Resumen El espectro de enfermedades asociadas con la deficiencia de la vitamina B 12 es amplio y abarca desde la ausencia de síntomas hasta el síndrome de malabsorción, insuficiencia medular, o síntomas neurológicos acompañados de parestesias, mielopatía o neuropatía. Existe evidencia sugestiva que indica que el empleo de inhibidores de bomba de protones (IBP) a largo plazo puede disminuir los niveles séricos de vitamina B12. Igualmente, estudios previos han asociado el déficit de vitamina B 12 a consumo en dosis altas de metformina, sin embargo, el mecanismo por el cual se genera la descompensación no está claro. Se ha llegado a describir una asociación aditiva de la administración de inhibidores bomba de protones/ Antagonistas receptor Histamina - 2 y metformina, sugiriendo que promueven la malabsorción de Vitamina B 12. Ambas categorías de medicamentos son ampliamente utilizadas, y en muchos casos sin prescripción médica, y su uso no debería ser pasado por alto. Cuando están clínicamente indicados, su uso debería ser monitorizado debido a la posibilidad de malabsorción de vitamina B 12 y sus consecuencias. Por tanto, en este artículo se revisan aspectos generales sobre la vitamina B12 y el estado del arte sobre la deficiencia de vitamina B12 en pacientes con consumo de metformina o uso de inhibidor de bomba de protones.

Abstract The spectrum of diseases associated with vitamin B12 deficiency is broad, ranging from no symptoms to malabsorption syndrome, spinal cord injury, neurological symptoms accompanied by paresthesia, myelopathy, or neuropathy. There is suggestive evidence that long-term use of proton pump inhibitors (PPIs) can lower serum levels of vitamin B12. Additionally, previous studies have associated vitamin B12 deficiency with high doses consumption of metformin; however, the mechanism in which this occurs is not clear. An additive association between the administration of proton pump inhibitors / Histamine H2 receptor antagonists, and metformin has been described, which suggest that these promote vitamin B12 malabsorption. Both categories of drugs are widely used, in many cases without a prescription, and its use should not be overlooked. When clinically indicated, their use should be monitored in view of the possibility of vitamin B12 malabsorption and its consequences. This article aims to review general aspects of vitamin B12 and delve into the state of the art regarding vitamin B12 deficiency in patients with metformin and / or proton pump inhibitor consumption.

RESUMO Contexto O escore de Rockall é a escala de prognóstico mais amplamente usada para avaliar o risco de complicações de sangramento gastrointestinal superior não varicoso. Vários estudos foram conduzidos em populações adultas com sangramento gastrointestinal superior não varicoso em diferentes partes do mundo, com achados conflitantes quanto à extensão da associação entre o escore e alguns desfechos de morbimortalidade. Há também controvérsias em relação ao melhor ponto de corte para a pontuação. Além disso, não foram realizados estudos que validem essa pontuação na Colômbia. Objetivo Avaliar o desempenho diagnóstico do escore de Rockall na previsão de ressangramento e mortalidade em pacientes com sangramento gastrointestinal superior não varicoso. Métodos Um estudo de coorte prospectivo foi conduzido em pacientes que necessitaram de endoscopia digestiva alta (EDA) para sangramento não varicoso. Os escores de Rockall pré e pós-endoscopia foram calculados e os resultados, incluindo mortalidade, mortalidade associada ao sangramento gastrointestinal superior não varicoso e ressangramento intra-hospitalar foram determinados nos pontos de tempo de 1 e 3 meses. A associação entre os escores e esses desfechos foram avaliados pelo teste de chi2 ou Fisher, enquanto a habilidade de discriminação do escore foi determinada pelas áreas sob a curva ROC (AUC). Alta capacidade de discriminação foi considerada existente nos casos em que uma AUC ≤0,7 com α=0,05 poderia ser rejeitada. Resultados No geral, 177 pacientes foram analizados. Os desfechos hospitalares em 1 e 3 meses foram de 12%, 17% e 23% para mortalidade geral, 6%, 12% e 15% para mortalidade com hemorragia digestiva alta e 19%, 30% e 37% para ressangramento. O escore de Rockall pós-endoscopia foi associado aos três desfechos nos três momentos avaliados, enquanto o escore pré-endoscopia foi associado apenas à mortalidade geral nos três momentos, e ressangramento em 1 e 3 meses. Em relação à capacidade de discriminação, embora a AUC fosse maior do que o esperado pela aleatoriedade (0,5) em todos os casos, apenas uma AUC ≤0,7 foi rejeitada no escore pós-endoscopia para mortalidade com hemorragia digestiva alta intra-hospitalar (AUC =0,901; 95%IC: 0,845—0,958), em 1 mês (AUC =0,836; 95%IC 0,717—0,954) e em 3 meses (AUC =0,869; 95%IC: 0,771—0,967), e para ressangramento em 1 mês (AUC =0,793; 95%IC: 0,725—0,861) e aos 3 meses (AUC =0,806; 95%IC: 0,741—0,871). Conclusão Foi encontrada associação entre o escore de Rockall, ressangramento e mortalidade em pacientes com hemorragia digestiva alta não varicosa. Apenas o escore pós-endoscopia teve alta capacidade preditiva para ressangramento e mortalidade por sangramento gastrointestinal superior não varicoso.

