Search

INTRODUCTION Knowing the natural history of ulcerative colitis (UC) is essential to understand the course of the disease, assess the impact of different treatment strategies and identify poor prognostic factors. One of the most significant matters in this regard is the need for surgery. OBJECTIVES To analyse the Colectomy Incidence Rate (CIR) from diagnosis to end of follow-up (31/12/2017) and identify predictive factors for colectomy. MATERIAL AND METHODS A retrospective study enrolling patients with a definitive diagnosis (DD) of UC or Unclassified Colitis (UnC) in the 2001-03 Navarra cohort. RESULTS We enrolled 174 patients with a DD of UC (E2 42.8%; E3 26.6%) and 5 patients with a DD of UnC: 44.1% women, median age 39.2 years (range 7-88) and median follow-up 15.7 years. A total of 8 patients underwent surgery (CIR 3 colectomies/103 patient-years: 3 at initial diagnosis (

Knowing the natural history of ulcerative colitis (UC) is essential to understand the course of the disease, assess the impact of different treatment strategies and identify poor prognostic factors. One of the most significant matters in this regard is the need for surgery.To analyse the Colectomy Incidence Rate (CIR) from diagnosis to end of follow-up (31/12/2017) and identify predictive factors for colectomy.A retrospective study enrolling patients with a definitive diagnosis (DD) of UC or Unclassified Colitis (UnC) in the 2001-03 Navarra cohort.We enrolled 174 patients with a DD of UC (E2 42.8%; E3 26.6%) and 5 patients with a DD of UnC: 44.1% women, median age 39.2 years (range 7-88) and median follow-up 15.7 years. A total of 8 patients underwent surgery (CIR 3 colectomies/103 patient-years: 3 at initial diagnosis (1 month), 2 in the first 2 years, 2 at 5 years from diagnosis and 1 at 12 years from diagnosis. All had previously received steroids; 5 had received immunomodulators and 2 had received biologics. In 7 patients (87%), surgery was performed on an emergency basis. The indication was megacolon in 3 (37.5%), severe flare-up in 3 (37.5%) and medical treatment failure in 2 (25%). In 5 cases (62.5%), an ileoanal pouch was made, and in 3 cases, a definitive ileostomy was performed. In the univariate analysis, patients with loss of more than 5 kg at diagnosis and admission at diagnosis had a lower rate of colectomy-free survival.In our series, colectomy rates are lower than usually reported. Most colectomies were performed in the first 5 years following diagnosis and had an emergency indication.

Introduction: obscure gastrointestinal bleeding is defined as bleeding from a source that cannot be identified on upper or lower gastrointestinal endoscopy and capsule endoscopy is the next step in these patients. Some patients may be unsuitable for conventional endoscopy and performing a capsule panendoscopic test as a first line procedure might potentially reduce the number of endoscopies and their subsequent risk. Aim: to analyze our experience with capsule endoscopy in the bleeding setting. Methods: the first 100 panendoscopic capsule procedures performed in our center from August 2011 until December 2016 were retrospectively reviewed. Results: positive findings were observed in 61.2 % of patients; 46.26 % had a previous negative gastroscopy and the capsule detected small bowel lesions in 67.7 % and colonic findings in 80.64 %. Taking into consideration that our population were high-risk patients (mainly because of comorbidities) and that we used up to 45 ml of sodium phosphate, sodium, potassium and creatinine changes were analyzed before and after procedure. The mean “before” values were 140.68, 4.04 and 1.36, respectively. The mean “after” values were 140.28, 3.9 and 1.35 (p = n.s.). According to our findings, no other endoscopic studies would be needed in 64.5 % of patients with negative gastroscopy. According to capsule results, conventional endoscopy could have been avoided in 68.6 % of cases. Conclusion: panendoscopy with a capsule may be useful and safe in bleeding high-risk patients, by selecting those who need therapeutic endoscopy, avoiding up to 68.6 % of diagnostic endoscopies in our series.

