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BACKGROUND: Self-expanding metal stents (SEMS) are being increasingly used to solve malignant colorectal obstruction (MCRO). Patients can then either undergo scheduled surgery or have the stent left in place as a definitive palliative treatment. The majority of reports on the use of SEMS in MCRO come from single centers; therefore, its use in general endoscopic practice is not clearly known. OBJECTIVE: To study the use of SEMS for MCRO in a wide endoscopic practice. DESIGN: Retrospective study. SETTING: A survey was carried out among endoscopists in 13 hospitals in Spain (6 tertiary referral centers and 7 community hospitals). PATIENTS: Those who presented with MCRO. INTERVENTIONS: A total of 175 attempts to insert colorectal SEMS were made during a 12-month period (October 2003 to September 2004). MAIN OUTCOME MEASURES: Technical and clinical success and possible differences according to the type of hospital. RESULTS: There was a mean of 1.2 attempts/mo per center (range, 2-0.5 attempts/mo per center). Insertion success was achieved in 162 (92.6%) and acceptable colonic decompression in 138 of 175 (78.8%) attempts and in 138 of 162 (85.1%) of successfully inserted stents. SEMS served as a bridge to scheduled surgery in 72 of 175 (41%) and as a palliative definitive treatment in 66 of 175 (37.7%). The major complication was perforation, which occurred in 7 of 175 occasions (4%) and led to death in 2 patients (1%). There were other less severe complications (25 [14%]). No significant differences in outcome of stent placement procedures were found between both categories of centers. LIMITATIONS: Retrospective study involving many centers and the possibility of bias for different assessments of outcomes. CONCLUSIONS: In this study, success rates for SEMS placement and colonic decompression in MCRO were acceptable, without substantial differences according to the type of hospital. This procedure appeared to be feasible in general endoscopic practice. [ABSTRACT FROM AUTHOR]

Background: EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown., Objective: To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist., Design: Multicenter retrospective study., Setting: Public health system hospitals with experience in ESCP in Spain., Patients: A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures., Intervention: ESCP., Main Outcome Measurements: Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed., Results: A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula., Limitations: Retrospective study., Conclusion: Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Objectives: 1. To determine the prevalence of Helicobacter pylori (H. pylori) infection in patients with gastroesophageal reflux disease (GERD), and to compare it with that in a control group. 2. To study the percentage of H. pylori-positive GERD patients according to different grades of esophagitis., Material and Methods: H. pylori prevalence by serological tests was compared among 692 patients with GERD and 200 healthy volunteer controls. Subsequently, the percentage of H. pylori was analyzed in the different grades of esophagitis, according to the Savary-Miller classification., Results: no differences between the GERD group and control group were detected regarding age (50.5+/-14.7 vs 50.7+/-16.4 years, ns) and sex (63 vs 66% of men, ns); on the other hand the prevalence of H. pylori was 40% in the GERD group facing 66% in the control group, p <0.01. There were no differences in H. pylori prevalence according to the different grades of esophagitis, but logistical regression analysis showed that the absence of H. pylori infection was associated with the presence of grade IV esophagitis., Conclusions: the prevalence of H. pylori infection in GERD patients is lower than that of the general population, and its absence is associated with more severe grades of the disease. These results indicate that H. pylori plays a protective role against GERD.

Objectives: 1. To determine the progression of endoscopic affectation in patients with gastroesophageal reflux disease (GERD). 2. To analyze the clinical parameters associated to grade IV of esophagitis, as well as the degree of endoscopic progression., Material and Methods: between 1996 and 2002, 692 patients with GERD have been followed prospectively (66% men and 33% women, with a mean age of 50.7 years). All were submitted to initial upper endoscopy, without treatment, and different clinical parameters associated to grade IV esophagitis were analyzed. During follow up, a new endoscopy was repeated in the event of symptomatic relapse, comparing the new findings with those of the initial exploration., Results: the initial endoscopy did not reveal signs of esophagitis in 49% of the patients. Grade I 11.2%, grade II 22%, grade III 8.1% and grade IV 8.7%. Multivariant analysis showed that advanced age (p <0.01), male sex (p <0.03), smoking (p <0.02) and absence of infection due to Helicobacter pylori (p <0.02) were independent factors associated to grade IV esophagitis. Throughout follow up, patients without esophagitis did not show evidence of esophagitis in successive endoscopies, and a higher grade was found in only 3 of the patients., Conclusions: the endoscopy did not reveal signs of esophagitis in approximately half of the patients. Advanced age, male sex, smoking and absence of Helicobacter pylori are risk factors associated with severe stages of esophagitis. Patients with reflux without esophagitis did not develop inflammatory disorders during follow-up, while those with esophagitis remained in the stage of the initial diagnosis.

