Normal transaminases in obese patients with metabolic associated steatohepatitis (MASH): a cohort of Peruvian patients.

INTRODUCTION: Metabolic associated steatohepatitis (MASH) is one of the most frequent causes of chronic liver disease. Liver transaminases are important biomarkers to measure liver injury, however, a proportion of patients with MASH may present with normal levels of transaminases. The levels of serum transaminases may not correlate with the severity of histopathological changes. OBJECTIVE: We aimed to identify the frequency of normal transaminases in obese patients with MASH, as well as to describe the clinical, biochemical and histological characteristics in this specific group of patients. MATERIALS AND METHODS: A retrospective cross-sectional study was conducted in the bariatric surgery service of a private clinic. Obese patients older than 18 years with a body mass index (BMI) >30Kg/m2 and 2 co-morbidities undergoing a gastric sleeve surgery were included. Measurement of biochemical routine laboratory exams was performed. Insulin resistance was calculated using the homeostasis evaluation model (HOMA-IR). All patients underwent liver biopsies prior to surgery and the diagnosis of MASH was based on the Brunt criteria. RESULTS: 159 obese patients with MASH were included, of which 47.2% had normal transaminases and 52.8% elevated transaminases. Factors associated with alteration in transaminases were: being male OR=4.02 (95% CI: 2.03- 7.96; p<0.01), diagnosis of type 2 diabetes mellitus OR=4.86 (95% CI: 1.97- 11.95; p<0.01) and levels of GGT >50 IU/L OR=7.50 (95% CI: 3.40-16.56; p<0.01). The values of HOMA-IR and GGT were significantly higher in the group of high transaminases (p<0.01). Differences in the degree of fibrosis were not associated with transaminases levels. CONCLUSION: In conclusion we found that the frequency of normal transaminases was 47.2% in obese patients with MASH. Factors associated with elevation in liver enzymes were being male, diagnosis of diabetes mellitus and elevation in GGT levels. The degree of fibrosis was not associated with elevations in liver transaminases. These findings suggest that transaminases levels alone are not accurate markers to assess liver injury, as they do not necessarily correlate with histological liver damage.

Latin American Association for the study of the liver (ALEH) practice guidance for the diagnosis and treatment of non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) currently represents an epidemic worldwide. NAFLD is the most frequently diagnosed chronic liver disease, affecting 20-30% of the general population. Furthermore, its prevalence is predicted to increase exponentially in the next decades, concomitantly with the global epidemic of obesity, type 2 diabetes mellitus (T2DM), and sedentary lifestyle. NAFLD is a clinical syndrome that encompasses a wide spectrum of associated diseases and hepatic complications such as hepatocellular carcinoma (HCC). Moreover, this disease is believed to become the main indication for liver transplantation in the near future. Since NAFLD management represents a growing challenge for primary care physicians, the Asociación Latinoamericana para el Estudio del Hígado (ALEH) has decided to organize this Practice Guidance for the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease, written by Latin-American specialists in different clinical areas, and destined to general practitioners, internal medicine specialists, endocrinologists, diabetologists, gastroenterologists, and hepatologists. The main purpose of this document is to improve patient care and awareness of NAFLD. The information provided in this guidance may also be useful in assisting stakeholders in the decision-making process related to NAFLD. Since new evidence is constantly emerging on different aspects of the disease, updates to this guideline will be required in future.

[Autoimmune hepatitis and pregnancy: a case series]. / Hepatitis autoinmune y embarazo: serie de casos.

We report four cases of female patients diagnosed with autoimmune hepatitis treated in the liver unit of the National Hospital Arzobispo Loayza in the period 2014-2018, these patients became pregnant during treatment. Pregnancy in all cases came to an end without any complications, patients received immunosuppressive treatment during pregnancy. We present the sequence of events with their results and a review of the literature.

