Revista Española de Enfermedades Digestivas

La enfermedad del hígado graso no alcohólico (EHGNA) asociada a obesidad: un proceso multifactorial

Efecto de la necrosectomía y el sistema de cierre asistido al vacío (VAC) sobre función mitocondrial y marcadores de estrés oxidativo en pancreatitis aguda severa

Background: Severe acute pancreatitis (SAP) is associated with high morbidity and mortality. Objective: To evaluate whether necrosectomy, alone or combined with vacuum-assisted closure (VAC), has any additional beneficial effects on mitochondrial function and/or oxidative stress markers in SAP. Methods: Patients with SAP, APACHE II score > 8, and inadequate response to management in an intensive care unit were included in a prospective observational study. Sixteen underwent necrosectomy and 24 underwent necrosectomy plus VAC every 48 h. Patients were then categorized as survivors or deceased. Submitochondrial membrane fluidity of platelets and F0F1-ATPase hydrolysis were measured to represent mitochondrial function. Oxidative/nitrosative stress was measured using lipoperoxides (LPOs), nitric oxide (NO), erythrocyte membrane fluidity, and total antioxidant capacity (TAC). Results: Membrane fluidity in submitochondrial particles of platelets remained significantly increased throughout the study, and then eventually rised in deceased patients managed with necrosectomy + VAC vs. survivors (p < 0.041). Hydrolysis was significantly increased from baseline to endpoint in all patients, predominating in those who died after management with necrosectomy (p < 0.03). LPO increased in all patients, and necrosectomy was more efficient for the eventual decrease in survivors (p < 0.039). NO was found to be increased for the baseline-endpoint result among both survivors and deceased patients with both management options. Erythrocyte membrane fluidity was increased in survivors managed with necrosectomy + VAC, and eventually returned to normal (p < 0.045). TAC was found to be consumed in all patients for the duration of the study. Conclusions: Mitochondrial dysfunction and oxidative/nitrosative stress with significant systemic antioxidant consumption were found. Necrosectomy was more efficient and better cleared LPOs. Necrosectomy + VAC improved erythrocyte membrane fluidity and increased survival.

Antecedentes: la pancreatitis aguda severa (PAS) se asocia con alta morbilidad y mortalidad. Objetivo: evaluar si la necrosectomía sola o necrosectomía + el sistema de cierre al vacío (VAC), ofrece efectos favorables adicionales en la función mitocondrial y/o marcadores de estrés oxidativo en PAS. Métodos: mediante un estudio observacional prospectivo, se incluyeron pacientes con PAS y APACHE II > 8 sin respuesta satisfactoria al manejo en la Unidad de Cuidados Intensivos. Dieciséis pacientes se sometieron a necrosectomía y 24 a necrosectomía + VAC cada 48 h. Se dividieron en sobrevivientes y fallecidos. Se determinó la fluidez de la membrana submitocondrial de las plaquetas y la hidrólisis de la F0F1-ATPasa como función mitocondrial. El estrés oxidativo/nitrosativo se midió mediante lipoperóxidos (LPO), óxido nítrico (ON), fluidez de la membrana de eritrocitos y capacidad antioxidante total (CAT). Resultados: la fluidez de membrana de partículas submitocondriales de plaquetas se mantuvo incrementada significativamente durante todo el estudio y aumentó al final en los fallecidos tratados con necrosectomía + VAC vs. los sobrevivientes (p < 0,041). La hidrólisis se encontró significativamente elevada desde el inicio hasta el final en todos los pacientes, predominando en los que fallecieron tratados con necrosectomía (p < 0,03). Hubo aumento de LPO en todos los pacientes aunque la necrosectomía fue más eficaz en la disminución al final en sobrevivientes (p < 0,039). El ON se encontró incrementado durante el resultado basal-final en sobrevivientes y fallecidos en ambas alternativas de tratamiento. La fluidez de la membrana de eritrocitos se encontró incrementada en los sobrevivientes tratados con necrosectomía + VAC y se normalizó al final (p < 0,045). La CAT se encontró consumida en todos los pacientes durante todo el estudio. Conclusiones: se encontró disfunción mitocondrial y estrés oxidativo/nitrosativo con consumo importante de los antioxidantes sistémicos. La necrosectomía fue más eficiente al eliminar mejor los LPO. La necrosectomía + VAC mejoró la fluidez de la membrana de eritrocitos e incrementó la sobrevida.