Objective: a) To analyse the probability of haemodynamic changes in patients with non-variceal upper gastrointestinal bleeding (NV-UGB), as well as the risk of bleeding in cases of peptic ulcer; and b) to compare an injection of epinephrine alone with epinephrine plus an sclerosing agent in ulcers with a high risk of persistent or recurrent bleeding., Methods: We studied 500 consecutive patients (295 males/205 females) who were admitted because of an NV-UGB episode. Haemodynamic evaluation and upper endoscopy were performed in all patients. They were randomised to receive an injection of epinephrine 1:10.000 or epinephrine plus 2% polidocanol in case of active bleeding, visible vessel or unstable clot., Results: 263/500 (52.6%) were taking NSAIDs before the acute bleeding. 70/96 (72.9%) patients with red haematemesis showed haemodynamic changes vs 15/107 (14%) with dark haematemesis and melena, and 29/281 (10.3%) with melena alone, p < 0.01, OR = 20. Duodenal ulcer was the cause of NV-UGB in 206 cases (40.6%) and gastric ulcer in 134 (27.2%). However, an endoscopic therapy was performed in 85 patients, 58 with gastric ulcers (19 with active bleeding, 33 with visible vessel and 6 with unstable clot) vs 27 with duodenal ulcers (6 with active bleeding, 19 with visible vessel and 2 with unstable clot), p < 0.01, OR = 4.7. 15/85 patients developed recurrent bleeding after injection therapy: 3 with a non-bleeding visible vessel and 10 with active bleeding (10 were treated with epinephrine and 2 with epinephrine plus 2% polidocanol, p < 0.04, OR = 8). A multivariate logistic regression analysis showed that age, active bleeding and type of injected agent were the only independent variables associated with failure of treatment and recurrent bleeding., Conclusions: a) 52.6% of patients with NV-UGB were taking NSAIDs before acute bleeding; b) epinephrine injection followed by a sclerosing agent is more effective in case of active bleeding; however, there is no difference in case of visible vessel or unstable clot; and c) age, active bleeding and type of treatment were the only independent variables associated with recurrent bleeding.

Hepatocellular carcinoma mainly affects patients with liver disease and rarely develops in healthy liver. Cirrhosis greatly increases the risk of developing this malignancy and consequently these patients are candidates for close follow-up and surveillance. The most commonly used screening programs are abdominal ultrasonography and serum alpha-fetoprotein determination. Without treatment, the prognosis of hepatocellular carcinoma is poor and mortality continues to be significant even in patients with small tumors detected during follow-up. We present the case of a 71-year-old male patient with alcoholic cirrhosis. The patient was diagnosed during follow-up of a single hepatocellular carcinoma of 4 cm in diameter. Although he refused all treatment, evolution was favorable, serum alpha-fetoprotein levels returned to normal and ultrasonographic images compatible with hepatocellular carcinoma disappeared. Three years after diagnosis, the patient was completely asymptomatic.

Objectives: Recent studies have reported a high prevalence of diabetes mellitus in populations infected with Virus C (HCV). The aim of this study is two-fold: a) to support the hypothesis of hyperinsulinemia as a risk factor for developing diabetes in these patients, with a prospective determination of baseline insulinemia in non-diabetic cirrhotic patients infected with HCV, comparing their values with those of a group of non-HCV non-diabetic cirrhotic patients; b) to investigate in both groups the factors associated to increased peripheral resistance to insulin., Material and Methods: Thirty two HCV cirrhotic diabetic patients (group I) and 41 non-diabetic cirrhotic patients of other etiologies (group II) participated in the study. Baseline insulinemia, as well as factors related to insulin resistance such as age, anthropometric indexes, stage of cirrhosis development using the Child-Pugh index, serum ferritin and treatment with insulin resistance inducing drugs were compared in both groups., Results: Average baseline insulinemia in group I was 21.5 mU/ml (18.6-24.4), vs 14 mU/ml (10-18) in group II (p < 0.001), and the percentage of hyperinsulinemia was 87.5% (72.5-95.9) vs 56.1% (40.8-70.6), respectively (p < 0.01). No differences were observed between the two groups when comparing the following variables: age [54.4 (48.3-60.6) vs 59.9 (56.3-62.7) years of age, NS], weight [72.9 (69.5-76.3) vs 74.2 (70.8-77.7) kg, NS], height [163.6 (160.5-166.7) vs 161.3 (159.4-163.2)] cm, NS], body mass index [27.6 (26.1-29.1) vs 28.4 (27.3-29.5) kg/m2 of height, NS]; and Child-Pugh staging score (A: 31 vs 27; B: 0 vs 7; C: 1 vs 7, NS). However, serum ferritin levels in group I patients were higher than those in Group II [123.3 (12.4-289.3) vs 65.5 (2.4-306) ng/ml, p < 0.05]. It must be considered that at the recruitment 3 patients in Group I were taking either diuretics or non-selective beta-adrenergic blockers, compared to 14 patients in Group II, p < 0.01. Finally, the multivariate logistic regression analysis showed that insulinemia values (OR = 1.21; CI 95% 1.09-1.34, p < 0.001) and ferritin levels (OR = 1.21; CI 95% 1.02-2.69, p < 0.04) were independent variables associated to HCV infection., Conclusions: HCV-positive non-diabetic cirrhotic patients have higher baseline insulinemia levels and increased prevalence of hyperinsulinemia than cirrhosis due to other etiologies. This could be explained by an increase of peripheral insulin resistance, mediated by the increase of iron deposits in these patients, and could be responsible for the increased risk of developing diabetes mellitus.