[The most common rheumatic diseases in patients with autoimmune liver disease in the Hospital Arzobispo Loayza from 2008-2013, Lima, Peru]. / Enfermedades reumatológicas más frecuentes en pacientes con enfermedad hepática autoinmune en el Hospital Nacional Arzobispo Loayza entre el 2008 al 2013, Lima, Perú

OBJECTIVE: To identify the most common autoimmune rheumatic diseases in patients with autoimmune liver disease in the Hospital Arzobispo Loayza (HAL) from 2008 -2013. MATERIALS AND METHODS: This is a transversal and descriptive study, we analyzed 125 medical records, only 86 patients fulfill the diagnostic criteria for autoimmune liver disease, of whom 46 had diagnosis of autoimmune hepatitis(AIH), 39 primary biliary cirrhosis(PBC) and just 1 primary sclerosing cholangitis (PSC). In our study group we looked for the clinical and laboratory characteristics most common and the frequency of cases in the HAL. RESULTS: Of the 46 patients with AIH, 16 (34.78%) were diagnosed with autoimmune rheumatic disease concurrence. Of these, 7 (15.22%) patients had Sjogren ́s Disease (SD), 6 (13.04%) had systemic lupus erythematosus (SLE) and 3 (6.52%) had rheumatoid arthritis (RA). We found 39 patients with PBC, 18 (46.15%) had other associated extrahepatic autoimmune disease, of whom 12 (30.77%) had SD, 3 (7.69%) SLE and 3 (7.69%) RA. One patient had the diagnosis of PSC, a sixty year old woman that had no concurrence with rheumatic disease. CONCLUSIONS: In our study was found that SD is the most common rheumatic disease in patients with AIH and PBC, followed by SLE and RA, with autoimmune liver disease with rheumatic symptoms and vice versa.

Normal transaminases in obese patients with metabolic associated steatohepatitis (MASH): a cohort of Peruvian patients

Introduction: Metabolic associated steatohepatitis (MASH) is one of the most frequent causes of chronic liver disease. Liver transaminases are important biomarkers to measure liver injury, however, a proportion of patients with MASH may present with normal levels of transaminases. The levels of serum transaminases may not correlate with the severity of histopathological changes. Objective: We aimed to identify the frequency of normal transaminases in obese patients with MASH, as well as to describe the clinical, biochemical and histological characteristics in this specific group of patients. Materials and methods: A retrospective cross-sectional study was conducted in the bariatric surgery service of a private clinic. Obese patients older than 18 years with a body mass index (BMI) >30Kg/m2 and 2 co-morbidities undergoing a gastric sleeve surgery were included. Measurement of biochemical routine laboratory exams was performed. Insulin resistance was calculated using the homeostasis evaluation model (HOMA-IR). All patients underwent liver biopsies prior to surgery and the diagnosis of MASH was based on the Brunt criteria. Results: 159 obese patients with MASH were included, of which 47.2% had normal transaminases and 52.8% elevated transaminases. Factors associated with alteration in transaminases were: being male OR=4.02 (95% CI: 2.037.96; p50 IU/L OR=7.50 (95% CI: 3.40-16.56; p<0.01). The values of HOMA-IR and GGT were significantly higher in the group of high transaminases (p<0.01). Differences in the degree of fibrosis were not associated with transaminases levels. Conclusion: In conclusion we found that the frequency of normal transaminases was 47.2% in obese patients with MASH. Factors associated with elevation in liver enzymes were being male, diagnosis of diabetes mellitus and elevation in GGT levels. The degree of fibrosis was not associated with elevations in liver transaminases. These findings suggest that transaminases levels alone are not accurate markers to assess liver injury, as they do not necessarily correlate with histological liver damage.

