To update the recommendations of the Pan American Crohn's and Colitis Organisation (PANCCO) for the treatment of moderate-to-severe ulcerative colitis (UC) in adults, incorporating recent evidence on new biologics, small molecules, subcutaneous formulations and appendectomy. The PAHO rapid GRADE methods were applied. PANCCO adapted the Colombian guideline 2025 for upadacitinib, tofacitinib, ozanimod and the switch to subcutaneous formulations, and developed de novo recommendations for etrasimod, guselkumab, risankizumab, ustekinumab, mirikizumab, filgotinib and appendectomy. The search was carried out in MEDLINE, Embase, Cochrane and Epistemonikos through February 2026, with quality appraised with ROBIS, AMSTAR-2, RoB 2.0 and ICEMAN; strength of recommendations was established using GRADE. Recommendations were issued for nine clinical questions. In moderate-to-severe UC, upadacitinib, tofacitinib, filgotinib, ustekinumab, mirikizumab, risankizumab and guselkumab are recommended; ozanimod and etrasimod are conditionally suggested, considering the cardiovascular profile. In patients with response to intravenous induction, switching to subcutaneous vedolizumab or subcutaneous infliximab is suggested. In UC refractory to advanced therapies, laparoscopic appendectomy is conditionally suggested as an adjuvant strategy. This third update expands the therapeutic armamentarium for moderate-to-severe UC in Latin America. Treatment choice should be individualized according to prior therapy, comorbidities, cardiovascular and thrombotic risk, availability and patient preferences.
Endoscopic retrograde cholangiopancreatography (ERCP) is the standard treatment for biliary tract diseases; however, in patients with Roux-en-Y gastric bypass, it is technically challenging due to altered anatomy. We report the case of a 43 year old woman with a history of gastric bypass who presented with abdominal pain, fever, and jaundice, and was diagnosed with choledocholithiasis complicated by cholangitis. After multidisciplinary evaluation, a single-session endoscopic ultrasound-guided transgastric ERCP (EDGE) was performed. A gastrogastric fistula was created using a Hot Axios lumen-apposing metal stent, which was subsequently dilated and secured to allow safe passage of the duodenoscope. During ERCP, type IV Mirizzi syndrome with an impacted stone was identified; therefore, a biliary stent was placed for drainage and infection control, with planned subsequent lithotripsy. This case highlights that the EDGE technique is an effective and minimally invasive alternative for biliary access in patients with surgically altered anatomy, demonstrating high technical success and an acceptable safety profile, and enabling treatment in a single endoscopic session.
OBJECTIVES:Helicobacter pylori infection relates to multiple gastric diseases, and its eradication is becoming more challenging due to antimicrobial resistance to commonly used antibiotics, especially clarithromycin. The aim of this study is to describe the antimicrobial susceptibility profiles of H. pylori isolates from Costa Rican patients. MATERIALS AND METHODS:Antimicrobial susceptibility was assessed for 14 H. pylori isolates using the E-test method for amoxicillin, clarithromycin, levofloxacin, metronidazole, tetracycline, and rifampicin. Due to its importance, the point mutations A2143G and A2144G related to clarithromycin resistance were also studied using PCR-RFLP. RESULTS:Resistance to clarithromycin (29%), levofloxacin (29%), metronidazole (29%), and rifampicin (7%) was found in the studied isolates. These included three isolates with multidrug resistance. A2143G mutation was detected in one isolate and A2144G was detected in two isolates, and the presence of mutations correlated significantly with phenotypic resistance to clarithromycin (r=0.8321, p=0.0071). CONCLUSIONS:Antibiotic resistance was high in the studied isolates from Costa Rica. The number of isolates is small, but the results highlight the need for further studies to assess the antibiotic resistance as a growing problem in the country. H. pylori culture and phenotypic tests are difficult, but molecular testing can be used as a quick and cheap option to monitor clarithromycin resistance.
OBJECTIVE:Hepatitis C virus (HCV) infection remains an important public health concern among people experiencing homelessness (PEH), yet data from Latin America are limited. We aimed to estimate HCV prevalence and describe associated risk factors and linkage to care in this population. MATERIALS AND METHODS:We conducted a retrospective study of 800 PEH in Santiago, Chile. Participants underwent rapid HCV antibody screening followed by confirmatory RNA testing. Standardized data on sociodemographic characteristics and potential risk factors were collected. RESULTS:Four participants tested positive for HCV, corresponding to a prevalence of 0.5%. Reported exposures among HCV-positive individuals included tattoos, high-risk sexual behaviors, previous blood transfusion, and cocaine use; none reported intravenous drug use. Linkage to care was limited, with only one individual (25%) initiating direct-acting antiviral therapy. Barriers included lack of health insurance coverage, administrative obstacles, unstable living conditions, and loss to follow-up. CONCLUSIONS:HCV prevalence in this cohort was low. However, distinct risk profiles and important gaps in treatment access were identified. These findings support the need for targeted microelimination strategies and strengthened linkage-to-care pathways for PEH in Latin America.
