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AIM: To assess the incremental benefit of narrow band imaging (NBI) and white light endoscopy (WLE), randomizing the initial technique for the detection of residual neoplasia at the polypectomy scar after an endoscopic piecemeal mucosal resection (EPMR). METHODS: We conducted an observational study in an academic center to assess the incremental benefit of NBI and WLE randomly applied 1:1 (NBI-WLE or WLE-NBI) in the follow-up of a post-EPMR scar by the same endoscopist. RESULTS: A total of 112 EPMR scars were included. The median baseline polyp size was 20 mm (interquartile range: 14-30). At first review, NBI and WLE showed good sensitivity (85.0% vs 78.9%), specificity (77.1% vs 84.2%) and overall accuracy (80.0% vs 82.5%). NBI after WLE (WLE-NBI group) improved accuracy, but this difference was not statistically significant [area under the curve (AUC): 86.8% vs 81.6%, P = 0.15]. WLE after NBI (NBI-WLE group) did not improve accuracy (AUC: 81.4% vs 81.1%, P = 0.9). Overall, recurrence was found in 39/112 (34.8%) lesions. CONCLUSION: Although no statistically significant differences were found between the two techniques at the first post-EPMR assessment, the use of NBI after WLE may improve residual neoplasia detection. Nevertheless, biopsy is still required in the first scar review.

Background. Individuals with a family history of colorectal cancer (CRC) have an increased risk of CRC. We evaluated the diagnostic yield of CCE in the detection of lesions and also two different colon preparations. Methods. A prospective multicenter study was designed to assess CCE diagnostic yield in a cohort of asymptomatic individuals with a family history of CRC. CCE and colonoscopy were performed on the same day by 2 endoscopists who were blinded to the results of the other procedure. Results. Fifty-three participants were enrolled. The sensitivity, specificity, PPV, and NPV of CCE for detecting advanced adenomas were 100%, 98%, 67%, and 100%. Sensitivity, specificity, PPV, and NPV of CCE for the diagnosis of individuals with polyps were 87%, 97%, 93%, and 88%, respectively. CCE identify 100% of individuals with significant or advanced lesions. Overall cleanliness was adequate by 60.7% of them. The PEG-ascorbic boost seems to improve colon cleanliness, with similar colonic transit time. Conclusion. CCE is a promising tool, but it has to be considered as an alternative technique in this population in order to reduce the number of colonoscopies performed. More studies are needed to understand appropriate screening follow-up intervals and optimize the bowel preparation regimen.

Introduccion: La Reseccion Endoscopica Mucosa (REM) de polipos colorrectales sesiles se asocia a una recurrencia de alrededor del 25%. No existe evidencia si NBI respecto Luz blanca (LB) pueda mejorar la deteccion de tejido residual en el seguimiento de estas lesiones. Objetivo: Evaluar la eficacia de NBI respecto LB para la deteccion de neoplasia residual en la cicatriz de una REM. Material y Metodo: Estudio prospectivo aleatorizado y controlado, unicentrico de lesiones REM colorrectales (mayo 2015-mayo 2016). El mismo endoscopista evaluo la cicatriz utilizando colonoscopios de Alta Definicion, de forma secuencial (NBI-LB o LB-NBI). Cualquier sospecha de neoplasia se clasifico de forma independiente dando un nivel de confianza bajo/alto. Se tomaron biopsias aunque la cicatriz fuera aparentemente normal. Resultados: Se incluyeron 120 lesiones de 111 pacientes (media de edad 67,8 anos; 57,5% hombres). Tamano mediano 20 mm (rango: 12 – 30); 80% colon derecho. El tiempo mediano hasta revision fue 3,9 meses. Para cada lesion, se tomaron como maximo 3 biopsias (numero total de puntos evaluados: 142). Las caracteristicas basales fueron similares en ambos grupos. NBI obtuvo respecto LB una sensibilidad superior, aunque no significativa (87,8% vs. 78,0%, p = 0,125). No hubo diferencias en especificidad (85,1% vs. 86,1%) ni en precision global (85,9% vs. 83,8%). Hubo 41/113 (36,3%) lesiones con recurrencia histologica. En el analisis univariado, la displasia residual se relaciono con el tamano, el peso corporal y el indice de masa corporal (IMC). En el multivariado, lesiones ≥25 mm (OR 2,73; IC95%: 1,15 – 6,47) e IMC ≥27 Kg/m2 (OR 3,03; IC95%: 1,34 – 6,89) fueron factores predictivos de displasia residual, con una AUC 0,69 (IC 95%: 0,59 a 0,79). Conclusiones: NBI tiene una eficacia similar a LB para la deteccion de displasia residual tras una REM. Aquellos pacientes con lesiones ≥25 mm tienen un alto riesgo de neoplasia residual.

