Relationship of basal and postprandial intraduodenal bile acid concentrations and plasma cholecystokinin levels with abdominal pain in patients with chronic pancreatitis.

Abdominal pain in patients with chronic pancreatitis has been related to an increase in plasma cholecystokinin (CCK) levels. The aim of the study was to disclose the relation of the altered response with the low intraduodenal bile acids levels found in these patients. Twenty patients with chronic pancreatitis were classified into groups I (n = 11) and II (n = 9) according to the presence or absence of pain. Intraduodenal trypsin and bile acids concentrations and plasma CCK levels were measured before and 30, 60, and 90 min after a test meal. Comparisons between values in both groups were carried out. Correlation of intraduodenal trypsin and bile acids with plasma CCK was analyzed. Patients with pain exhibited significantly lower intraduodenal trypsin levels at 30 and 90 min and lower basal and postprandial intraduodenal bile acids levels than patients without pain. In patients with pain, basal and postprandial plasma CCK levels were significantly higher than in patients without pain. A negative correlation was demonstrated between intraduodenal bile acids and plasma CCK. In patients with chronic pancreatitis and pain, a reduction in intraduodenal postprandial trypsin and basal and postprandial bile acids concentrations, as well as an increase in basal and postprandial plasma CCK levels, was encountered. A negative correlation between intraduodenal bile acids and plasma CCK concentrations was detected that may be implicated in the pathogenesis of pain.

Computed tomography findings of peritoneal tuberculosis: systematic review of seven patients diagnosed in 6 years (1996-2001).

OBJECTIVE: The aim of this study was to describe the computed tomography (CT) findings in patients with demonstrated peritoneal tuberculosis (TB) and their concordance with the three types from the traditional classification (wet, fibrotic, and dry plastic). METHODS: We reviewed the CT images of all patients with microbiologically proven peritoneal tuberculosis over a 6-year period (1996-2001). RESULTS: Seven patients were included. Ascites was present in 5 patients (free ascites in 3 patients and loculated in 2). Involvement of the mesentery was found in 5 patients, the omentum in 4, and the parietal peritoneum in 3. Tuberculous lymphadenitis was the most common associated finding (6 patients). Two patients had hepatic lesions. The fibrotic type was found in all the patients, and 5 patients had an association of the fibrotic and wet types. None of the patients had lesions consistent with the dry plastic type. CONCLUSION: Peritoneal tuberculosis is best described as a combination of ascites, peritoneal lesions, and lymphadenopathy, rather than the three types from the traditional classification.

[Multivisceral infarcts are complication of invasive aspergillosis]. / Infartos viscerales múltiples detectados por TAC en la aspergilosis invasiva.

Aspergillus fumigatus is one of the species of Aspergillus that causes aspergillosis. The clinical picture of invasive-disseminated aspergillosis is generally characterized by fever and respiratory distress that usually follows a fatal course. This form of intensive aspergillosis is suffered by severely immunossuppressed patients. There is another clinical form of severe aspergillosis, aortic aspergillosis, that appears after cardiac surgery. We present two cases of invasive aspergillosis complicated by multiple visceral infarcts involving the liver, spleen, kidneys, pancreas, thiroid and brain. Infarcts were confirmed in necropsy and appeared to be caused by an overwhelming amount of intravascular hiphae, which were observed in the infarcted areas acting forming septic embolus. We believe that multi-visceral infarcts are an underestimated complication of invasive aspergillosis. Given the progressive increase in the population of immunossuppressed patients, clinicians have to aware of all the possible presentations of invasive aspergillosis.

[Diagnosis with helical CT and echocardiography of patients with suspected chronic thromboembolic pulmonary hypertension]. / Diagnóstico con TAC helicoidal y ecocardiografía de la hipertensión pulmonar por tromboembolismo pulmonar crónico.

