RESUMO
BACKGROUND: Splanchnic vein thrombosis (SVT) is a well-recognised though little-studied complication in acute pancreatitis (AP). SVT risk factors, its clinical consequences and the role of anticoagulation (AC) therapy is scarce. AIMS: To evaluate the incidence and natural history of SVT in AP. METHODS: Post hoc analysis of a prospective multicentre cohort study involving 23 hospitals in Spain. AP complications were identified by computer tomography, and patients with SVT were re-evaluated after two years. RESULTS: A total of 1655 patients with AP were included. The overall incidence of SVT was 3.6%. SVT was significantly associated with male gender, younger age and alcoholic aetiology. Every local complication increased SVT incidence, and this risk rose gradually with larger extension and infection of necrosis. These patients had a longer hospital stay and underwent a greater number of invasive treatments, regardless of AP severity. Forty-six patients with SVT were followed up. SVT resolution rate was 54.5% in the AC group and 30.8% in the non-AC group with lower thrombotic complications in the SVT resolution group (83.3% vs 22.7%; p<0.001). No AC-related adverse events occurred. CONCLUSION: This study identifies the risk factors and negative clinical impact of SVT in AP. Our results justify future trials to demonstrate the role of AC in this clinical scenario.
Assuntos
Pancreatite , Trombose , Trombose Venosa , Humanos , Masculino , Pancreatite/complicações , Pancreatite/epidemiologia , Pancreatite/induzido quimicamente , Estudos de Coortes , Estudos Prospectivos , Doença Aguda , Trombose Venosa/epidemiologia , Trombose Venosa/etiologia , Trombose Venosa/tratamento farmacológico , Trombose/complicações , Anticoagulantes/uso terapêuticoRESUMO
Introduction: Background: the Practical Guideline is based on the current scientific ESPEN guide on Clinical Nutrition in Liver Disease. Methods: it has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. Results: a total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. Disease-related recommendations are preceded by general recommendations on the diagnosis of nutritional status in liver patients and on liver complications associated with medical nutrition. Conclusion: this Practical Guideline gives guidance to health care providers involved in the management of liver disease on how to offer optimal nutritional care.
Introducción: Introducción: la Guía Práctica se basa en la actual guía científica de la ESPEN sobre nutrición clínica en las enfermedades hepáticas. Métodos: se ha reducido y transformado en diagramas de flujo para facilitar su uso en la práctica clínica. La guía está dedicada a todos los profesionales, incluidos médicos, dietistas, nutricionistas y enfermeras, que trabajan con pacientes con enfermedad hepática crónica. Resultados: la guía presenta un total de 103 pronunciamientos y recomendaciones con breves comentarios para el manejo nutricional y metabólico de pacientes con (i) insuficiencia hepática aguda grave, (ii) esteatohepatitis alcohólica, (iii) enfermedad hepática grasa no alcohólica, (iv) cirrosis hepática, y (v) cirugía o trasplante de hígado. Conclusión: las recomendaciones relacionadas con enfermedades están precedidas por recomendaciones generales sobre el diagnóstico del estado nutricional en los pacientes hepáticos y sobre las complicaciones hepáticas asociadas a la nutrición médica.