La capsula endoscopica (CE) es la ultima novedad en endoscopia gastrointestinal y la primera tecnica capaz de explorar todo el intestino delgado. Recientemente se han introducido nuevos avances en este campo que incluyen la capsula de esofago (Pillcam ESO) y la capsula de colon (Pillcam COLON), con variaciones de la capsula inicial y que nos permiten identificar lesiones tambien en estos tramos del tubo digestivo1. En la decada de los anos 1980 se iniciaron los primeros estudios con CE (Gabriel Iddan, Israel 1981). Las primeras imagenes de estudios en animales fueron presentadas por el Dr. Swain en San Diego (Digestive Disease Week 2000)2. A partir de entonces, la capsula se ha convertido en una de las principales herramientas de imagen en el estudio del intestino delgado. El coste de esta exploracion y el estado actual de nuestro sistema sanitario hacen que tengamos que definir con exactitud cual es la utilidad real de la tecnica, en que enfermedades esta indicada y en que momento de su historia

Resumen Introduccion La perforacion del colon es una complicacion poco frecuente, aunque grave, de la endoscopia digestiva baja. El tratamiento es controvertido, aunque en la mayoria de los casos es quirurgico. Los objetivos de este estudio fueron determinar la incidencia de las perforaciones por colonoscopia en nuestro centro y conocer los resultados de las opciones terapeuticas empleadas. Material y metodos Estudio retrospectivo de las perforaciones producidas por colonoscopia entre enero de 2004 y octubre de 2009. Las variables analizadas fueron las siguientes: caracteristicas demograficas, indicacion de la colonoscopia, manifestaciones clinicas, pruebas diagnosticas utilizadas, tiempo entre la perforacion y el diagnostico, tipo de tratamiento, estancia hospitalaria y complicaciones. Resultados Durante el periodo de estudio se realizaron 13.493 colonoscopias. En 13 pacientes (0,1%) se produjo una perforacion del colon. Nueve perforaciones ocurrieron durante la realizacion de una colonoscopia diagnostica (0,08%) y las restantes 4 despues de una colonoscopia terapeutica (0,16%). En 10 casos, el diagnostico se realizo durante las primeras 12 h y en 5 de ellos, la perforacion se identifico durante el mismo procedimiento. La localizacion mas frecuente fue el sigma en 7 casos. En 11 pacientes se realizo tratamiento quirurgico y en 2 pacientes se resolvio con tratamiento conservador. La tecnica quirurgica mas utilizada fue la sutura simple seguida de la reseccion con anastomosis. Un paciente fallecio por sepsis intraabdominal. Conclusion Las perforaciones causadas por colonoscopia son complicaciones poco frecuentes, aunque graves. La mayoria de estos pacientes precisaran tratamiento quirurgico, y quedara reservado el tratamiento conservador para pacientes seleccionados.