ABSTRACT Background Rockall score is the most widely used prognostic scale for assessing risk of complications from non-varicose upper gastrointestinal bleeding (UGIB). Several studies have been conducted in adult populations with non-varicose UGIB in different parts of the world, with conflicting findings regarding the extent of association between the score and some morbidity and mortality outcomes. Also, there is controversy regarding the best cut-off point for the score. Moreover, no studies validating this score in Colombia have been carried out. Objective To assess the diagnostic performance of the Rockall score in predicting rebleeding and mortality in patients with non-varicose UGIB. Methods A prospective cohort study was conducted in patients requiring upper gastrointestinal endoscopy (UGIE) for non-varicose bleeding. The pre-and post-endoscopy Rockall scores were calculated and outcomes, including mortality, UGIB-associated mortality and in hospital rebleeding were determined at the 1 and 3-month time points. The association between the scores and these outcomes was assessed using the chi2 or the Fisher test, whereas the discrimination ability of the score was determined using the areas under the ROC curve (AUC). High discrimination ability was considered to exist in cases in which an AUC ≤0.7 with α=0.05 could be rejected. Results Overall, 177 patients were analyzed. In-hospital outcomes at 1 and 3 months were 12%, 17% and 23% for general mortality, 6%, 12% and 15% for UGIB mortality, and 19%, 30% and 37% for rebleeding. The post-endoscopy Rockall score was associated with the three outcomes at the three time points assessed, while the pre-endoscopy score was only associated with general mortality at the three time points, and rebleeding at 1 and 3 months. Regarding discrimination ability, although the AUC was greater than expected by randomness (0.5) in all cases, only one AUC ≤0.7 was rejected in the post-endoscopy score for in-hospital UGIB mortality (AUC=0.901; 95%CI: 0.845—0.958), at 1 month (AUC=0.836; 95%CI: 0.717—0.954) and at 3 months (AUC=0.869; 95%CI: 0.771—0.967), and for rebleeding at 1 month (AUC=0.793; 95%CI: 0.725—0.861) and at 3 months (AUC=0.806; 95%CI: 0.741—0.871). Conclusion An association was found between the Rockall score and rebleeding and mortality in patients with non-varicose UGIB. Only the post-endoscopy score had a high predictive ability for rebleeding and UGIB mortality.

Abstract Introduction: The platelet count/spleen diameter (PC/SD) ratio is a noninvasive method for the diagnosis of esophageal varices (EV) used as an alternative to endoscopy in patients with cirrhosis. Objective: To evaluate the diagnostic performance of the PC/SD ratio (cut-off point <909) to detect EV in patients with cirrhosis treated at a tertiary referral hospital in Bogotá D.C., Colombia. Materials and methods: A prospective diagnostic test accuracy study was conducted in 66 patients with cirrhosis treated at the Hospital Universitario de La Samaritana between July and December 2018. A descriptive analysis of the data was performed. In addition, the diagnostic performance of the PC/SD ratio (cut-off point <909) for the detection of EV was compared with the findings reported in the esophagogastroduodenoscopy (gold standard), calculating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-). A significance level of p<0.05 was considered. Results: The mean age of the participants was 65.5 years, 53.03% were female, and the most common causes of cirrhosis were alcohol consumption (40.90%) and autoimmune hepatitis (22.72%). EV was diagnosed in 48 patients (72.72%). The PC/SC ratio showed sensitivity of 60%, specificity of 78%, PPV of 0.88, NPV of 0.42, LR+ of 2.73, and LR- of 0.51. Conclusion: The low sensitivity, specificity, and NPV found in the present study suggest that the PC/SD ratio (cut-off point <909) may not be a useful diagnostic test for detecting EV in patients with cirrhosis.