Introducción: La esteatohepatitis asociada metabólica (MASH) es una de las causas más frecuentes de enfermedad hepática crónica. Las transaminasas hepáticas son biomarcadores importantes para medir el daño hepático; sin embargo, una proporción de pacientes con MASH pueden presentar niveles normales de transaminasas. Los niveles de transaminasas séricas pueden no estar correlacionados con la gravedad de los cambios histopatológicos. Objetivo: Nuestro objetivo fue identificar la frecuencia de transaminasas normales en pacientes obesos con MASH, así como describir las características clínicas, bioquímicas e histológicas en este grupo específico de pacientes. Materiales y métodos: Se realizó un estudio transversal retrospectivo en el servicio de cirugía bariátrica de una clínica privada. Se incluyeron pacientes obesos mayores de 18 años con índice de masa corporal (IMC) >30Kg/m2 y 2 comorbilidades sometidos a cirugía de manga gástrica. Se realizó la medición de los exámenes bioquímicos de laboratorio de rutina. La resistencia a la insulina se calculó mediante el modelo de evaluación de la homeostasis (HOMA-IR). Todos los pacientes se sometieron a biopsias hepáticas antes de la cirugía y el diagnóstico de MASH se basó en los criterios de Brunt. Resultados: Se incluyeron 159 pacientes obesos con MASH, de los cuales el 47,2% tenían transaminasas normales y el 52,8% transaminasas elevadas. Los factores asociados a la alteración de las transaminasas fueron: ser hombre OR=4,02 (IC 95%: 2,03-7,96; p50 UI/L OR=7,50 (IC 95%: 3,40-16,56; p<0,01). Los valores de HOMA-IR y GGT fueron significativamente mayores en el grupo de transaminasas altas (p<0,01). Las diferencias en el grado de fibrosis no se asociaron con los niveles de transaminasas. Conclusión: Encontramos que la frecuencia de transaminasas normales fue del 47,2% en pacientes obesos con MASH. Los factores asociados con la elevación de las enzimas hepáticas fueron el sexo masculino, el diagnóstico de diabetes mellitus y la elevación de los niveles de GGT. El grado de fibrosis no se asoció con elevaciones de las transaminasas hepáticas. Estos hallazgos sugieren que los niveles de transaminasas por sí solos no son marcadores precisos para evaluar el daño hepático, ya que no necesariamente se correlacionan con el daño hepático histológico.

[PREGNANCY AND HEPATITIS CIRRHOSIS] / Cirrosis Hepática y Gestación.

We report a case of a pregnant woman of 33 years old, suffering from hepatic cirrhosis by Hepatitis B with splenomegaly and portal hypertension, the 40 weeks pregnancy ended succesfully with a newborn weighting 2,900 g born by vaginal delivery.

[HEMOBILIA: REPORT OF TWO CASES] / Hemobilia: Reporte de Dos Casos.

Hemobilia is defined as the hemorrhage within the biliary tree. Maybe, the abnormal communication between blood vessels and the billiary tree, is due to trauma, inflammatory disorders, infections, gallstones, tumors and coagulation disorders. Two cases, which diagnosis were made with retrograde endoscopic cholangio pancreatography, are reported here.

[PREGNANCY AND LIVER CIRRHOSIS: REPORT OF A CASE] / Cirrosis Hepática y Gestación:Reporte de un Caso.

Pregnancy in women with liver cirrhosis is unusual, because of the metabolic alterations that the liver disease produces.We report a case of a cirrhotic alcoholic patient who was pregnant twice. The first pregnancy was successful delivering a baby of 2,500g. On the second one, the patient died because of digestive hemorrahage caused esophageal varices the fetus also died.

[CLINICAL AND IMMUNOLOGICL PROFILE IN 22 PATIENTS WITH PRIMARY BILIARY CIRRHOSIS] / Perfil clínico e inmunológico en 22 pacientes con diagnóstico histopatológico de cirrosis biliar primaria.

The primary biliary cirrhosis (PBC) is a no frequent entity in our country. Its diagnosis is based on clinical features, cholestasic pattern in liver function tests and the presence of antimitochondrial antibody in 90% of cases and other auto-antibodies in the serum, all this information is supported by characteristic hepatic histopathologic data. Also some clinical variants have been described that has suggested different denominations such as Overlap Syndrome, associated to autoimmune hepatitis and autoimmune colangitis, known by its persistent negativity of the antimitochondrials antibodies.The present study reports the clinical, biochemical and immunological findings of 22 patients with histopathologic diagnosis of PBC observed between 1994 and 1999, in Arzobispo Loayza Hospital and private offices, in Lima, Per .Results shown a cholestatic pattern in 100% of patients, jaundice in 95%, pruritus in 86%, hyperpigmentation of skin in 40.9%, hepatomegaly in 36.9% splenomegaly in 37.3% and xantelasma in 36%; alkaline phospatase was increased between 5 and 30 times the normal values in all patients, oxalacetic and piruvic transaminases were increased more than twice the normal values in 95% and 90%, respectively and hypercholesterolemia in 89% of patients; the antimitochondrial antibodies were positive in 64%, antinuclear antibodies in 32% and anti smooth muscle in 18%; 7 patients present associated autoimmune diseases, 4 with sicca syndrome, 2 with vitilige and 1 with hemolitic anemia. Three patients were classified as primary biliary cirrhosis, associated to autoimmune hepatitis; 4 patients died during the follow up and six patients were treated with ursodeoxicholic acid for more than six months.We can conclude that the profile found is a cholestasic pattern with jaundice in the majority of patients, low positivity of mitochondrial antibodies; there was no difference between AMA positive and negative patients, and in the third part of patients it was observed an associated immune disease and in three cases there was evidence of association with autoimmune hepatitis (Overlap Syndrome). Finally, the treatment with ursodeoxicolic acid improves some biochemical parameters, but apparently, they do not survival improve.

