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The diagnostic and therapeutic strategy in severe lower gastrointestinal bleeding (LGIB) varies depending on the patient's clinical situation. Actual clinical practice guidelines propose different management strategies. We aim to know the attitude of the gastroenterologists from different hospitalary centers in the management of this entity.Descriptive and observational study using an on-line questionnaire, addressed to gastroenterologists in Spain and Latin America, in December 2021.We included 281 anonymous questionnaires of gastroenterologists from Spain and Latin America. Diagnostic and therapeutic management of severe LGIB was heterogeneous among the participants. Regarding to the first diagnostic modalities they showed variability between performing computed tomography angiography (CTA) (44.5%), gastroscopy (33.1%), colonoscopy (20.6%) and arteriography (1.1%). The therapeutic attitude after a positive CTA mostly varied between performing arteriography (38.1%) and colonoscopy (44.1%). If negative CTA, in the majority of cases a gastroscopy was performed. If the patient needed intensive critical unit (ICU) care and to undergo colonoscopy, most participants performed an urgent colonoscopy (24h) (31% always, 43.4% in most cases); while if the patient did not require ICU admission this percentage was lower (10% always, 33.8% in most cases). The 40.9% of the participants admitted having doubts about the management of this patients and the 98.2% considered the need for a creation of an action protocol.There is a high interhospitalary variability on the management of severe lower gastrointestinal bleeding among gastroenterologists. It is necessary to unify the diagnostic and therapeutic management of this pathology.

Indocyanine green (ICG) guided lymphadenectomy has been proposed has a technique to improve the lymphadenectomy of patients with gastric cancer. Nevertheless, experience with this procedure is scarce in Western countries.A retrospective analytic study in a tertiary hospital in Spain was performed, comparing patients who underwent laparoscopic gastrectomy with (ICG cohort) and without (historic cohort) ICG guided lymphadenectomy.Thirty four patients were included (17 in each group). Although the number of positive nodes was similar in both groups (0.0 in the ICG cohort vs. 2 in the historic cohort, p = 0.119), the number of lymph nodes removed was higher in the ICG cohort (42.0 vs 28.0, p = 0.040). In the ICG cohort, more lymph nodes were positive for adenocarcinoma in the group of nodes that were positive for IGC (10.6% of the IGC + nodes vs. 1.9% in the ICG - nodes, p 0.001).ICG lymphadenectomy is a promising procedure that could improve the lymphadenectomy of patients with gastric cancer. ICG lymphadenectomy could be used to increase the number of lymph nodes removed in patients with a high-risk of nodal invasion or it could be used to reduce the surgical aggressiveness in fragile patients with a low-risk of nodal invasion.

Background & Aims Most fulfillment and benchmarking information for colonoscopy quality indicators has been obtained from studies of primary screening colonoscopies. We analyzed differences in the fulfillment of colonoscopy quality indicators based on the indication for endoscopy. Methods We performed an observational, multicenter, cross-sectional study of 14,867 patients who underwent endoscopy procedures for gastrointestinal symptoms (40.3%), a positive result from a fecal immunochemical test (36.0%), postpolypectomy surveillance (15.3%), or primary screening (8.4%), from February 2016 through December 2017 at 14 centers in Spain. We evaluated rates of adequate colon cleansing, cecal intubation, adenoma detection, and colorectal cancer detection, among others. We used findings from primary screening colonoscopies as the reference standard. Results Fewer than 90% of patients had adequate bowel preparation; 83.1% of patients with gastrointestinal symptoms had adequate bowel preparation (odds ratio [OR] compared with patients with primary screening colonoscopies, 0.62; 95% CI, 0.49–0.78) and 85.3% of patients receiving postpolypectomy surveillance had adequate bowel preparation (OR, 0.71; 95% CI, 0.55–0.91). The cecal intubation rate was also lower in patients with gastrointestinal symptoms (93.1%) (OR, 0.34; 95% CI, 0.22–0.52). The adenoma detection rate was higher in patients with a positive result from a fecal immunochemical test (46.4%) (OR, 2.01; 95% CI, 1.71–2.35) and in patients undergoing postpolypectomy surveillance (48.2%) (OR, 1.41; 95% CI, 1.20–1.67). The highest proportion of patients with colorectal cancer was in the gastrointestinal symptom group (5.1%) (OR, 5.24; 95% CI, 2.30–11.93) and the lowest was in patients undergoing surveillance (0.8%) (OR, 0.83; 95% CI, 0.32–2.14). Conclusions Fulfillment of colonoscopy performance measures varies substantially by indication. Policies addressing performance measures beyond colonoscopy screening procedures should be developed. Benchmarking recommendations could be adjusted according to colonoscopy indication.