Resumen Introducción. El índice de recuento de plaquetas/diámetro del bazo (RP/DB) es un método no invasivo para el diagnóstico de varices esofágicas (VE) que se usa como alternativa a la endoscopia en pacientes con cirrosis. Objetivo. Evaluar el rendimiento diagnóstico del índice RP/DM (punto de corte <909) para detectar VE en pacientes cirróticos atendidos en un hospital de tercer nivel de Bogotá D.C., Colombia. Materiales y métodos. Estudio prospectivo de validez de prueba diagnóstica realizado en 66 pacientes cirróticos atendidos en el Hospital Universitario de La Samaritana entre julio y diciembre de 2018. Se realizó un análisis descriptivo de los datos. Además, el rendimiento diagnóstico del índice RP/DM (punto de corte <909) para la detección de VE se comparó con los hallazgos de la esofagogastroduodenoscopia (prueba de oro), calculándose su sensibilidad, especificidad, valor predictivo positivo (VPP), valor predictivo negativo (VPN), razón de probabilidad positiva (LR+) y razón de probabilidad negativa (LR-). Se consideró un nivel de significancia de p<0.05. Resultados. La edad promedio de los participantes fue 65.5 años, 53.03% eran mujeres y las causas más comunes de cirrosis fueron consumo de alcohol (40.90%) y hepatitis autoinmune (22.72%). Las VE fueron diagnosticadas en 48 pacientes (72.72%). El índice RP/DM tuvo una sensibilidad de 60%, una especificidad de 78%, un VPP de 0.88, un VPN de 0.42, una LR+ de 2.73 y una LR- de 0.51. Conclusión. La baja sensibilidad, especificidad y VPN encontrados en el presente estudio sugieren que el índice RP/DM (punto de corte <909) podría no ser una prueba diagnóstica útil para detectar VE en pacientes cirróticos.

Resumen Introducción: la epidemiología de la disfagia está pobremente definida. Es un síntoma que se asocia con el envejecimiento, y en poblaciones jóvenes sigue siendo tema de incertidumbre. También es un problema que no siempre informan los pacientes y es poco comprendido en la población general. Objetivo: describir las características clínicas y epidemiológicas de la disfagia a partir de una muestra de pacientes adultos remitidos a un centro especializado en gastroenterología. Metodología: estudio observacional, descriptivo y retrospectivo, realizado en un centro especializado en gastroenterología en Bogotá D. C. durante 2016, en el cual se revisaron 3148 historias clínicas y se recopilaron aquellas de pacientes cuyo motivo de consulta fuera disfagia o la refirieran como síntoma asociado, y cuyo diagnóstico se confirmara con pruebas complementarias. Resultados: de 3148 historias clínicas, 85 (2,7 %) presentaron disfagia como motivo de consulta principal o síntoma asociado. La mayoría correspondió a mujeres (70,5 %). El grupo de edad más afectado fue entre 70 y 79 años. La enfermedad por reflujo gastroesofágico (ERGE) representó el diagnóstico más frecuente. Conclusión: la prevalencia de disfagia encontrada es similar a la reportada en la literatura. La ERGE es causa frecuente de disfagia. La disfagia continúa siendo un problema predominantemente de adultos mayores.

Abstract Introduction: The epidemiology of dysphagia is poorly defined. It is a symptom that is associated with aging but is still a matter of uncertainty in young populations. Also, it is is not always reported by patients and is poorly understood in the general population. Objective: The objective of this study was to describe the clinical and epidemiological characteristics of dysphagia in a sample of adult patients referred to a center specializing in Gastroenterology. Methodology: This is an observational, descriptive and retrospective study carried out in a specialized gastroenterology center in Bogotá DC in 2016. We reviewed 3,148 clinical histories of patients to identify those whose reason for consultation was dysphagia or who were referred to the clinic with dysphagia as an associated symptom and whose diagnoses had been confirmed by complementary tests. Results: Of the 3,148 medical records, 85 (2.7%) presented dysphagia as the main reason for consultation or as an associated symptom. The majority were women (70.5%). The largest proportion of those affected were between 70 and 79 years old. Gastroesophageal reflux disease was the most frequent diagnosis. Conclusion: The prevalence of dysphagia found is similar to that reported in the literature. Gastroesophageal reflux disease is a frequent cause of dysphagia. Dysphagia continues to be a problem especially among the elderly.