[ASSOCIATION OF DUODENAL DIVERTICULUM PRESENCE WITH CHOLEDOCHOLITHIASIS] / Asociación entre presencia deDivertículos Duodenales y Coledocolitiasis.

OBJECTIVES: The aim of this study was to investigate in aretrospective way the frequency of duodenal diverticulum and its association with choledocholithiasis. Methods:This study included 2728 consecutive patients who underwent ERCP during the period 1993-1997. Duodenal diverticulum was discovered in 122 cases (4.5%). In 22 patients cannulation was not achieved since it was not technically possible. Results: In 100 patients with successful cannulation, 54 cases with juxtapapillary diverticulum were encountered associated with choledocholithiasis. CONCLUSION: These data suggestthat duodenal diverticulum is associated with choledocholithiasis.

[CHOLEDOCHAL CYST: ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY(ERCP) DIAGNOSIS VALUE] / Quiste de Colédoco: Valor diagnósticode la Pancreatocolangiografía retrograda endoscópica.

We presented six cases of choledochal cysts all of whichwere diagnosed by ERCP. Patients were 12,13,17,20,29 and 36 years old. Five were female and one was a male. The main symptom was abdominal pain.The Endoscopic Retrograde Cholangiopancreatography showed the anatomic details of the biliary tree and the pancreaticobiliary ductal junction and also allowed us to decide the adecuate management of the patient.

Enfermedades reumatológicas más frecuentes en pacientes con enfermedad hepática autoinmune en el Hospital Nacional Arzobispo Loayza entre el 2008 al 2013, Lima, Perú / The most common rheumatic diseases in patients with autoimmune liver disease in the Hospital Arzobispo Loayza from 2008 -2013, Lima, Peru

Identificar las enfermedades reumatológicas autoinmunes más frecuentes en pacientes con enfermedad hepática autoinmune en el Hospital Arzobispo Loayza (HAL) desde el 2008 - 2013. Materiales y métodos: Este estudio es descriptivo, retrospectivo y transversal donde se analizaron 125 historias clínicas, del servicio de Gastroenterología del Hospital Arzobispo Loayza (HAL), Lima, Perú. Solo 86 pacientes cumplían con los criterios diagnósticos de Enfermedad hepática autoinmune, de los cuales 46 tenían diagnóstico de hepatitis autoinmune (HAI), 39 cirrosis biliar primaria (CBP) y solo 1 Colangitis esclerosante primaria (CEP). Se buscó las características clínicas y de laboratorios más frecuentes en nuestro grupo de estudio y la frecuencia de casos en el HAL. Resultados: De los 46 pacientes con HAI, 16 (34,78%) tuvieron diagnóstico de enfermedad reumatológica autoinmune concomitante. De estos, 7 (15,22%) pacientes fueron diagnosticados con enfermedad de Sjogren (ES), 6 (13,04%) con Lupus eritematoso sistémico (LES) y 3 (6,52%) con Artritis Reumatoide (AR). Se encontró 39 pacientes con CBP, 18 (46,15%) presentaron una enfermedad reumatológica, de los cuales 12 (30,77%) tuvieron ES, 3 (7,69%) LES y 3 (7,69%) AR. Se halló 1 paciente con diagnóstico de CEP, mujer de 60 años la cual no tenía enfermedad reumática concurrente. Conclusiones: Nuestro estudio muestra que la ES es la enfermedad reumática más común en pacientes con HAI y CBP, seguido de LES y AR, esto nos lleva a buscar estas patologías en pacientes con enfermedad hepática autoinmune con sintomatología reumatológica y viceversa...