Mixed Neuroendocrine-NonNeuroendocrine Neoplasms (MiNENs) are rare and aggressive entities, with scarce reports worldwide, especially from Latin America. We describe the first documented case of sigmoid MiNEN in Perú in a 77-year-old woman with a history of hypertension, diabetes, and osteoporosis who presented with left lower quadrant pain and abdominal distension. Colonoscopy revealed polyps, one of which was histologically consistent with a large-cell neuroendocrine carcinoma (NEC) and a high-grade tubular adenoma, each accounting for ≥30% of the lesion, fulfilling MiNEN criteria. Immunohistochemistry confirmed the diagnosis with an Antigen Kiel 67 [Ki-67] index of 70%. Positron Emission Computed Tomography (PET/CT) demonstrated focal uptake without nodal involvement. The patient underwent laparoscopic radical sigmoidectomy with colorectal anastomosis; histopathology confirmed submucosal invasion and metastasis in 5/14 lymph nodes. She was subsequently started on adjuvant carboplatin/etoposide chemotherapy and remains under oncological follow-up. This case underscores the diagnostic and therapeutic challenges of colorectal MiNENs, highlights the role of PET/CT as well as multidisciplinary management, and emphasizes the importance of considering radical resection even after endoscopic removal, given the high risk of recurrence and aggressive biological behavior.
Esophageal perforation is a severe digestive tract injury with serious complications and high mortality, representing a diagnostic challenge in the pediatric population due to the nonspecific nature of symptoms. Causes include external trauma, caustic ingestion, foreign body impaction, and iatrogenic injuries. We describe three pediatric patients with esophageal perforation of different etiologies successfully managed by endoscopic placement of fully covered metallic biliary stents, combined with broad-spectrum antibiotic therapy and nutritional support. Two cases were secondary to impacted foreign bodies (a plastic fragment and a coin), and one was due to caustic ingestion. In all cases, complete closure of the esophageal defect was achieved without the need for surgery, with resolution of the leak and favorable clinical outcomes. The use of covered biliary stents is an effective and safe alternative for the management of benign esophageal perforations in selected children, allowing defect closure and avoiding high-morbidity surgical interventions.
OBJECTIVES:To provide information on the sociodemographic, environmental, and clinical characteristics associated with Helicobacter pylori (H. pylori) infection in children. METHODS:A total of 183 children aged 4 to 17 years who underwent upper gastrointestinal endoscopy with biopsies at a high-complexity hospital in Medellín, Colombia, between April 2022 and March 2024 were included. Socioeconomic data, gastrointestinal symptoms, endoscopic, and histological findings were analyzed. The prevalence of H. pylori and its association with sociodemographic, clinical, and environmental factors were calculated. RESULTS:The prevalence of H. pylori infection was 23%. There was no association between infection and sociodemographic variables or symptoms. Infected patients more frequently presented with active chronic inflammation (97.6% vs. 13.5%, p<0.001), antral nodularity (50% vs. 7.1%, p<0.001), pangastric erythema (33.3% vs. 14.2%, p=0.005), a personal history of H. pylori infection (4.8% vs. 2,1%, p=0.009) was significantly more frequent in the infected group. A family history of gastric cancer was found in 2 patients in the infected group (4,8%). CONCLUSIONS:A similar prevalence to that reported in other Latin American studies was observed. The importance of integrating endoscopic and histological assessment with relevant sociodemographic and clinical factors is highlighted to enable a more rational identification of H. pylori, and to lay the groundwork for future research in our population.
