Revista Española de Enfermedades Digestivas

Fallo hepático agudo sobre crónico y factores pronósticos: momento de una nueva evaluación

Marcaciones pronósticas en pacientes con cirrosis admitidos en una unidad de cuidados intensivos gastroenterológicos

Background: prognostic scores have been validated in cirrhotic patients admitted to general Intensive Care Units. No assessment of these scores was performed in cirrhotics admitted to specialized Gastroenterology Intensive Care Units (GICUs). Aim: to assess the prognostic accuracy of Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA), Model for End-stage Liver Disease (MELD) and Child-Pugh-Turcotte (CPT) in predicting GICU mortality in cirrhotic patients. Methods: the study involved 124 consecutive cirrhotic admissions to a GICU. Clinical data, prognostic scores and mortality were recorded. Discrimination was evaluated with area under receiver operating characteristic curves (AUC). Calibration was assessed with Hosmer-Lemeshow goodness-of-fit test. Results: GICU mortality was 9.7%. Mean APACHE II, SAPS II, SOFA, MELD and CPT scores for survivors (13.6, 25.4, 3.5, 18.0 and 8.6, respectively) were found to be significantly lower than those of non-survivors (22.0, 47.5, 10.1, 30.7 and 12.5, respectively) (p < 0.001). All the prognostic systems showed good discrimination, with AUC = 0.860, 0.911, 0.868, 0.897 and 0.914 for APACHE II, SAPS II, SOFA, MELD and CPT, respectively. Similarly, APACHE II, SAPS II, SOFA, MELD and CPT scores achieved good calibration, with p = 0.146, 0.120, 0.686, 0.267 and 0.120, respectively. The overall correctness of prediction was 81.9%, 86.1%, 93.3%, 90.7% and 87.7% for the APACHE II, SAPS II, SOFA, MELD and CPT scores, respectively. Conclusions: in cirrhotics admitted to a GICU, all the tested scores have good prognostic accuracy, with SOFA and MELD showing the greatest overall correctness of prediction.

Tumores endocrinos o apudomas pancreáticos

Introduction and objective: pancreatic endocrine tumors (PET) are difficult to diagnose. Their accurate localization using imaging techniques is intended to provide a definite cure. The goal of this retrospective study was to review a PET series from a private institution. Patients and methods: the medical records of 19 patients with PETs were reviewed, including 4 cases of MEN-1, for a period of 17 years (1994-2010). A database was set up with ten parameters: age, sex, symptoms, imaging techniques, size and location in the pancreas, metastasis, surgery, complications, adjuvant therapies, definite diagnosis, and survival or death. Results: a total of 19 cases were analyzed. Mean age at presentation was 51 years (range: 26-67 y) (14 males, 5 females), and tumor size was 5 to 80 mm (X: 20 mm). Metastatic disease was present in 37% (7/19). Most underwent the following imaging techniques: ultrasounds, computed tomography (CT) and magnetic resonance imaging (MRI). Fine needle aspiration punction (FNA) was performed for the primary tumor in 4 cases. Non-functioning: 7 cases (37%), insulinoma: 2 cases [1 with possible multiple endocrine neoplasia (MEN)], Zollinger-Ellison syndrome (ZES) from gastrinoma: 5 (3 with MEN-1), glucagonoma: 2 cases, 2 somatostatinomas; carcinoid: 1 case with carcinoide-like syndrome. Most patients were operated upon: 14/19 (73%). Four (4/14: 28%) has postoperative complications following pancreatectomy: pancreatitis, pseudocyst, and abdominal collections. Some patients received chemotherapy (4), somatostatin (3) and interferon (2) before or after surgery. Median follow-up was 48 months. Actuarial survival during the study was 73.6% (14/19). Conclusions: age was similar to that described in the literature. Males were predominant. Most cases were non-functioning (37%). Most patients underwent surgery (73%) with little morbidity (28%) and an actuarial survival of 73.6% at the time of the study.