Valor de una estrategia diagnóstica ascendente: CRP y CT en el diagnóstico y manejo postoperatorio de complicaciones tras cirugía abdominal importante

Postoperative complications frequently follow major abdominal surgery and are associated with increased morbidity and mortality. Early diagnosis and treatment of complications is associated with improved patient outcome. In this study we assessed the value of a step-up diagnosis plan by C-reactive protein and CT-scan (computed tomography-scan) imaging for detection of postoperative complications following major abdominal surgery. An observational cohort study was conducted of 399 consecutive patients undergoing major abdominal surgery between January 2009 and January 2011. Indication for operation, type of surgery, postoperative morbidity, complications according to the Clavien-Dindo classification and mortality were recorded. Clinical parameters were recorded until 14 days postoperatively or until discharge. Regular C-reactive protein (CPR) measurements in peripheral blood and on indication -enhanced CT-scans were performed. Eighty-three out of 399 (20.6 %) patients developed a major complication in the postoperative course after a median of seven days (IQR 4-9 days). One hundred and thirty two patients received additional examination consisting of enhanced CT-scan imaging, and treatment by surgical reintervention or intensive care observation. CRP levels were significantly higher in patients with postoperative complications. On the second postoperative day CRP levels were on average 197.4 mg/L in the uncomplicated group, 220.9 mg/L in patients with a minor complication and 280.1 mg/L in patients with major complications (p < 0,001). CT-scan imaging showed a sensitivity of 91.7 % and specificity of 100 % in diagnosis of major complications. Based on clinical deterioration and the increase of CRP, an additional enhanced CT-scan offered clear discrimination between patients with major abdominal complications and uncomplicated patients. Adequate treatment could then be accomplished.

La resistencia a la insulina y el síndrome metabólico se relacionan con la enfermedad grasa del hígado pero no con el índice de adiposidad visceral en pacientes con obesidad severa

The visceral adiposity index (VAI) is a marker of visceral fat distribution and dysfunction. Visceral adiposity is related to non-alcoholic fatty liver disease (NAFLD); however, there is some controversy regarding the association between VAI and NAFLD. The aim of this study was to analyse the relationship between VAI and NAFLD and to describe the related factors in severely obese patients. A total of 139 patients who underwent bariatric surgery were included in this cross-sectional study. Liver biopsy was performed during surgery. Univariate and multivariate analysis were conducted to study the features related to VAI. A univariate analysis was conducted to identify which factors were associated with liver histology. In the univariate analysis, steatosis, liver inflammation, non-alcoholic steatohepatitis (NASH) and fibrosis were associated with VAI. In the multivariate analysis, only HOMA (Beta: 0.06; p < 0.01) and metabolic syndrome (Beta: 1.23; p < 0.01) were related to VAI. HOMA, the presence of metabolic syndrome, and waist circumference (WC) were statistically related to the NAFLD activity score (NAS score): HOMA: 0-2: 5.04; 3-4: 7.83; ≥ 5: 11,32; p < 0.01; MS: 0-2: 37 %; 3-4: 33.3 %; ≥ 5: 76%; p < 0.01; WC: 0-2: 128.7 cm; 3-4: 130.7; ≥ 5: 140.6; p < 0.01). For the prediction of NASH (NAS score ≥ 5), the AUROC curve were 0.71 (CI 95 %: 0.63-0.79) for VAI and 0.7 (CI 95 %: 0.62-0.78) for WC. In conclusion, HOMA, WC and metabolic syndrome are related to liver histology in patients with severe obesity. In the multivariate analysis, VAI was associated with HOMA and metabolic syndrome, but not with liver histology.