Irritable bowel syndrome (IBS) is a highly prevalent functional gastrointestinal disorder characterized by chronic abdominal pain, bloating, and altered bowel habits, with a substantial impact on quality of life and healthcare systems. In recent years, the gut microbiota has emerged as a central component in its pathophysiology. Patients with IBS exhibit alterations in microbial diversity and composition -known as dysbiosis- that vary according to clinical subtype: diarrhea-predominant, constipation-predominant, or mixed. These alterations are associated with intestinal epithelial barrier dysfunction, low-grade inflammation mediated by mast cells and proinflammatory cytokines, disturbances in fermentation and gas production, and dysregulation of the microbiota-gut-brain axis, a multidirectional communication system integrating the central nervous system, the enteric nervous system, and the gut microbiota. Microbial metabolites -including short-chain fatty acids, serotonin, tryptamine, and histamine- actively participate in the modulation of motility, visceral sensitivity, and neuroimmunoendocrine responses. In this context, microbiota-targeted therapeutic strategies have emerged, including probiotics, prebiotics, synbiotics, a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet, rifaximin, and fecal microbiota transplantation, showing promising but heterogeneous results. Emerging therapies such as postbiotics and phage therapy open new perspectives. This review analyzes the pathophysiological mechanisms linking dysbiosis to IBS and evaluates the main microbiota-directed therapeutic interventions.
Primary myelofibrosis is a chronic myeloproliferative neoplasm characterised by extramedullary hematopoiesis. Portal hypertension represents a significant cause of mortality in these patients. Diagnosis of portal hypertension is typically based on clinical manifestations and is often confirmed by upper gastrointestinal endoscopy, which allows for the identification of oesophageal varices and facilitates endoscopic intervention. Management options include general supportive measures, chemotherapy, splenectomy, and radiation therapy. This report describes a 53-year-old woman with a history of myelofibrosis who presented with abdominal pain and anaemia. Upper gastrointestinal video endoscopy revealed oesophageal varices, and subsequent confirmation of portal hypertension prompted a percutaneous liver biopsy, which demonstrated myelofibrosis. After appropriate management, the patient had a favourable clinical outcome.
Irritable bowel syndrome (IBS) is a disorder of gut-brain axis interaction characterized by abdominal pain and alterations in stool form and/or frequency. The previous concept of a "functional disorder" has often been misinterpreted as "the opposite of organic" or "purely psychological," leading to stigmatization and even delegitimization of this condition. However, evidence supports that IBS has an underlying organic basis mediated by the complex interaction of multiple measurable and quantifiable pathophysiological alterations. These alterations include genetic predisposition, changes in the intestinal microbiota, visceral hypersensitivity, abnormalities in central pain processing, gastrointestinal motility disturbances, impaired intestinal barrier function, and environmental influences. Together, these elements are integrated through the gut-brain axis model, in which they form multiple positive feedback loops that initiate, exacerbate, and perpetuate IBS manifestations. In this review, we discuss in depth the underlying pathophysiological alterations of IBS to remind and raise awareness among healthcare professionals about the organic nature of this syndrome. Additionally, we summarize modern therapeutic approaches and their limitations in light of these organic alterations.
With increasing antibiotic resistance, treatment of H. pylori infection has gradually become a challenge for clinicians. OBJECTIVES:To compare the efficacy and safety of dual therapy plus bismuth (DTB) with quadruple therapy with bismuth (DBT) for the treatment of H. pylori in patients with at least one previous eradication therapy failure. The primary objective was eradication of H. pylori at 6 weeks after treatment. MATERIALS AND METHODS:Randomized, open-label, superiority clinical trial evaluating H. pylori eradication in patients with at least one prior treatment failure. Participants were randomly assigned to receive a 14-day course of bismuth-based dual therapy (TDB: esomeprazole 40mg three times daily, amoxicillin 1g three times daily, and bismuth subsalicylate 262mg four times daily) or bismuth-based quadruple therapy (TQB: esomeprazole 40mg three times daily, amoxicillin 1g three times daily, doxycycline 100mg twice daily, and bismuth subsalicylate 262mg four times daily). RESULTS:A total of 267 of 283 subjects were randomized; 11 were excluded due to exclusion criteria and 5 declined participations. Eradication rates by intention-to-treat and per-protocol analyses were 90.1% (119/131; 95% CI: 84.7-94.7%) and 95.8% (113/118; 95% CI: 90.5-98.2%) for TDB, and 78.7% (107/136; 95% CI: 71.1-84.7%) and 84.7% (94/111; 95% CI: 76.8-90.2%) for TQB. Superiority of TDB was confirmed (p=0.001 in ITT; p=0.04 in PP). Adverse events occurred in 30.5% (33/131) of TDB patients and 44.1% (60/136) of TQB patients (p=0.001). CONCLUSIONS:Bismuth-based dual therapy is a superior alternative to classical bismuth quadruple therapy for the treatment of patients with at least one failed therapy for H. pylori, as it provides greater eradication with superior safety and compliance.