Background/Aim: Cefotaxime is considered the first-choice antibiotic for empirical treatment in cirrhotic patients developing bacterial infections. It has been suggested that amoxicillin-clavulanic acid could be an alternative to cefotaxime, particularly in patients developing bacterial infections while on prophylactic norfloxacin. The aim of the present study was to compare amoxicillin-clavulanic acid with cefotaxime in the treatment of bacterial infections in cirrhosis. Methods: Ninety-six hospitalized cirrhotic patients with suspicion of bacterial infection were prospectively included and randomized into two groups: one group ( n =48) received amoxicillin-clavulanic acid, first intravenously 1 g-0.2 g every 8 h, and then orally 500 mg-125 mg every 8 h, and the other group ( n =48) received intravenous cefotaxime 1 g every 6 h. Patients were stratified for previous prophylaxis with norfloxacin and ascitic fluid infection. Results: Sixteen patients were excluded from the analysis because bacterial infection was not demonstrated or because of secondary peritonitis. Therefore, 38 patients from the amoxicillin-clavulanic acid group and 42 from the cefotaxime group were finally analyzed. There were 24 ascitic fluid infections in each group. Infection resolution (86.8% vs 88%, 95% CI: −0.15 to 0.13, p NS), spontaneous bacterial peritonitis resolution (87.5% vs 83.3%, 95% CI: −0.15 to 0.24, p NS), duration of treatment, incidence of complications, time of hospitalization and hospital mortality were similar in both groups. Considering patients on prophylactic norfloxacin, infection resolution was also similar (100% vs 83.3%, 95% CI: −0.04 to 0.37, p NS). No adverse events were observed in either of the two groups. The cost of antibiotics was statistically lower in the amoxicillin-clavulanic acid group ( p Conclusions: Amoxicillin-clavulanic acid is as effective as cefotaxime in the treatment of bacterial infections in cirrhotic patients, but is less expensive and can be administered orally. These results suggest that amoxicillin-clavulanic acid is an effective alternative to cefotaxime for the empirical treatment of bacterial infections in cirrhosis.

Introduccion: La capsula endoscopica (CE) es una tecnica util en el diagnostico y seguimiento de la enfermedad inflamatoria intestinal (EII). Material y Metodos: Determinar la utilidad de la CE en el diagnostico y plan terapeutico de pacientes con sospecha de EII o con EII ya diagnosticada. Se incluyeron 242 individuos (262 CE), remitidos entre 2007 y 2012, para realizar CE por sospecha de EII (grupo A, 63 casos) o por aparicion de nuevos sintomas/estudio de extension en pacientes con EII establecida (grupo B, 188 casos, se registraron indice de Harvey-Bradshaw (H-B), PCR, VSG). Para valorar los resultados de la CE se utilizaron los indices de Lewis y CECDAI. Se analizaron las nuevas exploraciones y modificaciones de tratamiento tras la CE, la correlacion entre indices endoscopicos y H-B, PCR/VSG. Resultados: Los hallazgos de la CE determinaron un nuevo diagnostico en el 42.9% de casos (grupo A: 38.1%, 21 enfermedad de Crohn (EC), 3 otros diagnosticos; grupo B: 4.8%, 9 EC, con diagnostico previo de colitis ulcerosa). En 30.3% de casos del grupo B se describio una nueva extension de la EII (principalmente L1+L4 en 26 casos, L3+L4 en 10 casos). Los hallazgos de la CE indicaron la realizacion de nuevas exploraciones en un 26% de casos de ambos grupos (11 colonoscopias, 11 enteroRMN y 9 enteroscopias). En el 33.9% de casos del grupo A y en el 40.4% de casos del grupo B determinaron cambios en el tratamiento. Lewis y CECDAI mostraron un buen coeficiente de correlacion (0.944, p < 0.001), pero no se observaron correlaciones estadisticamente significativas entre ellos y H-B, PCR y VSG. Conclusiones: La CE es una tecnica util en el diagnostico de nuevos casos de EII y en la optimizacion del tratamiento en EII establecida. Los indices endoscopicos no tienen una buena correlacion con los datos clinicos y analiticos.