Introducción y objetivo: los tumores endocrinos pancreáticos (TEP) son difíciles de diagnosticar. Su localización exacta mediante métodos de imagen tiene el propósito de lograr una curación definitiva. El objetivo de este trabajo retrospectivo fue revisar una serie institucional privada de TEP. Pacientes y métodos: se revisaron las historias clínicas de 19 pacientes con TEP, 4 casos con NEM-1, observados durante 17 años (1994-2010). Se creó una base de datos con diez parámetros: edad y sexo, síntomas, métodos diagnósticos de imagen, tamaño y situación en el páncreas, metástasis, cirugía, complicaciones, tratamientos complementarios, diagnóstico definitivo, supervivencia o éxitus. Resultados: en total se analizaron 19 casos. La edad media de presentación fue 51 años (intervalo: 26-67 años) (14 varones y 5 mujeres), con un tamaño del tumor de 5 a 80 mm (X: 20 mm). El 37% (7/19) tenían metástasis. En la mayoría se practicaron los siguientes métodos de imagen: ecografía, TAC y RM. La PAAF del tumor primitivo se practicó en 4 casos. No funcionantes: 7 casos (37%), insulinomas: 2 casos (1 con posible NEM), SZE por gastrinomas: 5 (3 con NEM-1), glucagonoma: 2 casos, 2 somatostatinomas, carcinoide: 1 caso con síndrome carcinoide-like. La mayoría de los enfermos fueron intervenidos quirúrgicamente 14/19 (73%). En cuatro (4/14: 28%) pacientes hubo complicaciones postoperatorias después de pancreatectomías: páncreas, seudoquiste y colecciones abdominales. Algunos casos fueron tratados con quimioterapia (4), somatostatina (3) e interferón (2) antes o después de la cirugía. La mediana de seguimiento fue de 48 meses. La supervivencia actuarial en el momento del estudio fue del 73,6% (14/19). Conclusiones: la edad fue similar a lo descrito en la literatura. El sexo predominante fue el masculino. La mayoría fueron no funcionantes (37%). La mayoría fueron intervenidos quirúrgicamente (73%), con escasa morbilidad (28%) y con una supervivencia actuarial en el momento de cerrar el estudio del 73,6%.

Riesgo de cáncer por irradiación durante ERCP: ¿Es un problema clínico real?

Background: in recent years many factors have been shown to influence dose received by the patient during ERCP. Therefore it is necessary to update radio induced cancer risk. Objectives: to calculate lifetime attributable risk of cancer during ERCP. To compare the risk with the most common X-ray examinations. Design: descriptive study with 393 consecutive ERCP performed at one center. Equipment used was Philips BV pulsera. In each exploration demographic and anthropometric variables of the patient were collected. Dosimetric quantities were calculated from exposure parameters. Effective dose was estimated using specific conversion factors. Organ doses and radio induced cancer incidence was estimated. Results: dose area product was 0.82 mGym² (IQR 0.4-1.5) with an average fluoroscopy time of 2 minutes and 45 seconds. Entrance surface dose was 30.7 mGy (IQR 15-60.8) and effective dose was 0.44 mSv (IQR 0.2-0.9). Multivariate analysis identified that difficult papillary cannulation (β0.4; p = 0.009), patient age (β-0.01; p = 0.001) and therapeutic applied (β= 0.89; p < 0.001) influenced dose-area product. The ERCP dose would be equivalent to the radiation received by twenty chest radiographs and would be about fourteen times smaller than a barium enema or twenty times less than that received during an abdominal CT. Lifetime attributable risk of cancer incidence was 4.08 and 16.81 per million procedures in diagnostic and therapeutic ERCP respectively. Conclusions: from the radiological point of view, ERCP is a safe technique that uses low exposure levels compared to other explorations commonly used in medicine. It implies a reasonably low risk of radio induced cancer.

Factores predictivos de mortalidad intrahospitalaria en pacientes con sangrado de tubo digestivo alto no variceal

Objective: to determine the independent predictors of in-hospital death of Hispanic patients with nonvariceal upper gastrointestinal bleeding (NVUGB). Experimental design: prospective and observational trial. Patients: in a period between 2000 and 2009, all patients with NVUGB admitted to our hospital were studied. Demographical and clinical characteristics, endoscopic findings and laboratory tests were evaluated χ² and Mann-Whitney U analyses were performed for comparisons, and binary logistic regression was employed to identify independent predictors of in-hospital mortality. Results: 1,067 patients were included, 65% male with a mean age of 58.8 years. Mean number of comorbidities per patient was 1.6 ± 0.76. The most frequent cause of bleeding were gastric and duodenal ulcers (55.4%); 278 patients (25.8%) received endoscopic treatment of which 69.1% had combined therapy. Rebleeding occurred in 36 patients (3.4%) of which 50% died. In-hospital mortality was 10.2%, of which only 3.1% was associated to bleeding. When comparing causes of death among patients with and without comorbidities, only hypovolemic shock was found significative (48.3 vs. 25%; p = 0.020). Binary logistic regression found that the number of comorbidities, Rockall scale score; serum albumin < 2.6 g/dL on admission; rebleeding and length of hospital stay were independent risk factors of in-hospital mortality. Conclusion: the number of comorbidities, the Rockall scale score, an albumin level < 2.6 g/dL, the presence of rebleeding and hospital stay were predictors of in-hospital mortality in patients with NVUGB