Assuntos
Falência Hepática Aguda , Transplante de Fígado , Humanos , Cirrose Hepática , Estado Nutricional , Apoio NutricionalRESUMO
Severe acute pancreatitis complicated by infection is associated with high mortality. Invasive treatment is indicated in the presence of infected (suspected) pancreatic and/or peripancreatic necrosis (IPN) in the absence of response to intensive medical support. Step-up approach (SUA) has been demonstrated to lower complication rate compared to upfront open surgery. However, this approach has not been associated with lower mortality, and no factors have been studied that could help to identify the high risk patients. In this study, we aimed to analyse those factors associated with mortality following the invasive treatment of IPN, focusing on the role of surgical necrosectomy. A retrospective and observational study based on a multicentre prospective database was conducted. The database was coordinated by the Hospital General Universitario de Alicante, Spain and the Spanish Association of Pancreatology. Demographics, clinical data, and laboratory and imaging findings were collected. Atlanta 2012 criteria were considered to classify acute necrotizing pancreatitis and for the definition of IPN. Step-up approach was used in all centres with the intention of avoiding surgery whenever possible. Surgical necrosectomy was performed by open approach. From January 2013 to October 2014, a total of 1655 patients with the diagnosis of acute pancreatitis were included in our database. 1081 were recruited for the final analysis. Out of them, 205 (19%) were classified into acute necrotizing pancreatitis. 77 (8.3%) patients underwent invasive treatment of INP and were included in our study. Overall mortality was 29.9%. Upfront endoscopic or percutaneous drainage was performed in 60 (77.9%) patients and mortality was 26.6%. Out of 60, 22 (36.6%) patients subsequently received rescue surgery; mortality in rescue surgery group was 18.3%. Upfront surgery was carried out in 17 (22.1%) patients; mortality in this group was 41%. At univariate analysis, surgical necrosectomy, extrapancreatic infection, immunosuppression and de-novo haemodialysis were associated with mortality. At multivariate analysis, only surgical necrosectomy was significantly associated with mortality (p = 0.002 OR 3.89). Surgical approach for IPN is associated with high mortality rate. However, these data should be interpreted with caution, since we are not able to assess whether this occurs due to the need of surgery as the only resort when the other approaches are not feasible or fail.
Assuntos
Desbridamento/métodos , Drenagem/métodos , Endoscopia do Sistema Digestório/mortalidade , Endoscopia do Sistema Digestório/métodos , Pâncreas/cirurgia , Pancreatectomia/mortalidade , Pancreatectomia/métodos , Pancreatite Necrosante Aguda/mortalidade , Pancreatite Necrosante Aguda/cirurgia , Pancreatite/mortalidade , Pancreatite/cirurgia , Idoso , Análise de Dados , Bases de Dados Factuais , Desbridamento/mortalidade , Drenagem/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of this study was to compare and validate the different classifications of severity in acute pancreatitis (AP) and to investigate which characteristics of the disease are associated with worse outcomes. SUMMARY OF BACKGROUND DATA: AP is a heterogeneous disease, ranging from uneventful cases to patients with considerable morbidity and high mortality rates. Severity classifications based on legitimate determinants of severity are important to correctly describe the course of disease. METHODS: A prospective multicenter cohort study involving patients with AP from 23 hospitals in Spain. The Atlanta Classification (AC), Revised Atlanta Classification (RAC), and Determinant-based Classification (DBC) were compared. Binary logistic multivariate analysis was performed to investigate independent determinants of severity. RESULTS: A total of 1655 patients were included; 70 patients (4.2%) died. RAC and DBC were equally superior to AC for describing the clinical course of AP. Although any kind of organ failure was associated with increased morbidity and mortality, persistent organ failure (POF) was the most significant determinant of severity. All local complications were associated with worse outcomes. Infected pancreatic necrosis correlated with high morbidity, but in the presence of POF, it was not associated to higher mortality when compared with sterile necrotizing pancreatitis. Exacerbation of previous comorbidity was associated with increased morbidity and mortality. CONCLUSION: The RAC and DBC both signify an advance in the description and differentiation of AP patients. Herein, we describe the complications of the disease independently associated to morbidity and mortality. Our findings are valuable not only when designing future studies on AP but also for the improvement of current classifications.