OBJECTIVES:Evidence on golimumab for ulcerative colitis (UC) is scarce in Latin America. We aimed to assess the real-world effectiveness and safety of golimumab in a multicenter Chilean cohort. MATERIALS AND METHODS:We conducted a retrospective, observational study including adult patients with moderate-to-severe UC treated with golimumab under the Chilean government coverage program (July 2019-August 2023). Clinical, biomarker, endoscopic, and histological outcomes were evaluated at weeks 16 and 52. Dose optimization strategies and adverse events (AEs) were recorded. RESULTS:Seventy-nine patients were included (69.6% women; median disease duration 8 years). Most were anti-TNF naïve (94%). At week 16.81% achieved symptomatic remission, 77% biomarker remission, 35% endoscopic remission, and 38% histological remission. At week 52, 43 patients remained on treatment; of these, 93% achieved symptomatic remission, 98% biomarker remission, 63% endoscopic remission, and 42% histological remission. Dose optimization was required in 62% of patients, and early optimization was associated with higher remission stability. Kaplan-Meier analysis showed 75% clinical remission at 24 months. Adverse events were infrequent, with no colectomies reported. CONCLUSIONS:In this first Chilean and Latin American multicenter real-world study, golimumab proved effective and safe for moderate UC, achieving high rates of clinical and biomarker remission, particularly with early dose optimization. Despite newer biologics and small molecules, golimumab remains a valid therapeutic option in regions with limited access.
Hepatic actinomycosis is a rare infection caused by Actinomyces spp. It is characterized by nonspecific clinical presentation and imaging findings that may mimic hepatic neoplasms. We report the case of a 43-year-old man presenting with a three-month history of right upper quadrant pain and weight loss. Magnetic resonance imaging revealed an infiltrative hepatic mass involving segments IV, V, and VIII, suggestive of malignancy. Percutaneous biopsy was inconclusive; therefore, an extended right hepatectomy with segmental colectomy was performed. The definitive diagnosis was established by histopathological examination, which demonstrated sulfur granules and filamentous structures consistent with Actinomyces spp. The patient received prolonged antibiotic therapy, with favorable clinical evolution and no evidence of recurrence during follow-up. Hepatic actinomycosis is an entity with limited representation in the Latin American literature and should be considered in the differential diagnosis of atypical liver masses, even in the absence of predisposing factors. Its presentation may mimic hepatic malignancy and lead to unnecessary major surgical interventions. In clinical practice, it is essential to maintain a high index of suspicion for infectious etiologies, particularly when initial biopsies are inconclusive.
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic procedure in the management of biliary and pancreatic disorders, although it carries an inherent risk of complications. Stapfer type III perforations, which may occur during the procedure due to instrumental manipulation, can require the placement of a biliary stent to maintain drainage and control the leak. However, late migration of the biliary stent is an infrequent but serious complication, capable of perpetuating the biliary leak and promoting infections and/or secondary pancreatitis.
Chronic constipation is a frequent gastrointestinal disorder that significantly impairs quality of life and has a multifactorial etiology. High-resolution anorectal manometry (HR-ARM) allows for an objective evaluation of anorectal function. In Peru, evidence regarding its findings in the adult population is scarce. OBJECTIVE:To describe the findings obtained through high-resolution anorectal manometry in adults with primary chronic constipation, according to the London Classification, in three private institutions in Lima, Peru. MATERIALS AND METHODS:A retrospective descriptive study was conducted in three private institutions in Lima between January 2020 and December 2024. Reports of manometry from patients over 18 years old with a diagnosis of functional chronic constipation and normal colonoscopy findings were included. Data were analyzed using STATA v.18, applying descriptive statistics and the Chi-square test. RESULTS:A total of 122 patients were evaluated (81.2% women). According to the London Classification, the most frequent findings were anal normotension with hypocontractility (62.3%), normal expulsion with abnormal coordination (43.4%), and preserved anorectal inhibitory reflex (97.5%). Regarding rectal sensitivity, hyposensitivity was the most common finding (38.5%), followed by normal parameters (37.8%). Analysis by age and sex showed significant differences in resting anal pressure (p=0.045), desire to defecate (p=0.048), and rectal urgency (p=0.007). CONCLUSIONS:The most frequent manometric findings in patients with primary chronic constipation were anal hypocontractility, impaired anorectal coordination, and rectal hyposensitivity. These results highlight differences according to age and sex, underscoring the importance of incorporating the London Classification to achieve a more accurate diagnosis and personalized clinical management.