Objetivo: determinar los factores de riesgo para mortalidad intrahospitalaria en pacientes hispanos con sangrado de tubo digestivo alto no variceal (STDANV). Diseño experimental: estudio prospectivo y observacional. Pacientes: del año 2000 al 2009 se estudiaron pacientes con STDANV. Se evaluaron variables demográficas y clínicas así como resultados de laboratorio y hallazgos endoscópicos. Se utilizaron análisis de χ² y U de Mann-Whitney para las comparaciones y de regresión logística binaria para la identificación de factores predictores de mortalidad. Resultados: se estudiaron 1.067 pacientes (65% hombres) con promedio de edad de 58,8 años. La media de comorbilidades por paciente fue 1,6 ± 0,76. La causa más frecuente de sangrado fueron las úlceras en estómago y duodeno (55,4%); 278 pacientes (25,8%) recibieron alguna forma de tratamiento endoscópico, siendo combinado en el 69,1%. Resangraron 36 pacientes (3,4%) de los cuales 50% fallecieron. La mortalidad intrahospitalaria fue del 10,2%, y el 3,1% se relacionó directamente al sangrado. Al comparar la mortalidad entre pacientes con y sin comorbilidades, solo la presencia de choque hipovolémico tuvo diferencias estadísticamente significativas (48,3 vs. 25%; p = 0,020). La regresión logística mostró que el número de comorbilidades, el puntaje de Rockall, la albúmina al ingreso < 2,6 g/dl, el resangrado y la estancia hospitalaria fueron factores de riesgo independientes para mortalidad. Conclusión: el número de comorbilidades, el puntaje de Rockall, la presencia de albúmina sérica < 2,6 g/dl, el resangrado y la estancia hospitalaria son predictores de mortalidad intrahospitalaria en pacientes hispanos con STDANV.

**Contrastes ultrasónicos versus sonoelastografía en patología digestiva**

A review is made of the indications of ultrasonographic contrast enhancement as applied to conventional ultrasonography and endocopic ultrasonography (EUS) as opposed to the use of EUS-sonoelastography today.

Se efectúa una revisión sobre las indicaciones de los contrastes ecográficos (CE), sonográficos o ultrasónicos aplicados a la ultrasonografía convencional (US) y a la ultrasonografía endoscópica (USE), en contraposición a las aplicaciones que tiene hoy en día la sonoelastografía mediante USE.

Sarcoma de Kaposi del recto

Estenosis pilórica, debut de enfermedad de Crohn

Diagnóstico de la enfermedad de Whipple por técnicas de biología molecular. Aportación de dos casos

extraintestinal manifestations, species-specific PCR using different sequences of the T. whippleii genome from different tissue types and biological fluids is recommended. The diagnosis of Whipple's disease (WD) is based on the existence of clinical signs and symptoms compatible with the disease and in the presence of PAS-positive diastase-resistant granules in the macrophages of the small intestine. If there is suspicion of the disease but no histological findings or only isolated This study reports two cases: the first patient had diarrhea and the disease was suspected after an endoscopic examination of the ileum, while the second patient had multi-systemic manifestations, particularly abdominal, thoracic, and peripheral lymphadenopathies. In both cases, the diagnosis was confirmed using molecular biology techniques to samples from the small intestine or from a retroperineal lymph node, respectively.

El diagnóstico de la enfermedad de Whipple (EW) se basa en la existencia de una clínica compatible y en el hallazgo de gránulos PAS +, diastasa resistente, en los macrófagos del intestino delgado. Si hay sospecha de enfermedad pero no evidencia histológica o manifestaciones extraintestinales aisladas se precisa el estudio mediante PCR específicas de distintas secuencias del genoma de T. whippleii en tejidos y fluidos biológicos. Se presentan dos casos, uno con diarrea en el que se sospechó la enfermedad tras ileoscopia y otro con manifestaciones multisistémicas, sobre todo adenopatías abdominales, torácicas y periféricas. En ambos, el estudio molecular del intestino delgado y de una linfadenopatía retroperitoneal respectivamente confirmó el diagnóstico.

La endoscopia en las enfermedades hepáticas

Vólvulo gástrico agudo: una urgencia quirúrgica

Pancreatitis aguda recurrente debido a tumor mucinoso papilar intraductal de páncreas

Metástasis laríngea como primera manifestación de un hepatocarcinoma

Vipoma pancreático benigno

Quiste de duplicación gástrica