Background and Aims It is known that sodium picosulfate–magnesium citrate (SPMC) bowel preparations are effective, well tolerated and safe, and that split-dosing is more effective for colon cleansing than previous-day regimens. Anesthetic guidelines consider that residual gastric fluid is independent of clear liquid fasting times. However, reluctance to use split-dosing persists. This may be due to limited data on residual gastric fluid volumes (RGFVs) and split-dosing bowel preparations, and that these may not be perceived as standard clear liquids. Furthermore, no studies are available on RGFV/residual gastric fluid pH (RGFpH) and SPMC. We aimed to evaluate the cleansing effectiveness and the RGFV/RGFpH achieved after an SPMC split-dosing regimen compared with a SPMC previous-day regimen. Methods This was a single-center observational study. A total of 328 outpatients scheduled for simultaneous EGD and colonoscopy and following a split-dosing or previous-day regimen of SPMC were included. We prospectively measured colon cleanliness by using the Ottawa Bowel Preparation Scale, RGFV, and RGFpH. Results Ottawa Bowel Preparation Scale scores for overall, right, mid-colon, and colon fluid were significantly better in the split-dosing group. In the split-dosing group, the 3- to 4-hour fasting time consistently achieved the best cleansing quality. RGFV was significantly lower in the split-dosing group (11.09 vs 18.62, P Conclusions Split-dosing SPMC provides higher colon cleansing quality with lower RGFVs than previous-day SPMC regimens. SPMC in split-dosing acts exactly as a standard clear liquid acts, and thus anesthetic guidelines on this issue may be applied with no concerns.

Introduction: The socioeconomic burden of irritable bowel syndrome with constipation (IBS-C) has never been formally assessed in Spain. Patients and methods: This 12-month (6-month retrospective and prospective periods) observational, multicentre study assessed the burden of moderate-to-severe IBS-C in Spain. Patients were included if they had been diagnosed with IBS-C (Rome III criteria) within the last 5 years and had moderate-to-severe IBS-C (IBS Symptom Severity Scale score [IBS-SSS] >= 175) at inclusion. The primary objective was to assess the direct cost to the Spanish healthcare system (HS). Results: A total of 112 patients were included, 64 (57%) of which had severe IBS-C at inclusion. At baseline, 89 (80%) patients reported abdominal pain and distention. Patient quality of life (QoL), measured by the IBS-C QoL and EQ-5D instruments, was found to be impaired with a mean score of 59 and 57 (0100, worst-best), respectively. Over the 6-month prospective period the mean IBS-C severity, measured using the IBS-SSS showed some improvement (315234 [0500, bestworst]). During the year, 89 (80%) patients used prescription drugs for IBS-C, with laxatives being the most frequently prescribed (n = 70; 63%). The direct cost to the HS was (sci)1067, and to the patient was (sci)568 per year. The total direct cost for moderate-to-severe IBS-C was (sic)1635. Discussion: The majority of patients reported continuous IBS-C symptoms despite that 80% were taking medication to treat their IBS-C. Overall healthcare resource use and direct costs were asymmetric, with a small group of patients consuming the majority of resources. (C) 2018 Elsevier Espana, S.L.U. All rights reserved.

Background Patients with type 1 diabetes mellitus (DM1) have an increased risk of celiac disease (CD). Since CD can be seronegative, more sensible tests for detection are needed. In seronegative patients, CD diagnosis may be difficult because of a lack of specificity. Flow cytometry analysis of lymphocyte populations can be useful in this situation. We aimed to study the prevalence of CD in adult DM1 using human leukocyte antigen (HLA) compatibility-based screening. A secondary goal was to study the role of flow cytometry as a complementary tool in these patients. Methods We selected 200 patients with DM1, of whom 190 (95%) had HLA DQ2, DQ8 or both. Of these, 136 agreed to participate and provided epidemiological data. All patients underwent blood tests and gastroscopy. Results Sixteen patients had a histology consistent with CD. After ruling out other diagnoses, 6 patients were diagnosed with CD, 2 of whom had negative antibodies. All were DQ2.5 homozygous, with a CD prevalence of 9.8% in this group. In the flow cytometry analysis of duodenal biopsy samples, when we compared all non-CD with CD patients, we found that the γ/δ intraepithelial lymphocyte (IEL) percentage was significantly higher and the CD3 negative IEL percentage significantly lower in the CD group. We found similar results when we compared only those with histological lesions. Conclusions Screening of CD in patients with DM1 by HLA detects only 1% of seronegative patients with CD. DQ2.5 homozygous patients are at most risk of developing CD. The study of lymphocyte populations in the duodenal biopsy by flow cytometry discriminates patients with CD from those without CD with high sensitivity and specificity. Keywords Celiac disease, flow cytometry, HLA typing, type 1 diabetes mellitus Ann Gastroenterol 2017; 30 (2): 179-185