La enfermedad de Crohn (EC) es una patología inflamatoria crónica y multifactorial que puede afectar cualquier parte del tracto gastrointestinal, con manifestaciones sistémicas, extraintestinales y atípicas. El síndrome de activación macrofágica o síndrome de linfohistiocitosis hemofagocítica (HLH) es una condición inflamatoria grave y poco común, que puede presentarse en enfermedades subyacentes como infecciones, neoplasias o patologías autoinmunes, cuya asociación con EC es extremadamente rara. Describimos el caso de un masculino de 8 años con síntomas inespecíficos como dolor en miembros inferiores, lumbalgia y dolor abdominal progresivo, evolucionando a insuficiencia respiratoria y choque cardiogénico, requiriendo ingreso a la unidad de cuidados intensivos (UCI). Presentó bicitopenia, fiebre persistente, exantema, derrame pleural bilateral, hiperferritinemia, hipertrigliceridemia y signos de inflamación sistémica, por lo cual se sospechó HLH. Se descartaron infecciones y neoplasias hematológicas. Recibió inmunoglobulina, antibióticos de amplio espectro, antifúngicos y manejo inmunomodulador. A nivel digestivo presentó deposiciones diarreicas melénicas, hematoquecia, distensión abdominal y calprotectina fecal elevada. Una tomografía evidenció engrosamiento de paredes colónicas y adenomegalias mesentéricas. Mediante esofagogastroduodenoscopia, colonoscopia y biopsias se confirmó EC, instaurándose tratamiento con infliximab, con respuesta clínica positiva. Este caso resalta una presentación atípica de EC con HLH, planteando importantes retos diagnósticos y terapéuticos.
Olmesartan es un fármaco antihipertensivo ampliamente empleado. Aunque sus reacciones adversas más frecuentes son cefalea, síntomas pseudogripales y mareo, se han descrito casos de enteropatía tipo esprúe caracterizados por diarrea crónica y atrofia vellositaria intestinal sin respuesta a dieta sin gluten. Mucho menos conocida es la afectación hepática por olmesartan, habiéndose reportado elevaciones discretas de aminotransferasas en menos del 2% en ensayos clínicos, no superiores a pacientes que recibieron placebo. Sin embargo, en los últimos años, se han notificado casos de hepatitis aguda grave con tiempo de latencia variable. La coexistencia de ambos efectos adversos, potencialmente graves, es muy infrecuente, habiéndose descrito en la literatura únicamente en dos pacientes hasta la fecha. El presente caso clínico trata de una mujer de 66 años, en tratamiento crónico con la asociación de olmesartan medoxomilo/amlodipino/hidroclorotiazida. Más de dos años después de su inicio, presenta clínica de diarrea crónica de 4-6 deposiciones diarias. Meses más tarde, coincidiendo con una reagudización de diarrea crónica con alteraciones hidroelectrolíticas que precisan ingreso hospitalario, desarrolló ictericia y una alteración del perfil hepático grave que llevaron a un estudio completo de ambos cuadros. Tras un estudio completo, se sospechó de esta toxicidad dual infrecuente por olmesartan. Tras su retirada hubo una resolución completa de los síntomas y de las alteraciones analíticas.
La fístula duodeno-cava (FDC) es una entidad extremadamente infrecuente, que puede tener consecuencias letales. Se asocia a procesos infecciosos, neoplásicos, trauma o cuerpos extraños. Reportamos un caso de FDC secundaria a la migración de un alambre metálico desde el duodeno hacia la vena cava inferior (VCI), acompañado de trombosis de la venosa extensa. Varón de 48 años sin antecedentes médicos relevantes que consultó por fiebre y dolor abdominal inespecífico. Se interna con diagnóstico inicial de Dengue agudo en contexto de epidemia por dicho virus. La tomografía computada reveló un cuerpo extraño metálico lineal que atravesaba la segunda porción duodenal, penetrando la pared visceral y alojándose en la luz de la VCI, con aire en su interior y trombosis venosa extensa. Se realizó video endoscopía digestiva alta (VEDA), con extracción exitosa del cuerpo extraño. El paciente recibió antibióticoterapia endovenosa durante 10 días y anticoagulación oral por 6 meses. La evolución clínica fue favorable, el paciente se recuperó sin complicaciones. La FDC por cuerpo extraño es extremadamente rara. El manejo endoscópico puede ser exitoso en casos seleccionados, evitando procedimientos quirúrgicos invasivos.