Se realizó un estudio observacional descriptivo de los pacientes sometidos a esofagogastroduodenoscopia durante los años 2004 y 2009 en el Hospital Universitario de La Samaritana y con diagnóstico histológico de cáncer gástrico gástrico (CG). Se encontraron 259 casos, con predominio de los hombres (153 hombres, 106 mujeres), con edad promedio de 66 años. Fue notoria la proporción de pacientes (40%) que consultaron por hemorragia digestiva alta y con diagnóstico final de CG. El 97% de casos correspondió a tumores avanzados, y la morfología Bormann III y IV fueron las más comunes (72% y 16% respectivamente). Se observó una leve mayoría (53%) de adenocarcinomas de tipo intestinal respecto al difuso. La localización proximal de los tumores (cardias, fondo, cuerpo) fue la predominante (56,4%), en especial entre hombres (65%). La mayoría de los pacientes (69,4%) provenía de regiones del departamento de Cundinamarca situadas por encima de los 2.000 metros sobre el nivel del mar (msnm). Se plantea la necesidad de crear programas de detección temprana del CG en las regiones de alta incidencia.

This is a descriptive observational study of patients upon whom esophagogastroduodenoscopies had been performed at the hospital Universitario de La Samaritana from 2004 to 2009 and who had been diagnosed histologically with Gastric Cancer (GC). 259 cases, 153 men and 106 women, with average ages of 66 years were included. A very high proportion of patients (40%) who had sought medical assistance because of digestive hemorrhaging were ultimately diagnosed with GC. 97% of these cases had advanced tumors with Bormann levels III and IV being the most common (72% and 16% respectively). A large percentage of patients (53%) had diffuse intestinal adenocarcinomas. Proximal locations of these tumors in the cardia, fundus, corpus) predominated (56.4%) especially among male patients (65%). The majority of these patients (69.4%) came from regions of the department of Cundinamarca located more than 2,000 meters above sea level. Early detection programs for GC need to be established in regions of high incidence.

Se presenta un grupo de 75 pacientes adultos colombianos, con diagnóstico de gastritis crónica atrófica de acuerdo a los criterios de Sydney, de los cuales el 28% presentó deficiencia de vitamina B12 y al 9% se le diagnóstico anemia perniciosa. Las cifras de hemoglobina, volumen corpuscular medio no se correlacionaron con el déficit de vitamina B12. No se encontró una asociación estadística del déficit de la vitamina B12 con el género, edad mayor de 60 años de los pacientes o con la presencia del Helicobacter pylori (H. pylori). La edad promedio de los pacientes con déficit de vitamina B12 o con anemia perniciosa es menor a la que tradicionalmente se reporta para estas enfermedades

We present a group of 75 Colombian adults who were diagnosed with chronic atrophic gastritis in accordance with the Sydney criteria. 28% of the group had vitamin B12 deficiencies: 9% were diagnosed with Pernicious anemia. Hemoglobin and mean corpuscular volume were not correlated with vitamin B12 deficiency. We found no statistical association of vitamin B12 deficiency with gender, patients over 60 years of age, or the presence of Helicobacter pylori (H. pylori). The average age of patients with vitamin B12 deficiency or pernicious anemia is less than that traditionally reported for these diseases

En un estudio con 63 pacientes adultos, sometidos a endoscopia digestiva alta por síntomas dispépticos, se tomaron biopsias de mucosa gástrica para realizar: la prueba rápida de ureasa, histología convencional, cultivo selectivo para H. pylori y determinación de la susceptibilidad de los aislamientos bacterianos a la claritromicina mediante la técnica de difusión en disco (Kirby-Bauer). El porcentaje de recuperación del H. pylori (cultivo positivo) fue del 73%, se determinaron para el cultivo una sensibilidad de 66% y una especificidad del 100%. Se observó una prevalencia de la resistencia primaria a la claritromicina del 15%. No se observaron diferencias significativas por género, edad, diagnóstico endoscópico o histológico entre los pacientes con aislamientos sensibles o resistentes al antibiótico.