Objective The use of colonoscopy as a primary screening test for colorectal cancer (CRC) in average risk adults is a subject of controversy. Our primary objective was to build a predictive model based on a few simple variables that could be used as a guide for identifying average risk adults more suitable for examination with colonoscopy as a primary screening test. Methods The prevalence of advanced adenomas was assessed by primary screening colonoscopy in 2210 consecutive adults at least 40 yr old, without known risk factors for CRC. Age, gender, and clinical and biochemical data were compared among people without adenomas, those with nonadvanced adenomas, and those with any advanced neoplasm. A combined score to assess the risk of advanced adenomas was built with the variables selected by multiple logistic regression analysis. Results Neoplastic lesions were found in 617 subjects (27.9%), including 259 with at least one neoplasm that was 10 mm or larger, villous, or with moderate-to-severe dysplasia, and 11 with invasive cancers. Advanced lesions were more frequent among men, older people, and those with a higher body mass index (BMI). These three variables were independent predictors of advanced adenomas in multivariate analysis. A score combining age, sex, and BMI was developed as a guide for identifying individuals more suitable for screening colonoscopy. Conclusions Age, gender, and BMI can be used to build a simple score to select those average risk adults who might be candidates for primary screening colonoscopy.

The Peutz-Jeghers syndrome (PJS) is an autosomal dominant hamartomatous poliposis describred in 1921. Hemminki in 1997 described the presence of LKB-1 mutation tumor-suppressor gen. The patients with PJS develop a higher cumulative incidence of gastrointestinal, pancreas and extraintestinal tumors, being oc casion of a renew interest on hamartomatous polyposis syndro mes regarding the clinical care, cancer surveillance treatment and long term follow-up. We report the case of a 38 years old male, diagnosed of PJS who developed a multiple adenocarcinoma in duodenum and ye yunum. Surgically treated and with a long-term free disease survival of 11 years represents the sixth case reported in the spanish literature of PJS associated with a gastrointestinal tumor. A critical review, molecular alterations and the established criteria of tumor screening and surveillance are reviewed.

Radioembolization is a new tool for the treatment of hepatic tumors that consists in the injection of biocompatible microspheres carrying radioisotopes into the hepatic artery or its branches. METHODS: We have performed radioembolization in 78 patients with hepatic tumors using resin-based microspheres loaded with yttrium-90. All patients were previously evaluated to minimize the risk of hazardous irradiation to nontarget organs and to obtain the data needed for dose calculation. RESULTS: We report a complication found in three cases (3.8%) that consists of abdominal pain resulting from gastroduodenal lesions and that had a chronic, insidious course. Microscopically, microspheres were detected in the specimens obtained from all affected gastric areas. Since these gastroduodenal lesions do not appear when nonradiating microspheres are injected in animals, lesions are likely to be due to radiation and not to an ischemic effect of vascular occlusion by spheres. CONCLUSIONS: We believe that a pretreatment evaluation that includes a more thorough scrutiny of the hepatic vascularization in search of small collaterals connecting to the gastroduodenal tract can help prevent this awkward complication

For colorectal cancer screening, the predictive value of distal findings in the ascertainment of proximal lesions is not fully established. The aims of this study were to assess distal findings as predictors of advanced proximal neoplasia and to compare the predictive value of endoscopy alone vs. combined endoscopic and histopathologic data. METHODS: Primary colonoscopy screening was performed in 2210 consecutive, average-risk adults. Age, gender, endoscopic (size, number of polyps), and histopathologic distal findings were used as potential predictors of advanced proximal neoplasms (i.e., any adenoma > or =1 cm in size, and/or with villous histology, and/or with severe dysplasia or invasive cancer). Polyps were defined as distal if located in the descending colon, the sigmoid colon, or the rectum. Those in other locations were designated proximal. RESULTS: Neoplastic lesions, including 11 invasive cancers, were found in 617 (27.9%) patients. Advanced proximal neoplasms without any distal adenoma were present in 1.3% of patients. Of the advanced proximal lesions, 39% were not associated with any distal polyp. Older age, male gender, and distal adenoma were independent predictors of advanced proximal neoplasms. The predictive ability of a model with endoscopic data alone did not improve after inclusion of histopathologic data. In multivariate logistic regression analysis, the predictive ability of models that use age, gender, and any combination of distal findings was relatively low. The proportion of advanced proximal neoplasms identified if any distal polyp was an indication for colonoscopy was only 62%. CONCLUSIONS: A strategy in which colonoscopy is performed solely in patients with distal colonic findings is not effective screening for the detection of advanced proximal neoplasms in an average-risk population