Resumen Introduccion El esofago de Barrett (EB) es una lesion esofagica ocasionada mayoritariamente por reflujo gastroesofagico acido. El control del reflujo acido es uno de los principales objetivos del tratamiento de esta patologia. Objetivo Evaluar en nuestra area de salud el grado de control del reflujo acido en los pacientes con EB en funcion del tratamiento de mantenimiento recibido, medico o quirurgico. Metodos Estudio retrospectivo de pacientes con diagnostico endoscopico e histologico de EB. Un grupo de pacientes recibio tratamiento medico con inhibidores de la bomba de protones (IBP) y otro grupo fue sometido a intervencion quirurgica (funduplicatura de Nissen). Se compararon datos epidemiologicos y resultados de pHmetria (tiempo de pH 5 min, puntuacion de DeMeester) de cada grupo. La pH-metria se realizo con IBP en el grupo de tratamiento medico y en el grupo de cirugia sin consumo de antisecretores acidos. Se definio fracaso del tratamiento como un pH Resultados Fueron incluidos 128 pacientes con EB (tratamiento medico 75, tratamiento quirurgico 53). Ambas cohortes eran homogeneas respecto a sus caracteristicas demograficas. Las puntuaciones de DeMeester, fraccion de tiempo de pH Conclusiones El grado de control del reflujo acido gastroesofagico es suboptimo en un elevado porcentaje de pacientes con EB. El tratamiento medico ofrece resultados inferiores a la cirugia antirreflujo y se deberia intentar optimizar sus resultados.

Introduction Barrett's oesophagus (BE) is an oesophageal injury caused by gastroesophageal acid reflux. One of the main aims of treatment in BE is to achieve adequate acid reflux control. Objective To assess acid reflux control in patients with BE based on the therapy employed: medical or surgical. Methods A retrospective study was performed in patients with an endoscopic and histological diagnosis of BE. Medical therapy with proton pump inhibitors (PPI) was compared with surgical treatment (Nissen fundoplication). Epidemiological data and the results of pH monitoring (pH time 5 min, DeMeester score) were evaluated in each group. Treatment failure was defined as a pH lower than 4 for more than 5% of the recording time. Results A total of 128 patients with BE were included (75 PPI-treated and 53 surgically-treated patients). Patients included in the two comparison groups were homogeneous in terms of demographic characteristics. DeMeester scores, fraction of time pH p p Conclusions Treatment results were significantly worse with medical treatment than with anti-reflux surgery and should be optimised to improve acid reflux control in BE. Additional evidence is needed to fully elucidate the utility of PPI in this disease.

Resumen Introduccion La vitamina D (VD) participa en multitud de funciones extraesqueleticas en el organismo y cada vez es mas importante su relacion con las enfermedades hepaticas cronicas (EHC). Objetivos Analizar la prevalencia de deficit o insuficiencia de VD en los pacientes con EHC de nuestra area. Evaluar si el aporte de VD influye en la concentracion serica y se asocia a mejoria de la funcion hepatica. Material y metodos Realizamos un estudio en 2 fases. En el primer tiempo se analizaron caracteristicas clinico-epidemiologicas de 94 pacientes con EHC; en un segundo tiempo, se administraron diferentes dosis de calcifediol (25-OH-VD) a aquellos pacientes con deficit ( Resultados El 87% de los pacientes tenian concentraciones deficitarias o insuficientes de VD, con una media de 18,8 ng/mL, siendo menor en los cirroticos (15,9 ng/mL) (p = 0,002) y en la etiologia por alcohol. Igualmente la concentracion serica de VD era inversamente proporcionales al grado de funcion hepatica: Child A (16,52 ng/mL) vs. C (7,75 ng/mL). Tras el aporte con VD, se consiguio normalizar los niveles en el 94% de los pacientes, mejorar significativamente la cifra de plaquetas, de albumina (p Conclusion Dada la alta prevalencia de deficit o insuficiencia de VD deberia plantearse la necesidad de cribado en la poblacion con EHC. El aporte de VD podria ser seguro y eficaz.