To identify the most common autoimmune rheumatic diseases in patients with autoimmune liver disease in the Hospital Arzobispo Loayza (HAL) from 2008 -2013. Materials and methods: This is a transversal and descriptive study, we analyzed 125 medical records, only 86 patients fulfill the diagnostic criteria for autoimmune liver disease, of whom 46 had diagnosis of autoimmune hepatitis(AIH), 39 primary biliary cirrhosis(PBC) and just 1 primary sclerosing cholangitis (PSC). In our study group we looked for the clinical and laboratory characteristics most common and the frequency of cases in the HAL. Results: Of the 46 patients with AIH, 16 (34.78%) were diagnosed with autoimmune rheumatic disease concurrence. Of these, 7 (15.22%) patients had Sjogren´s Disease (SD), 6 (13.04%) had systemic lupus erythematosus (SLE) and 3 (6.52%) had rheumatoid arthritis (RA). We found 39 patients with PBC, 18 (46.15%) had other associated extrahepatic autoimmune disease, of whom 12 (30.77%) had SD, 3 (7.69%) SLE and 3 (7.69%) RA. One patient had the diagnosis of PSC, a sixty year old woman that had no concurrence with rheumatic disease. Conclusions: In our study was found that SD is the most common rheumatic disease in patients with AIH and PBC, followed by SLE and RA, this leads us to look for these diseases in patients with autoimmune liver disease with rheumatic symptoms and vice versa...

Cirrosis hepática y gestación / Pregnancy and hepatitis cirrhosis

Reportamos un caso de gestación en una mujer de 33 años con cirrosis hepática por hepatitis B, asociada a esplenomegalia e hipertensión portal. El embarazo llegó a término obteniéndose un producto vivo nacido por vía vaginal de 2,900 g.

Endocarditis trombótica no bacteriana asociada a hepatocarcinoma / Nonbacterial trombotic endocarditis related to hepatocarcinoma

Presentamos el caso de una paciente de 80 años con endocarditis trombótica no bacteriana (ETNB) asociada a hepatocarcinoma. Se revisan aspectos epidemiológicos y clínico -patológicos de esta entidad, cuyo diagnóstico temprano podría prevenir las embolizaciones. Este constituye el primer caso publicado en la literatura nacional.

A case of a woman with nonbacterial thrombotic endocarditis (NBTE) associated with hepatocarcinoma is here presented. Epidemiologic and clinicopathologic aspects are reviewed, early clinical suspicion may prevent embolization. ¡t represents the first case reported in the national literature.

Síndrome de Peutz-Jeghers: a propósito de un reporte familiar en el Hospital Arzobispo Loayza / The Peutz-Jeghers syndrome

El Síndrome de Peutz-Jeghers (SPJ) es una entidad rara autosómica dominante, caracterizada por lesiones hiperpigmentadas en boca, manos y pies; con presencia de pólipos gastrointestinales que ocasionan cuadros de anemia aguda o crónica, obstrucción intestinal y dolor abdominal. Histológicamente, estos pólipos son hamartomas en los que, estudios recientes establecen hoy un riesgo real para transformación neoplásica maligna. Las endoscopías altas y bajas y la enteroscopía intraoperatoria con polipectomía respectiva, constituye el tratamiento de elección, mejorando cualitativamente el pronóstico en estos pacientes. Describimos en esta oportunidad un caso familiar de una paciente, mujer de 24 años con cuadro suboclusivo a repetición, asi mismo el de su hermano, con similar clínica; además el de su madre fallecida de carcinoma de colon presentando ella también el mismo síndrome; y finalmente el hijo de la paciente, de un año y medio de edad que presenta lesiones hiperpigmentadas en los labios

Pancreatocolangiografía retrograda endoscópica y esfinterotomía en las parasitosis / Endoscopic retrograde colangio pancreatography and esphinterotomy in parasitic diseases

Presentamos seis pacientes con obstrucción de la vía billar debida a parásitos (Fasciola hepática, Ascaris lumbricoides y quiste hidatídico) que se diagnosticaron y manejaron endoscópicamente. Este es el primer trabajo nacional que resalta la importancia de la pancreatocolangiografía retrógrada endoscópica en el manejo de estas parasitosis. Por otro lado se destaca que no obstante la litiasis coledociana es la causa más común de ictericia extrahepática; debe considerarse a la parasitosis de la vía biliar en el diagnóstico diferencial.