Assuntos
Amilases/sangue , Pancreatite Necrosante Aguda/diagnóstico , Idoso , Biomarcadores/sangue , Progressão da Doença , Feminino , Seguimentos , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Pancreatite Necrosante Aguda/sangue , Pancreatite Necrosante Aguda/mortalidade , Prognóstico , Estudos Prospectivos , Índice de Gravidade de Doença , Espanha/epidemiologia , Taxa de Sobrevida/tendências , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Available evidence assessing the impact of small intestinal bacterial overgrowth (SIBO) following gastrectomy is limited. OBJECTIVES: To evaluate the prevalence of SIBO after gastrectomy and its association with malnutrition. To describe the antibiotic treatment required to correct it and if nutritional status improves. MATERIAL AND METHODS: A prospective cohort study was performed at the Agencia Sanitaria Costa del Sol (Costa del Sol Health Agency) from 2012 to 2015. A hydrogen-methane breath test with oral glucose overload was performed. Demographic variables and nutritional parameters were collected at baseline and one month after effective treatment of SIBO. The antibiotic regimens and the number of treatment lines used were assessed. RESULTS: Sixty gastrectomy patients were analysed, 58.3% of which were male. A sub-analysis of the curve was performed at 45min to minimise possible false positives, and SIBO was identified in 61.6% of cases. SIBO patients tended to have a lower BMI, although this trend was not statistically significant. After treatment with rifaximin, 94.6% of patients were still positive for SIBO, which fell to 85.7% after metronidazole. The rate of total antibiotic treatment failure was 67.6%. No statistically significant changes were found in nutritional parameters after treatment. CONCLUSIONS: SIBO was identified in 61.6% of patients after gastrectomy. No correlation was found with any malnutrition parameter. Rifaximin and metronidazole were found to be largely ineffective in eradicating SIBO. When treatment was effective, the impact on malnutrition was negligible and may have been associated with other factors.
Assuntos
Gastrectomia , Intestino Delgado/microbiologia , Estado Nutricional , Feminino , Humanos , Masculino , Desnutrição/epidemiologia , Desnutrição/microbiologia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/microbiologia , Estudos ProspectivosRESUMO
Given the liver's multiple synthetic, regulatory and detoxifying functions, one of the characteristics accompanying severe hepatocellular dysfunction is the presence of malnutrition. This disorder is highly frequent in liver cirrhosis, even in the relatively early stages of the disease. Independently of the cause of the cirrhosis, poor nutritional status is associated with a worse prognosis and therefore early intervention to correct nutrient deficiency can prolong life expectancy, improve quality of life, reduce complications and increase the probability of successful transplantation. The present article reviews current knowledge of the diagnosis and management of malnutrition in patients with cirrhosis. Special attention is paid to the concept of the late evening snack and its characteristics, composition and probable benefits in the course of the disease.
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Cirrose Hepática/dietoterapia , Apoio Nutricional , Carboidratos da Dieta/administração & dosagem , Carboidratos da Dieta/farmacocinética , Proteínas Alimentares/administração & dosagem , Proteínas Alimentares/farmacocinética , Suplementos Nutricionais , Ingestão de Energia , Nutrição Enteral , Alimentos Formulados , Intolerância à Glucose/etiologia , Encefalopatia Hepática/complicações , Humanos , Hipertensão Portal/complicações , Cirrose Hepática/complicações , Síndromes de Malabsorção/etiologia , Desnutrição/dietoterapia , Desnutrição/etiologia , Desnutrição/prevenção & controle , Refeições , Metabolismo , Estado Nutricional , Nutrição Parenteral , Qualidade de Vida , LanchesRESUMO
Drug-induced gastrointestinal tract lesions are becoming more frequent but are generally little known. Although a large number of drugs have gastrointestinal adverse effects, there are few characteristic patterns. Acute ischemic gastritis is an uncommon entity that is rarely distinguished from other forms of intestinal ischemia. We report the case of a 69-year-old woman who was diagnosed with an unusual gastric lesion in the context of an acute exacerbation of her anemia.
Assuntos
Anemia/complicações , Úlcera Gástrica/etiologia , Doença Aguda , Idoso , Feminino , HumanosRESUMO
Primary Esophageal Melanoma (PEM) is an extremely rare neoplasm, with less than 270 cases described. Although clinical presentation is similar to any other esophageal neoplasm, MEP's behavior is more aggressive and fatal in most cases. We report two new cases of MEP diagnosed through endoscopy and anatomical-pathological analysis of collected biopsies. Both samples were positive for HMB-45 and S100, so the presence of primary melanoma in other location was ruled out. The form of presentation as left miosis with no eyelid ptosis or enophthalmos should be highlighted in the first case, which was described by this early manifestation. Unfortunately, the neoplasm could not be excised when diagnosed because the thoracic artery was found to be affected through echoendoscopy. In the second case, in spite of the fact that the neoplastic extension was only local, and neoplasm was subject to transhiatal esophagectomy, the patient had multiple post-surgical complications and died nineteen days after the surgical procedure. Furthermore, bibliographic review is applied to diagnosis, treatment options, and prognosis of this exceptional neoplasm.