colonoscopy was not different in the Prepsystem (19 3 min) and the PEG (22 1 min) groups. Blood electrolytes were not significantly modified after bowel cleansing in both groups. Patient satisfaction was good to excellent in all cases in the Prepsystem group. Conclusion: The Prepsystem water infusion protocol appeared as effective as the splitted PEG protocol for bowel cleansing before colonoscopy. Patient tolerance of the Prepsystem was good. Further studies should evaluate the benefit of this protocole in patients with contraindications or poor tolerance to PEG cleansing or in ambulatory patients. Su1550 Establishing the Learning Curve for Achieving Competency in Performing Colonoscopy: a Systematic Review Neal Shahidi*, George Ou, Jennifer J. Telford, Robert a. Enns Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada Background: Training in colonoscopy (CSPY) is a difficult but an integral part of gastroenterology and surgical training programs. However, the number of procedures required to achieve competence is not well established, leading to significant heterogeneity among current guidelines. Aims: To assess the learning curve for achieving competency in performing CSPYs during gastroenterology and surgical training. Methods: Two investigators (NS and GO) independently searched MEDLINE (1946 June 2013) and the grey literature (bibliographies of included studies, pertinent review articles and guidelines) to identify relevant citations. Subsequently, after full-text review, studies meeting inclusion underwent data extraction with discrepancy among investigators resolved by consensus. A threshold of 90% independent cecal intubation rate (ICIR) was used as a minimum reference for competence. Results: 18 unique study populations, encompassing 38,000 CSPYs were included in our analysis. When stratifying by markers of competence: 10 studies used ICIR; 6 studies used ICIR with a cecal intubation time (CIT) limit; 1 study used ICIR with a procedural time limit; and 2 studies provided more comprehensive definitions of competence. Among the 10 studies that solely quantified ICIR, 4 studies were able to reach the reference competence estimate during analysis (90% ICIR), with trainees reaching competence between 140 to 305 CSPYs. In studies additionally setting a CIT (15 minutes 30 minutes) limit, competence was reached in 5 studies between 100 to 300 CSPYs. Of the 2 studies who provided more comprehensive estimates of competence, their reference competence thresholds were reached between 275 to 467 CSPYs. Conclusions: Our results suggest that as the definition of competence becomes more robust (i.e. acceptable for clinical practice) and incorporates more than just ICIR and CIT that the threshold to achieve competency continues to rise well above current recommendations. With newer levels of competence being promoted, present guidelines need to reassess the level of training required to adequately train endoscopists. Su1551 Split-Dose Sodium Picosulfate and Magnesium Citrate Preparation for Colonoscopy: Cleansing Effectiveness and Residual Gastric Volume and pH CeSar Prieto*, RAMoN AngoS, Maria Teresa BeteS, Susana De La Riva, Iago RodriGuez Lago, Cristina Carretero, Maite Herraiz, Alejandra Alzina Perez, Miguel a. MUnOz-Navas Gastroenterology, Clinica Universidad de Navarra, Pamplona, Spain Background: Split dose bowel preparations result in superior bowel cleanness. Although there is evidence that smaller residual gastric volumes (RGV) are obtained with fasting times of 2-4 hours when compared with more than 4 hours, and the relationship between fasting times for clear liquids and risk of pulmonary aspiration has not been demonstrated, there is still concern about the increased risk of aspiration when using a split-dosing regimen. Low-volume bowel preparation containing sodium picosulfate and magnesium citrate (PMC) has shown to be better tolerated, and at least as effective, as other cleansing agents. Aim: To compare the cleansing efficacy, RGV, gastric pH and tolerabilty between a PMC split-dose regimen and a traditional evening-before-procedurecomplete PMC regimen. Methods: Patients aged 18 to 80 ys. requiring elective gastroscopy (EGD) and colonoscopy in the same day were invited to participate. Exclusion criteria were: known gastroparesis, gastric outlet obstruction, hiatal herniaO4 cm, previous gastrointestinal resections excluding appendicectomy, renal insufficiency, active inflammatory bowel disease, and elevated anesthesic risk (ASA III-IV). Patients were distributed to split-dose group (1) or traditional regimen group (2) exclusively depending on the hour and date of medical visit. Group 1 patients were instructed to take a PMC sachet at 19:00 the evening before the procedure, and a second sachet 4 hours before the procedure. Group 2 patients were instructed to take 1 sachet at 15:00 and second sachet at 20:00 both the evening before the procedure. Tolerability was assesed by completing a questionnaire just before the procedure. Colonoscopy was performed immediately after EGD. Total gastric volume was suctioned off and collected in a graded AB318 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 specimen trap. Colon cleansing efficacy was assesed by Ottawa Bowel Preparation Scale (OBPS). Results: 206 patients were included (group 1: 116; group 2: 90). There were no significant differences in patient characteristics between the two groups. Mean time interval ( SD) between last reported ingestion was 3.63 hours ( 1.02) (range 2-6 hours) in the split-dosing group, and 11.59 ( 1.64) in the traditional regimen group. Mean RGV was significantly lower in group 1 than in group 2 (11.65 vs.17.50 ml; p!0.005). pH of RGV in group 1 was slightly higher than group 2 (2.06 vs.1.45; ns). Total, mid-colon and right-colon OBPS scores were significantly bettter in group 1 than in group 2 (3.47 vs 4.38, p!0.01; 1.18 vs 0.91, p!0.05; 1.16 vs 1.67 p!0.001, respectively). No significant differences in tolerabilty were found. No patient had evidence of aspiration. Conclusions: Patients receiving split-dose regimen of PMC have lower residual gastric volumes and superior cleansing levels, specially in right colon, than those receiving traditional regimen, suggesting an efficacy and safety adventage. SPLITDOSING (n[116) Mean (± SD) TRADITIONAL REGIMEN (n [ 90) Mean (± SD)