Purpose Bethesda guidelines are used to recognize patients at risk for Lynch syndrome. However, obtaining personal and familial tumor data can sometimes be difficult. The Microsatellite Path Score (MsPath), a pathological score, based on age, tumor location, and pathologic features, has been developed to effectively predict colorectal cancer with DNA mismatch repair (MMR) deficiencies. However, the MsPath model's performance in an unselected, population-based colorectal cancer (CRC) population is unknown. Patients and Methods We analyzed all patients with CRC regardless of age, personal or family history, and tumor characteristics from the EPICOLON study, an independent, prospective, multicenter, population-based cohort (N = 1,222). All patients underwent tumor microsatellite instability (MSI) analysis and immunostaining for MLH1/MSH2, and those with MMR underwent tumor BRAF mutation analysis and MLH1/MSH2 germline testing. All the pathologic features were centralized and evaluated blinded to the MMR status. Results MsPath score for prediction of having MSI high, with the recommended MsPath cutoff score ≥1.0, had a sensitivity, specificity, and positive predictive value (PPV) of 92.8% (95% CI, 86.9 to 98.3), 64.1% (95% CI, 61.1 to 66.8), and 15.8% (95% CI, 12.2 to 18.6), respectively. MsPath score had a sensitivity, specificity, and PPV of 81.8% (95% CI, 59.0 to 99.8), 60.6% (95% CI, 57.8 to 63.4), and 1.9% (95% CI, 0.7 to 3.1), respectively, for the identification of MLH1/MSH2 gene carriers. Application of the MsPath score, resulted in two (18%) of 11 mutation carriers being missed, both pathogenic germline MSH2 mutations. Conclusion In the general nonselected population, the MsPath score accurately predicted the probability of bearing a MSI high CRC, but it was insufficiently accurate to use for the selection of patients warranting MLH1/MSH2 mutation testing in the setting of Lynch syndrome.

Introduction Colon perforation is a fairly uncommon, but serious, complication during endoscopy of the lower gastrointestinal tract. Treatment is controversial, although surgery is used in the majority of cases. The aims of this study were to determine the incidence of perforations due to colonoscopy in our hospital and to find out the results of the treatment options used. Material and methods Retrospective study of perforations caused by colonoscopy between January 2004 and October 2008. The variables analysed were: demographic characteristics, colonoscopy indication, clinical signs and symptoms, diagnostic tests used, time between perforation and the diagnosis, treatment type, hospital stay and complications. Results A total of 13,493 colonoscopies were performed during the study period. A perforation of the colon was found in 13 (0.1%) patients. Nine perforations occurred whilst performing a diagnostic colonoscopy (0.08%) and the remaining 4 after a therapeutic colonoscope (0.16%). In 10 of the cases the diagnosis was made within the first 12 h, and in 5 of these the perforation was identified during the procedure itself. The most common location was the sigmoid, in 7 cases. Surgical treatment was carried out on 11 patients, and in the other two it was resolved by conservative treatment. The most used surgical technique was simple suture followed by resection with anastomosis. One patient died due to intra-abdominal sepsis. Conclusion Perforations caused by colonoscopy are rare, but serious, complications. The majority of these patients required surgical treatment, with conservative treatment being reserved for selected patients.

AIM: To investigate the clinical impact of capsule endoscopy (CE) after an obscure gastrointestinal bleeding (OGIB) episode, focusing on diagnostic work-up, follow-up and predictive factors of rebleeding. METHODS: Patients who were referred to Hospital del Mar (Barcelona, Spain) between 2007 and 2009 for OGIB who underwent a CE were retrospectively analyzed. Demographic data, current treatment with non-steroid anti-inflammtory drugs or anticoagulant drugs, hemoglobin levels, transfusion requirements, previous diagnostic tests for the bleeding episode, as well as CE findings (significant or non-significant), work-up and patient outcomes were analyzed from electronic charts. Variables were compared by χ2 analysis and Student t test. Risk factors of rebleeding were assessed by Log-rank test, Kaplan-Meier curves and Cox regression model. RESULTS: There were 105 patients [45.7% women, median age of 72 years old (interquartile range 56-79)] and a median follow-up of 326 d (interquartile range 123-641) included in this study. The overall diagnostic yield of CE was 58.1% (55.2% and 63.2%, for patients with occult OGIB and overt OGIB, respectively). In 73 patients (69.5%), OGIB was resolved. Multivariate analysis showed that hemoglobin levels lower than 8 g/dL at diagnosis [hazard ratios (HR) = 2.7, 95%CI: 1.9-6.3], patients aged 70 years and above (HR = 2.1, 95%CI: 1.2-6.1) and significant findings in CE (HR = 2.4, 95%CI: 1.1-5.8) were independent predictors of rebleeding. CONCLUSION: One third of the patients presented with rebleeding after CE; risk factors were hemoglobin levels < 8 g/dL, age ≥ 70 years or the presence of significant lesions.