In a study of 63 adult patients, subjected to upper gastrointestinal endoscopy due to gastrointestinal disorders or indigestion, gastric mucous biopsies were taken in order to realize a rapid urease test, conventional histology, selective culture for H. pylori and to determine susceptibility of bacterial isolates to clarithromycin using Kirby-Bauer disk diffusion technique. The percentage of H. pylori recuperation (positive culture) was 73%. A sensitivity of 66% was determined for the culture, and a specificity of 100% was also determined. A prevalent primary resistance to clarithromycin of 15% was observed. Significant differences were not observed due to gender, age, endoscopic or histological diagnoses among the patients with sensitive isolates or resistance to antibiotics.

Se realizó un estudio observacional, analítico de casos y controles, con 1.850 adultos sometidos a endoscopia digestiva alta remitidos al centro médico Endocentro Ltda. en Bogotá DC, por diversos síntomas y que no hubieran recibido tratamiento previo con antibióticos, antibacterianos o medicamentos que alteren la secreción gástrica. Se encontró una prevalencia para la gastritis crónica folicular de 8,4% (102 pacientes), 73 mujeres y 29 hombres, con edad promedio de 33,5 años, se detectó la presencia de actividad inflamatoria en el 99% y de H. pylori en el 98% de los pacientes. El grupo control estuvo formado por 1.100 pacientes con otros tipos de gastritis crónica diferente a la folicular, 698 mujeres y 412 hombres, edad promedio de 48,3 años y presencia de actividad inflamatoria y de H. pylori en el 72,1% y 63,3% respectivamente. Se determinó, en el género femenino, un aumento mínimo del riesgo, sin significancia estadística de presentar cambios de gastritis crónica folicular OR = 1,48 (IC 95% 0,93-2,41). En los pacientes jóvenes menores de 35 años y en los infectados por H. pylori se observó un riesgo aumentado de presentar cambios de gastritis folicular OR = 7,57 (IC 95% 4,82- 11,97) y OR =28,94 (IC 95% 7,72- 243,23) respectivamente. Se observó mayor actividad inflamatoria en los pacientes con gastritis crónica folicular, OR = 38,96 (IC 95% 6,76-1558,64).

An observation study, which analyzed cases and controls, was realized with 1850 adults subjected to upper digestive endoscopy, who were sent to the Endocentro Ltda. Medical center in Bogota, Colombia, due to diverse symptoms, and who had not received previous treatment with antibiotics, antibacterial medication or medication that altered gastric secretion. Chronic follicular gastritis was found in 8.4% (102 patients), 73 women and 29 men, with an average age of 33.5 years. Inflammation activity was detected in 99% and H. pylori in 98% of the patients. The controlled group was made up of 1100 patients with other kinds of chronic gastritis different from follicular gastritis. With these 1100 patients, 698 women and 412 men, with an average age of 48.3 years, inflammatory activity was found in 72.1% and H. pylori in 63.3%. In the feminine gender, a minimum risk increase was determined, without presenting changes in chronic follicular gastritis of statistical significance OR = 1.48 (95% IC 0.93-2.41). In the young patients who were less than 35 years old and in those infected by H. pylori, a higher risk for follicular gastritis changes was observed OR = 7.57 (95% IC 4.82-11,97) and OR =28.94 (95% IC 7.72-243.23) respectively. A greater inflammatory activity was observed in patients with chronic follicular gastritis, OR = 38.96 (95% IC 6.76-1558.64).

Los divertículos del tercio medio del esófago (esófago torácico) son una rara entidad. Es diagnosticada de manera incidental pues la mayoría de pacientes no manifiesta síntomas. Son verdaderos divertículos de pulsión y en más de 2/3 de los casos se asocian con alteraciones de la motilidad esofágica. Sólo requieren tratamiento endoscópico o quirúrgico los pacientes con síntomas y en especial con manifestaciones respiratorias secundarias a episodios de broncoaspiración. Se presenta el caso de un hombre con esta alteración atendido en nuestra institución.

The midesophageal diverticula (in the thoracic esophagus) are strange entities. They are diagnosed unexpectedly since most of the patients do not show any symptoms. They are Zenker diverticula and epiphrenic diverticula and in more than 2/3 of the cases they are associated with cases of esophageal motility disorders. Only the patients with symptoms and specially those with secondary respiratory signs and inhalation episodes require endoscopic or surgical treatment. We have a case of one man with this disease who was treated at our institution.

Se presenta el caso de una anciana con disfagia orofaríngea secundaria a una barra cricofaríngea; se hace una revisión de esta patología.

This is a report about Cricopharyngeal dysphagia related to a Cricopharyngeal bar