To describe clinical practice with infliximab (IFX) in ulcerative colitis (UC); identification of predictive factors for IFX treatment discontinuation due to insufficient response and for colectomy.Retrospective, multicentric and observational study including every UC IFX-treated patient in 10 Spanish hospitals. Variables analyzed: epidemiological data; variables for poor prognosis; IFX prior treatments; characteristics of the IFX treatment; time from the UC diagnosis to induction with IFX; time from induction to colectomy or until data collection. Predictive and protective factors for IFX discontinuation due to lack of response and for colectomy were analyzed with binary logistic regression and Cox analysis.Follow-up time from induction with IFX to the collection of data or colectomy: 36.7 ± 25.7 months. Prior treatment with immunomodulator medications (IMM): 79%; IFX + immunosuppressant therapy: 77%; discontinuation of IFX: 26%, colectomy 16%. Independent predictive or protective factors for IFX discontinuation: IMM resistance (OR: 2.9, p = 0.022, 95% CI: 1.2-7.2), prior use of leukocytapheresis (OR: 3.3, p = 0.024, 95% CI: 1.1-9.4), IFX + IMM therapy (OR: 0.3, p = 0.022, 95% CI: 0.1-0.9, and HR: 0.4, p = 0.006, 95% CI: 0.2-0.8) and corticosteroid use in induction (HR: 1.9, p = 0.049, 95% CI: 1.0-3.8). Independent predictive or protective factors for colectomy: Use of leukocytapheresis (OR: 3.0, p = 0.036, 95% CI: 1.1-8.4), IFX + IMM therapy (OR: 0.3, p = 0.022, 95% CI: 0.1-0.8, and HR: 0.3, p = 0.011, 95% CI: 0.1-0.8) and severe cortico-resistant flare-up (HR: 2.5, p = 0.032, 95% CI: 1.1-5.9).Prior use of IMM and leukocytapheresis, the use of corticosteroids in induction and a severe cortico-resistant flare predict a worse response to IFX and the need for colectomy. Combination therapy is a protective factor for both.

Vitamin D (VD) is known to have multiple extra-skeletal health functions. There is emerging interest in exploring the relationship between vitamin D and chronic liver disease (CLD).To determine the prevalence of VD deficiency in patients with CLD in our setting and to assess whether VD supplementation influences plasma levels and is associated with improved liver function.We conducted a study in 2 phases. First, we analysed clinical and epidemiological characteristics in 94 patients with CLD; second, different doses of calcifediol (25-OH-VD) were administered to patients with VD deficiency (20ng/mL) and insufficiency (20-30ng/mL). Plasma concentrations and liver function (Child-Pugh and MELD) at the end of treatment were compared with baseline data.Deficient or insufficient VD levels were found in 87% of the patients, with an average concentration of 18.8ng/mL. Levels were lower in patients with cirrhosis (15.9ng/mL) (P=.002) and in alcoholic liver disease. VD levels were inversely proportional to the degree of liver function: Child A (16.52ng/mL) vs C (7.75ng/mL). After VD supplementation, optimal serum levels were achieved in 94% of patients and significant improvements were observed in platelet count, albumin levels (P.05) and functional status assessed by the Child-Pugh scale (P.05).Given the high prevalence of VD deficiency or insufficiency, the need for screening should be considered in the population with CLD. VD supplementation could be safe and effective.