We report six patients with billary duct obstruction due to parasites (Fasciola hepatica, ascarlasis and hydatid cyst) that were diagnosed and managed with the endoscopic approach. This is the first national paper which relevants the importance of endoscopic retrograde cholangio pancreatography in the management of this parasitosis. Despite choledocholithiasis is the most common cause of extrahepatic jaundice, biliary tree parasitosis must be considered in the differential diagnosis.

Perfil clínico e inmunológico en 22 pacientes con diagnóstico histopatológico de cirrosis biliar primaria / Clinical and immunological profile in 22 patients with primary biliary cirrhosis

La cirrosis biliar es una entidad poco frecuente en nuestro medio; su diagnóstico se sustenta en hallazgos clínicos, patrón colestásico en las pruebas de función hepatica y la presencia de anticuerpos anti-mitocondriales en el 90 por ciento de los casos y otros autoanticuerpos presentes en el suero, toda esta información esta respaldada por datos histopatológicos hepáticos característicos. También se han descrito algunas formas clínicas que han sugerido denominaciones diferentes como Sindrome de sobreposición (overlap syndrome), asociada a hepatitis autoinmune y la colangitis autoinmune, que se caracteriza por la persistente negatividad de los anticuerpos antimitocondriales. En el presente estudio se reportan los hallazgos clínicos, bioquímicos e inmunológicos de 22 pacientes con diagnóstico histopatológico vistos entre 1994 y 1999, en el Hospital Arzobispo Loayza y la consulta privada. Los resultados mostraron un patrón colestásico en el 100 por ciento de los pacientes, ictericia en el 95 por ciento, prurito en el 86 por ciento, hiperpigmentación de la piel en el 40.9 por ciento, hepatomegalia en 36.9 por ciento, esplenomegalia en 37.3 por ciento y xantelasma en el 36 por ciento; la fosfatasa alcalina estuvo elevada entre 5 y 30 veces los valores normales en todos los pacientes, las transaminasas oxalacética y pirúvica elevada más de dos veces los valores normales en el 95 por ciento y 90 por ciento respectivamente e hipercolesterolemia en el 89 por ciento de los pacientes; los anticuerpos anti mitocondriales fueron positivos en el 64 por ciento, los antinucleares en el 32 por ciento y antimúsculo liso en el 18 por ciento; siete pacientes presentaron enfermedades autoinmunes asociadas, 4 con sindrome seco, 2 con vitiligo y 1 con anemia hemolítica. Tres pacientes fueron catalogados como cirrosis biliar primaria, asociada a hepatitis autoinmune; cuatro pacientes fallecieron durante el seguimiento y seis pacientes fueron tratadas con ácido ursodeoxicólico por más de 6 meses...

Asociación entre presencia de divertículos duodenales y coledocolitiasis / Association of duodenal diverticulum presence with choledocholithiasis

Objetivos: El objetivo de este estudio fue investigar retrospectivamente la frecuencia de presentación del divertículo duodenal y su asociación con la coledocolitiasis. Métodos: El estudio incluyó 2728 pacientes a quienes se les realizó PCRE durante el período 1993 a 1997. El divertículo duodenal fue descubierto en 122 casos (4,5 por ciento). En 22 pacientes no se pudo realizar la canulación ya que no fue técnicamente posible. Resultados: en cien pacientes con éxito en la canulación se encontraron 54 casos con divertículos yuxtapapilar asociado a coledocolitiasis (54 por ciento). Conclusión: Estos datos sugieren que existe asociación del divertículo duodenal y la coledocolitiasis.

Cirrosis hepática y gestación: reporte de un caso / Pregnancy and liver cirrhosis: report of a case

La gestación en mujeres cirróticas es inusual, por las alteraciones metabólicas queesta enfermedad produce. Presentamos el caso de una paciente con cirrosis alcohólica que tuvo dos embarazos. El primero fue a término con un recién nacido de 2,500 g; en el segundo, la paciente falleció por hemorragia digestiva por várices esofágicas; hubo óbito fetal.

pregnancy in women with liver cirrhosis is unusual, beca use of the metabolic alterations that the liver disease produces. We report a case of a cirrhotic alcoholic patient who was pregnant twice. The first pregnancy was successful delivering a baby of 2,500 g. On the second one, the patient died because of digestive hemorrahage caused esophageal varices the fetus also died.