Assuntos
Neoplasias Esofágicas/diagnóstico , Melanoma/diagnóstico , Idoso , Anisocoria/etiologia , Transtornos de Deglutição/etiologia , Neoplasias Esofágicas/patologia , Esofagectomia , Esofagoscopia , Evolução Fatal , Gastroplastia , Humanos , Metástase Linfática , Masculino , Melanoma/patologia , Melanoma/secundário , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Complicações Pós-Operatórias , PrognósticoRESUMO
El melanoma esofágico primario (MEP) es una neoplasia extremadamente rara, con menos de 270 casos descritos. Aunque la presentación clínica es similar a cualquier otra neoplasia esofágica, su comportamiento es más agresivo y fatal en la mayoría de los casos. Presentamos dos nuevos casos de MEP diagnosticados mediante endoscopia y estudio anatomopatológico de las biopsias obtenidas, siendo en ambos casos las muestras positivas para HMB-45 y S100, descartando así mismo la presencia de melanoma primario en otra localización. En el primer caso merece destacar la forma de presentación como miosis izquierda sin ptosis palpebral ni enoftalmos, siendo el primer caso descrito con esta manifestación inicial, lamentablemente al momento del diagnóstico fue irresecable, demostrando así mismo por ecoendoscopia afectación de la aorta torácica. El segundo caso a pesar de ser una neoplasia sin extensión locorregional y sometido a esofaguectomía transhiatal presentó múltiples complicaciones postoperatorias falleciendo al decimo noveno día de la intervención. Así mismo se hace una revisión bibliográfica sobre diagnóstico, opciones de tratamiento y pronóstico de esta excepcional neoplasia.
Primary Esophageal Melanoma (PEM) is an extremely rare neoplasm, with less than 270 cases described. Although clinical presentation is similar to any other esophageal neoplasm, MEP's behavior is more aggressive and fatal in most cases. We report two new cases of MEP diagnosed through endoscopy and anatomical-pathological analysis of collected biopsies. Both samples were positive for HMB-45 and S100, so the presence of primary melanoma in other location was ruled out. The form of presentation as left miosis with no eyelid ptosis or enophthalmos should be highlighted in the first case, which was described by this early manifestation. Unfortunately, the neoplasm could not be excised when diagnosed because the thoracic artery was found to be affected through echoendoscopy. In the second case, in spite of the fact that the neoplastic extension was only local, and neoplasm was subject to transhiatal esophagectomy, the patient had multiple post-surgical complications and died nineteen days after the surgical procedure. Furthermore, bibliographic review is applied to diagnosis, treatment options, and prognosis of this exceptional neoplasm.
Assuntos
Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Endoscopia , Melanoma , Neoplasias EsofágicasRESUMO
INTRODUCTION: The incidence of inflammatory bowel disease, and of ulcerative colitis in particular, varies widely according to geographical area and has been reported to have increased in the last few years, although some of the differences observed may be due to the methodology employed. OBJECTIVES: To determine the incidence of ulcerative colitis in our area and to compare it with that described in other areas of Spain and Europe, as well as to describe certain clinico-epidemiological aspects of this disease. MATERIAL AND METHODS: A descriptive, prospective, population-based study was performed from 2000-2001 in patients diagnosed with ulcerative colitis in the catchment area of the Hospital Costa del Sol, with a population of 210,384 inhabitants. The crude incidence rate was adjusted by the direct method, using the European standard population (EU-25, 2000) as the reference population; 95% confidence intervals were calculated. RESULTS: Forty-three patients (23 men [53.5%] and 20 women [46.5%], with a mean age of 35.23 years [SD=15.42]) were included. Thirty-three percent were residents of the Hospital Costa del Sol's catchment area and were included in the calculation of incidence. The crude incidence was 7.84 and the incidence adjusted by age and sex to the European population was 7.26 per 100,000 inhabitants/year. CONCLUSIONS: The incidence of ulcerative colitis in the area of the Hospital Costa del Sol is higher than that found in other studies performed in the autonomous community of Andalusia as well as that observed in some studies performed in the north of the Peninsula.
