal complication of pancreatitis, with a reported mortality rate of90% in untreated patients. The diagnosis of pancreatic pseudoaneurysm requires a high index of suspicion and the abdominal angiography is the gold standard. Transcatheter embolization is an alternative to surgery for treatment in selected patients. Early diagnosis and treatment decrease the mortality dramatically. We describe a patient with a gastrointestinal bleeding from a ruptured pancreatic pseudoaneurysm, with an angiography diagnosis and transcatheter embolization. We treated the pseudocyst with an endoscopic drainage. A review of literature is presented.

A prospective study of the prevalence of monosymptomatic celiac disease presented as ferropenic anemia in patients admitted for study such complication of was carried out. All the patients were evaluated by gastroscopy and biopsy of the distal duodenal segment, regardless of endoscopic appearance. Patients presenting an endoscopic lesion clearly suggestive as the origin of the chronic bleeding were excluded from the study. The prevalence of celiac disease, the only manifestation of which was ferropenic anemia, was 3.3% in this series. What is important to note in this study is the importance of duodenal biopsy in the study of ferropenic anemia, with the aim of avoiding diagnostic delay of a possible monosymptomatic celiac disease as the cause of the anemia.

Abdominal pain is the most frequent symptom of chronic pancreatitis and may, on occasions, lead to great treatment problems. The case of a 35-years-old patient diagnosed with chronic calcifying pancreatitis of enolic etiology who showed dilatation of the main pancreatic duct and intracanalicular lithiasis is reported. Medical, endoscopic and surgical alternatives failed but fragmentation of the lithiasis by extracorporeal lithotripsy was successful.

Background: The satisfaction of patients with inflammatory bowel disease (IBD) with healthcare services may be related to the assistance of health personnel, the information they receive about their illness and the treatments available, adequacy of facilities and the time you spend in the health professional’s office as well as the control of their disease. These patients have specific requirements that make the quality of the health service they receive is as important as the effectiveness of the treatments received. So far the satisfaction questionnaires have focused almost exclusively on treatment. The aim of this study was to determine the perception of nurses on IBD patients’ satisfaction with healthcare services. Methods: An observational, prospective, multicentre study. The questionnaire (it was elaborated and validated for this study) was administered to nurses (28 items) and patients (31 items), with six dimensions and 5 closed answers (from “strongly disagree” to “strongly agree”). The overall score is expressed in a 0 100 scale (a higher score indicates greater satisfaction). Results: The mean(SD) score of the overall perception of satisfaction of patients (N = 327) by nursing staff (N = 32), is 82.2(8.5) and 82.0(10.9) the mean patient satisfaction. Except for the dimension that measures satisfaction with information received by the patient [73.1(23.5)] in all dimensions were less scored by nurses than by patients. The mean(SD) satisfaction with healthcare staff attention was 80.4(23.4), with doctor attention 82.8(23.4), with centre facilities 69.5(23.5), with accessibility to the centre 73.4(23.6) and with received support 76.3(23.7). The aspects with which the patient is less satisfied, according nurses perception, are those related to information (particularly the disease information through leaflets and how to contact with patient associations). Conclusions: Although the patients seem to be more satisfied with healthcare services than nurses thought, there are still areas for improvement to provide a fully satisfactory healthcare to IBD patients. ON002 Efficacy of nurse-driven outpatient clinic for follow-up of inflammatory bowel disease patients on treatment with thiopurinic immunosuppresants M. Lopez1 *, A. Villoria1, A. Dosal1, L. Moreno1, N. Mane1, M. Pujol1, X. Calvet2. 1Parc Tauli, Digestive, Sabadell, Spain, 2CIBERehd, Instituto de Salud Carlos III, Parc Tauli Digestive, Sabadell, Spain

Introduccion La elevacion de los niveles sericos de los nucleotidos de la 6-tioguanina (6TGN) en los pacientes tratados con tiopurinas se ha relacionado con una mayor probabilidad de alcanzar la remision, pero la traduccion clinica de este hallazgo es dudosa. Objetivos y metodos Estudio prospectivo y multicentrico para establecer la utilidad de la determinacion sistematica de 6TGN como predictor o marcador de la eficacia de la azatioprina (AZA) o mercaptopurina (MP) en los pacientes con EII. Se determinaron los niveles sericos de 6TGN y 6-metilmercaptopurina-ribonucleotidos (6MMPR) en pacientes que comenzaban tratamiento con AZA/MP por corticoresistencia o corticodependencia. Esta determinacion se realizo periodicamente durante el descenso de los esteroides y, una vez suspendidos estos, hasta la aparicion de un nuevo brote (persistencia de la corticoresistencia o dependencia) o durante 6 meses en los casos en los que se mantenia la respuesta clinica. Solo se incluyeron pacientes cuya actividad de la tiopurina-metil-transferasa (TPMT) era mayor de 5 U/ml. Resultados Se incluyeron inicialmente 153 pacientes y 140 finalizaron el estudio (edad media 36 anos, 50% varones, 72% con enfermedad de Crohn. No se encontraron diferencias significativas en los niveles medios de 6TGN (o en las razones 6TGN/6MMPR o 6TGN/TPMT) a las 2, 4, 6 semanas y 2, 4 o 6 meses tras abandonar los esteroides, entre aquellos pacientes que en cada momento estaban o no en remision clinica. El area bajo la curva ROC que evalua la fiabilidad de los niveles de 6TGN en el diagnostico de respuesta clinica en cada punto fue menor de 0,7 en todos los casos. Entre los niveles de 6TGN, no se encontro ningun punto de corte con una sensibilidad y especificidad util, incluidos los valores de 230 o 250 pmol/8×108 (que son los habitualmente propuestos en la literatura). El area bajo la curva ROC que evalua la fiabilidad de la determinacion de 6TGN a las 2 semanas, 1, 2 o 4 meses tras iniciar AZA/MP para predecir la respuesta al final del seguimiento fue tambien menor de 0,7 en todos los casos. Una vez mas, no se encontro ningun punto de corte util. Se describio toxicidad relacionada con AZA/MP en 9 casos (6,4%), incluyendo solo 3 casos de mielotoxicidad y ninguno de hepatotoxicidad. No se encontraron diferencias significativas en los niveles de 6TGN de aquellos pacientes que sufrieron toxicidad relacionada con tiopurinicos. Especificamente, los niveles de 6TGN no se correlacionaron con el riesgo de sufrir mielotoxicidad. Conclusion La determinacion sistematica de los metabolitos de la AZA en los pacientes con EII que reciben tratamiento con tiopurinas, con el objetivo de predecir o valorar la respuesta al tratamiento o su seguridad, no puede ser recomendada.