Aims: To establish independent predictive risk factors for APA in averagerisk population. Methods: From 1988 to 1998 screening total colonoscopy was performed in consecutive average-risk people, with strict exclusion criteria. Clinical, biochemical, endoscopic and histologic data were recorded. The term advanced was used for adenomas with villous component, moderate-severe dysplasia or ≥1cm. Adenomas were defined as distal if they came from the descending colon or distally. Univariate comparisons were assesed using the Chi2 Test and logistic regression. Backward stepwise logistic regression was used for multivariate analyses. Results: APA were detected in 125 of 2210 subjects (5.66%); 56 (44.8%) had no index distal adenoma. Independent predictors for presenting APA, after adjustment for the endoscopist who performed the endoscopy, are shown in the table. Conclusions: Almost half cases with APA did not present a distal index lesion. Distal polyp characteristics which were independent risk factors for APA were villous component and moderate-severe dysplasia.This multivariate model offers guidelines for clinicians in the approach to patients with distal tubular adenomas.

Evidence from controlled trials suggest that removing adenomatous polyps reduce the incidence of colorectal cancer. Nowadays, it is clear that only a small proportion of adenomas go on to develop into cancer. Advanced adenomas (AA; adenoma ≥ 1 cm in size, with villous component, or with moderate to high-grade dysplasia) are associated with an increased risk of malignancy. Aims: To establish independent predictive factors of AA in average-risk asymptomatic population. Methods: From 1988 to 1998 screening total colonoscopy was performed, as a part of a routine medical checking, in 2210 consecutive average-risk asymptomatic people, in whom strict exclusion criteria were applied. Clinical, biochemical, endoscopic and histologic data were recorded. Univariate comparisons were assessed using the Chi2 test and logistic regression. Backward stepwise logistic regression was used for multivariate analysis. Results: Colonic polyps were detected in 885 of 2210 patients and neoplastic lesions in 617 (27.9%). 11 subjects (0.5%) presented malignant polyps or carcinoma. AA were found in 268 patients (12.1%). The variables selected by univariate analyses to enter the multivariate model were: age (p