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a serious disease with a very high mortality after variable periods of time. Early diagnosis of CTEPH is critical because thromboendarterectomy can improve survival, hemodimamics and functional capacity. Based on our experience we have performed a review of diagnostic techniques. Echocardiography, pulmonary angiography, fiberoptic angioscopy, helical CT an MRI. For each diagnostic procedure we have analysed its accuracy, invasiveness and easiness of use. We conclude that currently the most useful techniques are echocardiography (to asses pulmonary hypertension), and helical CT which is a good alternative to pulmonary angiography and can detect very specific findings such as dilatation of central pulmonary arteries, eccentric localized thrombi and mosaic attenuation of the pulmonary parenchyma. Even more accurate findings can be expected by the use of multislice CT, which could allow to asses the degree of narrowing of the pulmonary vessels and bronchial circulation.

[Imaging advances in the diagnosis of neuroendocrine tumors]. / Avances en la localización de los tumores neuroendocrinos con las ténicas de imagen.

We present two cases of neuroendocrine tumors: insulinoma and glucagonoma. Several diagnostic procedures are analysed including those useful to localize the tumor and its possible metastasis, as ultrasound, computed tomography, magnetic resonance imaging, angiography, endoscopic ultrasonography and somatostatin receptor scintigraphy. We suggest that the work up should begin with lesser invasive procedures such as CT and In111-labelled pentetreotide scan.

[Spontaneous infectious spondylodiscitis in an internal medicine department: epidemiological and clinical study in 41 cases]. / Espondilodiscitis infecciosa espontánea en un servicio de medicina interna: estudio epidemiológico y clínico de 41 casos.

INTRODUCTION: The clinical-epidemiological characteristics of patients who were diagnosed of spontaneous infectious spondylodiscitis (SIS) in our Internal Medicine Department are analyzed and the related factors associated with the increase of the incidence are evaluated. PATIENTS AND METHODS: A cross-sectional, retrospective study of patients diagnosed of SIS from 1996 to 2005 was conducted. The study was divided in two periods: A (1996-2000) and B (2001-2005) and two main etiologic groups (pyogenic SIS and mycobacterial SIS) were compared. RESULTS: A total of 41 patients were diagnosed of SIS: 13 (31.7%) in period A and 28 (68.3%) in period B. Mean age was 58.5 +/- 17.6 years (range: 29-89). There were 73.2% men and all women presented in period B (0 vs 11, p = 0.008). Backgrounds were: 28 (68.3%) predisposing factors for SIS, 22 (53.6%), previous infections and 23 (56.1%) spinal diseases. There were not changes in the backgrounds during the study. The etiology of SIS was: 26 (63.4%) pyogenic, 12 (29.3%) mycobacterial and 3 (7.3%) brucellar. Patients with pyogenic SIS were older (63.6 +/- 3.2 vs 51.2 +/- 5.1 years, p = 0.035) and had less from onset of symptoms to diagnosis (62 +/- 12 vs 291 +/- 66 days, p = 0.0001) than patients with mycobacterial SIS. Total incidence of SIS and incidence of pyogenic SIS increased significantly during the study: (1.7/1000 admissions/year, p = 0.0057) and (1/1000 admissions/year, p = 0.0476). In the multivariate analysis, time from onset of symptoms to diagnosis was the only variable independently associated with the pyogenic etiological group (OR: 0.985, 95% CI: 0.975, 0.996, p = 0.005). CONCLUSIONS: In our study, the increasing incidence of SIS was related to an increase in pyogenic SIS incidence. Although older age and some backgrounds could be orientative of SIS etiology, these factors did not increase during the study.

[Cost-effectiveness of computerized axial tomography in the diagnosis of traditional clinical picture of fever of unknown origin]. / Rentabilidad de la tomografía axial computarizada en el diagnóstico de la fiebre de origen desconocido clásica.