Gastrostomía endoscópica percutánea: actualización de sus indicaciones, tratamiento, complicaciones y cuidados

Background: Numerous disorders impairing or diminishing a patient's ability to swallow may benefit from a PEG tube placement. This is considered the elective feeding technique if a functional digestive system is present. Methods: A PubMed-based search restricted to the English literature from the last 20 years was conducted. References in the results were also reviewed to identify potential sources of information. Results: PEG feeding has consistently demonstrated to be more effective and safe than nasogastric tube feeding, having also replaced surgical and radiological gastrostomy techniques for long term feeding. PEG is considered a minimally invasive procedure to ensure an adequate source for enteral nutrition in institutionalized and at home patients. Acute and chronic conditions associated with risk of malnutrition and dysphagia benefit from PEG placement: Beyond degenerative neuro-muscular disorders, an increasing body of evidence supports the advantages of PEG tubes in patients with head and neck cancer and in a wide range of situations in pediatric settings. The safety of PEG placement under antithrombotic medication is discussed. While antibiotic prophylaxis reduces peristomal wound infection rates, co-trimoxazole solutions administered through a newly inserted catheter constitutes an alternative to intravenous antibiotics. Early feeding (3-6 hours) after PEG placement firmly supports on safety evidences, additionally resulting in reduced costs and hospital stays. Complications of PEG are rare and the majority prevented with appropriated nursing cares. Conclusions: PEG feeding provides the most valuable access for nutrition in patients with a functional gastrointestinal system. Its high effectiveness, safety and reduced cost underlie increasing worldwide popularity.

Gammagrafía con hematíes desnaturalizados en el diagnóstico de esplenosis peritoneal en paciente con antecedente de hepatocarcinoma: a propósito de un caso

Colitis izquierda necrótica por enema de agua caliente

Síndrome LPAC secundario a deleción del exón 4 del gen ABCB4 en un paciente con hepatitis C

Low-phospholipid-associated cholelithiasis syndrome (LPAC) is associated with ABCB4 genetic mutation. ABCB4 encodes MDR3 protein, involved in biliary phosphatidylcholine excretion. Higher prevalence in women, biliary symptoms in young adults and ursodesoxycholic acid (UDCA) response are the main features. We report the case of a 48-year-old man with hepatitis C, genotype 1b, fibrosis F3, null responder to Peg-IFNα2b/ribavirin and nephritic colic. In 2011 he developed jaundice, pruritus and epigastric pain. He showed increased serum levels of AST, ALT, GGT, bilirubin and alpha-fetoprotein, and viral load (14,600,000IU/mL). Pancreatic-CT, endoscopic ultrasonography and echo-Doppler showed non-cirrhotic chronic liver disease. The episode resolved spontaneously and one year later he suffered a similar episode. UDCA was started with excellent response. An immunohistochemistry study and sequencing of ABCB4 did not find alteration. MLPA® technique detected heterozygous deletion of the full exon 4 confirming LPAC syndrome diagnosis.

El síndrome LPAC (low-phospholipid-associated cholelithiasis syndrome) está asociado a mutaciones del gen ABCB4, que codifica la proteína MDR3, esencial en la secreción de fosfatidilcolina en las sales biliares. Este síndrome se caracteriza por una mayor prevalencia en mujeres, síntomas biliares en adultos jóvenes y excelente respuesta al ácido ursodesoxicólico (AUDC). Presentamos el caso de un hombre de 48 años con hepatitis C, genotipo 1b, fibrosis F3, nula respuesta Peg-IFN-α-2b/ribavirina y cólicos nefríticos de repetición. En 2011 desarrolló ictericia, prurito y dolor cólico epigástrico acompañado de aumento sérico de AST, ALT, GGT, bilirrubina y alfafetoproteína, y carga viral (14.600.000 UI/ml). La endoscopia oral, la ecoendoscopia, la angio-TAC y la ecografía-doppler evidenciaron hepatopatía crónica no cirrótica. El cuadro se autolimitó y un año después sufrió un episodio similar. Iniciamos tratamiento con AUDC, con excelente respuesta clínica. El estudio inmunohistoquímico y la secuenciación completa del gen ABCB4 no mostraron alteraciones. La técnica MLPA® detectó deleción heterocigota del exón 4 completo y confirmó la sospecha de síndrome LPAC.