Acquired systemic amyloidosis may develop during the course of a number of chronic inflammatory diseases, including inflammatory bowel disease. Amyloidosis, although rare, is life-threatening, especially when it involves the kidneys. It is important to recognize this complication, especially since colchicine has been proposed as a possible treatment.We present a 25-year-old female diagnosed at the age of 13 years with Crohn's disease with involvement of the terminal ileum and right colon. Surgery was performed because of inflammatory activity unresponsive to corticosteroid and immunosuppressive drugs. She subsequently presented nephrotic syndrome due to secondary amyloidosis, which responded well to colchicine treatment.

Aims: a) To prospectively study the frequency of diabetes mellitus in cirrhotic patients with hepatitis C virus (HCV) infection, comparing it with that in cirrhotic patients without HCV infection and b) to investigate basal insulinemia values in both groups, as well as the possible factors causing insulinemia., Material and Methods: Fifty patients with cirrhosis due to HCV infection (group I) and 50 patients with cirrhosis due to other etiologic agents (group II) were studied. In both groups the percentage of diabetic patients, basal insulinemia values and the factors associated with insulin resistance were compared: age, anthropometric indexes, stage of cirrhosis according to Child-Pugh score, plasmatic ferritin concentrations and treatment with drugs inducing insulin resistance., Results: The percentage of diabetics in group I was 36% (18/50) compared with 18% (9/50) in group II (p < 0.05) and basal insulinemia values were 23.5 +/- 9.7 microU/ml compared with 15.7 +/- 9.9 microU/ml respectively (p < 0.05). No differences between the groups were found in the following variables: age (58.7 +/- 16.2 vs. 60.6 +/- 10.0 years), weight (73.2 +/- 10.7 vs 73.9 +/- 11.2 Kg), height (161.9 +/- 8.8 vs. 161.1 +/- 6.8 cm), body mass index (28.2 +/- 3.1 vs. 28.5 +/- 5.2 Kg/height m2) or Child-Pugh stage (A: 40 vs 34, B: 7 vs. 10, C: 3 vs. 6, NS). In contrast, serum ferritin concentrations were much higher in patients in group I than in those in group II [137.7 (12.4-410.2) vs. 87.6 (2.4-420.0) ng/ml p < 0.05]. At the time of inclusion in this study 10 patients in group I were receiving diuretics or non-selective beta adrenergic blockers compared with 24 patients in group II (p < 0.05)., Conclusions: Diabetes mellitus is more prevalent in patients with cirrhosis due to HVC than in those with cirrhosis due to other etiologic agents. Moreover, basal insulinemia values are higher in these patients, which could be explained by an increase in half insulin resistance associated with an increase in iron deposits.

The benefits of immunosuppressive agents in inflammatory bowel disease have been the subject of controversy. However, extensive clinical data have conclusively proved their efficacy with respect to potential toxicity. Azathioprine is one of the most widely used immunosuppressive agents in the treatment of Crohn's disease and its effectiveness has been proved in corticosteroid dependent, corticosteroid-refractory and fistulizing Crohn's disease. We present a 24-year-old male, treated with azathioprine for corticosteroid dependent Crohn's disease who was admitted to hospital with constant fever, lymphadenopathy and liver function abnormalities secondary to infectious mononucleosis after a primary infection with Epstein-Barr virus. The patient developed constitutional symptoms and progressive jaundice and 14 days after hospital admission died because of massive upper gastrointestinal bleeding due to hemorrhagic erosive gastropathy.