Barrett's oesophagus (BE) is an oesophageal injury caused by gastroesophageal acid reflux. One of the main aims of treatment in BE is to achieve adequate acid reflux control.To assess acid reflux control in patients with BE based on the therapy employed: medical or surgical.A retrospective study was performed in patients with an endoscopic and histological diagnosis of BE. Medical therapy with proton pump inhibitors (PPI) was compared with surgical treatment (Nissen fundoplication). Epidemiological data and the results of pH monitoring (pH time4, prolonged reflux5min, DeMeester score) were evaluated in each group. Treatment failure was defined as a pH lower than 4 for more than 5% of the recording time.A total of 128 patients with BE were included (75 PPI-treated and 53 surgically-treated patients). Patients included in the two comparison groups were homogeneous in terms of demographic characteristics. DeMeester scores, fraction of time pH4 and the number of prolonged refluxes were significantly lower in patients with fundoplication versus those receiving PPIs (P.001). Treatment failure occurred in 29% of patients and was significantly higher in those receiving medical therapy (40% vs 13%; P.001).Treatment results were significantly worse with medical treatment than with anti-reflux surgery and should be optimized to improve acid reflux control in BE. Additional evidence is needed to fully elucidate the utility of PPI in this disease.

espanolIntroduccion: la intensificacion del tratamiento con infliximab (IFX) en la colitis ulcerosa (CU) es mas frecuente de lo establecido en estudios pivotales. Objetivos: establecer la frecuencia y forma con la que intensificamos en CU en practica clinica, los factores predictores y comparar la evolucion entre los pacientes con tratamiento intensificado y no intensificado. Metodos: estudio retrospectivo de 10 hospitales y 144 pacientes con respuesta a la induccion con IFX. Se analizaron variables predictoras de la intensificacion con analisis de regresion de Cox. Se comparo la evolucion, perdida de respuesta a IFX y colectomia segun tratamiento intensificado o no intensificado. Resultados: tiempo de seguimiento desde la induccion hasta la recogida de datos: 38 meses [rango intercuartil (RIC) 20-62]. Tiempo de tratamiento con IFX: 24 meses (RIC, 10-44). El 37% de los pacientes requirio intensificacion. Se acorto el intervalo en 36 pacientes, se aumento la dosis en 7, ambas en 10. La introduccion simultanea de inmunosupresores tiopurinicos (INM) e IFX predijo la intensificacion de forma independiente [Hazard ratio (HR) 0,034 p 0,006 IC 0,003-0,371]. En los pacientes con tratamiento intensificado fue mas frecuente la suspension de IFX por perdida de respuesta (30,4% vs. 10,2% p 0,002), la reintroduccion de corticoides (35% vs. 18%, p 0,018) y la colectomia (22% vs. 6,4% p 0,011). El 17% de los pacientes intensificados volvio a recibir 5 mg/kg cada 8 semanas. Conclusiones: la intensificacion es frecuente y en ocasiones reversible. La introduccion del INM en el momento de la induccion con IFX predice la no intensificacion. La intensificacion, aunque eficaz, se asocia a una peor evolucion. EnglishIntroduction: Infliximab (IFX) therapy intensification in ulcerative colitis (UC) is more common than established in pivotal studies. Objectives: To establish the frequency and form of intensification for UC in clinical practice, as well as predictors, and to compare outcomes between intensified and non-intensified treatment. Methods: A retrospective study of 10 hospitals and 144 patients with response to infliximab (IFX) induction. Predictive variables for intensification were analyzed using a Cox regression analysis. Outcome, loss of response to IFX, and colectomy were compared between intensified and non-intensified therapy. Results: Follow-up time from induction to data collection: 38 months [interquartile range (IQR), 20-62]. Time on IFX therapy: 24 months (IQR, 10-44). In all, 37% of patients required intensification. Interval was shortened for 36 patients, dose was increased for 7, and 10 subjects received both. Concurrent thiopurine immunosuppressants (IMM) and IFX initiation was an independent predictor of intensification [Hazard ratio, 0.034; p, 0.006; CI, 0.003-0.371]. In patients on intensified therapy IFX discontinuation for loss of response (30.4% vs. 10.2%; p, 0.002), steroid reintroduction (35% vs. 18%; p, 0.018), and colectomy (22% vs. 6.4%; p, 0.011) were more common. Of patients on intensification, 17% returned to receiving 5 mg/kg every 8 weeks. Conclusions: Intensification is common and occasionally reversible. IMM initiation at the time of induction with IFX predicts non-intensification. Intensification, while effective, is associated with poorer outcome.