Tuberculosis peritoneal: diagnóstico radiológico

Peritoneal tuberculosis (TB) is an extrapulmonary form of presentation of tuberculosis. HIV infection is a primary risk factor for this condition. Diagnosis requires microbiological or histopathological confirmation in addition to supporting radiological imaging studies. Abdominal ultrasonography and CT are useful to obtain a radiographic diagnosis, with typical findings including diffuse peritoneal thickening, presence of ascites in varying volumes, adenopathies, and caseating nodes. We report 2 cases of patients with ascites and nodular peritoneal thickening on diagnostic images, as well as high CA-125 levels in laboratory tests. In both patients, a diagnosis of peritoneal tuberculosis was reached following a US-guided peritoneal biopsy.

La tuberculosis (TBC) peritoneal es una de las formas de presentación extrapulmonar de la tuberculosis. La infección por VIH es uno de los principales factores de riesgo para esta enfermedad. El diagnóstico requiere una confirmación microbiológica o histopatológica, además de pruebas radiológicas que lo apoyen. En el diagnóstico radiológico son útiles la ecografía y la TC abdominal, los hallazgos característicos son el engrosamiento peritoneal difuso, la presencia de ascitis en cantidades variables, adenopatías y nódulos caseificantes. Presentamos 2 casos de pacientes con ascitis y engrosamiento nodular del peritoneo en las pruebas de imagen y un CA 125 elevado en las pruebas de laboratorio. En ambos casos se llegó al diagnóstico de tuberculosis peritoneal después de realizar biopsia peritoneal guiada por ecografía.

Tres casos de hepatotoxicidad por un suplemento dietético destinado a frenar la caída del cabello

Liver toxicity associated with herbal remedies and dietary supplements is an increasing concern. Several toxic hepatitis cases have been reported in the literature in association with products intended for weight loss where green tea extracts are an ingredient. Three hepatotoxicity cases are reported below in association with the use of Inneov masa capilar®, a dietary supplement intended to stop hair loss whose primary component is green tea catechins. In all of them, other potential causes of acute hepatitis were ruled out. We highlight the importance of awareness regarding these substances at history taking in order to identify and report hepatic adverse reactions secondary to apparently safe herbs as described in the present manuscript.

La toxicidad hepática asociada al uso de productos de herboristería y suplementos nutricionales es un fenómeno creciente. En la literatura se han comunicado varios casos de hepatitis tóxica en relación con productos utilizados para la pérdida de peso que incluyen extractos de té verde en su composición. A continuación se describen tres casos de hepatotoxicidad relacionados con la toma de Inneov masa capilar®, un suplemento nutricional destinado a detener la caída del cabello cuyo componente principal son las catequinas de té verde. En todos ellos se descartaron otras posibles causas de hepatitis aguda. Recalcamos la importancia de incluir la ingesta de este tipo de sustancias a la hora de realizar la anamnesis para poder detectar y notificar las reacciones hepáticas adversas secundarias a productos herbales de apariencia inocua, como el descrito en el manuscrito.

Cuerpos extraños en el tracto digestivo alto: ¿qué entendemos por un cuerpo extraño en el esófago?

Páncreas ectópico como causa rara de ictericia obstructiva

Carcinoma neuroendocrino de vía biliar extrahepática

Tumor carcinoide del conducto biliar común

La ausencia de HLA-DQ2 y HLA-DQ8 no excluye la enfermedad celiaca en pacientes brasileños

Dermatitis herpetiforme en hombres brasileños con enfermedad celiaca: una serie de casos

Tetania y convulsiones, síntomas de debut de la enfermedad de Crohn