Diagnostic strategy in fever of unknown origin has been changing in recent decades. The objective of this study is to define the role of thoracoabdominal computerized axial tomography in the first diagnostic stage. A sample of 24 patients with classical fever of unknown origin from our hospital Internal Medicine department was selected between January 1995 and December 2002. Cost-effectiveness of diagnostic thoracoabdominal computerized axial tomography compared to that of abdominal echography was analyzed; the information obtained with both diagnostic techniques for the final diagnosis was also evaluated. Computerized axial tomography contributed data suggestive of the diagnosis in 10 of 24 patients (41.7%); abdominal echography only gave orienting information to the diagnosis in 2 cases (8%). In 9 (90%) of the 10 patients with computerized axial tomography specific alterations, a conclusive definitive diagnosis (with analysis of biological sample) was possible. Accordingly, the use of this technique is justified at the beginning of the study of the classical fever unknown origin in order to orient the clinician to resort to other more directed and specific diagnostic techniques and with higher diagnostic cost-effectiveness.

[Clinical-biological and radiological study of Wegener's granulomatosis in a university hospital]. / Estudio clínico-biológico y radiológico de la granulomatosis de Wegener en un hospital universitario.

UNLABELLED: Wegener's granulomatosis is a rare systemic vasculitis that fundamentally affects the kidney and respiratory tract. Although the histological findings are very characteristic, they do not occur in all cases, which makes diagnosis difficult. METHODS: The main clinical, biological and radiological characteristics of 13 cases of Wegener's granulomatosis diagnosed in a university hospital of the center of Spain are collected in this present paper. RESULTS: The majority of the patients were men in their 50's. Fever and general syndrome were usual presentations of the disease. Upper respiratory tract (10 cases) and lung involvement (9), followed by renal involvement (8), were the most common. Alveolar infiltrates and bilateral nodules were the most common findings in the X-ray and thoracic CT scan, although the latter permits a greater definition of the lesions. Measurement of antibodies against cytoplasma of the neutrophils (ANCA) was positive in 8 patients (6 cANCA and 2 pANCA). Renal biopsy was used most for the histologic diagnosis, where focal and segmental glomerulonephritis was the most common finding. The majority of the patients received steroids plus cyclophosphamide as induction treatment. CONCLUSIONS: Wegener's disease is a rare systemic vasculitis. The existence of hematuria or respiratory tract involvement in a patient with fever suggests the diagnosis. Conducting a CT scan and ANCAs measurement are useful tools for its diagnosis, since the histology is not definitive.

[Risk factors of a new cardio-embolic cerebral accident in non-valvular atrial fibrillation treated with acenocoumarol]. / Factores de riesgo de un nuevo accidente cerebral cardioembólico en la fibrilación auricular no valvular tratada con acenocumarol.

OBJECTIVES: To investigate the risk factors determining the appearance of a new cardio-embolic cerebral accident on secondary thrombophylaxis of non-valvular auricular fibrillation (NVAF). DESIGN: Controlled observational study on a series of patients treated with acenocoumarol for a period of 2.8 years. SETTING: Anticoagulation Unit of the La Paz Hospital and patients from Madrid Area 5. PARTICIPANTS: 172 patients with NVAF, over 55 and with fibrillation for at least a year, and who had suffered at least one ischaemic cerebral accident. All were treated with acenocoumarol and controlled at an INR of 2.5. The risk factors were determined and the appearance of new cardio-embolic phenomena was watched during the study period. MEASUREMENTS AND MAIN RESULTS: 12 cardio-embolic phenomena were recorded (11 CVA and one peripheral embolism). The univariate study showed there was a significant association between patients who suffered a new ictus and those who suffered heart failure (p < 0.05) and had a history of more than one ictus before the start of the study (p < 0.05). Multivariate analysis found that what had independent predictive value was having suffered more than one ictus. CONCLUSIONS: The greatest threat for developing a new ischaemic CVA during anticoagulation in NVAF is having a history of two or more previous ictus, as if the tendency to recur was due to these patients having more extensive atherosclerosis.