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Colite Ulcerativa/diagnóstico , Colite Ulcerativa/epidemiologia , Adolescente , Adulto , Feminino , Hospitais , Humanos , Incidência , Masculino , Estudos Prospectivos , EspanhaRESUMO
Eosinophilic enteritis is a rare disease characterized by eosinophilic infiltration of different wall layers of the gastrointestinal tract, from the esophagus to the rectum, by eosinophilic cells. The most frequently affected structures are the stomach and small intestine. The pathogenesis of eosinophilic enteritis is not well understood and is often related to a personal or familial history of atopy. Clinical symptoms depend on the affected layers. Thus malabsorptive syndrome, intestinal strictures or ascites depend on a mucosal, muscular or serosa layer infiltration, respectively. We present three cases of eosinophilic gastroenteritis with distinct clinical presentations.
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Enterite/diagnóstico , Eosinofilia/diagnóstico , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-IdadeAssuntos
Mixoma/patologia , Neoplasias Pélvicas/patologia , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
We compared the incidence of and factors associated with hepatocellular carcinoma (HCC) among hepatitis C virus (HCV)-monoinfected subjects and human immunodeficiency virus (HIV)/HCV-coinfected individuals, both with decompensated cirrhosis. In a retrospective study, a cohort of 180 individuals with HIV coinfection and 1037 HCV-monoinfected patients with decompensated HCV-related cirrhosis from eight centres in Spain were analyzed. HCC was found in 234 (23%) HCV-monoinfected subjects and in four (2%) HIV-coinfected subjects (p<0.001). At the time of the first hepatic decompensation, 188 (17%) and 4 (2%) (p<0.001) patients in the former and in the latter group, respectively, showed HCC. Fifty-four (11%) patients without HCC at baseline developed such a disease during follow-up. There were no incident cases among the HIV-coinfected population. The density of incidence (95% IC) of HCC in HIV/HCV-coinfected and HCV-monoinfected patients was 0 (0-1.70) and 3.31 (2.70-4.64) cases per 100 person-years (p<0.001), respectively. Lack of HIV infection [adjusted odds risk (AOR) (95% IC)=16.7 (3.9-71.1)] and high alanine aminotransferase levels [AOR (95% IC)=2.5 (1.1-5)] were the only two independent predictors of the emergence of HCC. In the group of patients in whom the date of HCV infection could be estimated, the time elapsed until HCC diagnosis was shorter among HIV-coinfected subjects. The incidence of HCC in patients with HCV-related cirrhosis after the first hepatic decompensation is lower in HIV-coinfected patients. This is probably due to the fact that HIV infection shortens the survival of HCV-coinfected patients with end-stage liver disease to such an extent that HCC not had a chance to emerge.
Assuntos
Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/virologia , Infecções por HIV/complicações , Hepatite C Crônica/complicações , Cirrose Hepática/complicações , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/virologia , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVES: The purpose of this study was: 1) To determine the effect of non invasive ventilation (NIV) in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure, and 2) To find out whether there are differences in the results according to the site where ventilation in applied. PATIENTS AND METHOD: Meta-analysis of randomized controlled trials (RCTs) published included studies in MEDLINE, EMBASE, Cochrane Controled Trials Register and Teseo. Study selection included RCTs in COPD patients with acute respiratory failure with PaCO2 > 45 mmHg or pH < 7.35, with underwent NIV versus standard therapy. Mortality, rate of tracheal intubation and length of stay were analized. Individual studies were rated as to their validity and quality by two investigators using the Jadad score. A different meta-analysis was made for intensive-care unit (ICU) RCTs and wards RCTs. RESULTS: Five ICU RCTs and four ward RCTs were included. There was a reduction in hospital mortality (ICU, OR = 0.35; 95% confidence interval [CI], 0.15 to 0.83; n = 166; p = 0.02; ward, OR = 0.39; 95% CI, 0.20 to 0.76; n = 296; p = 0.005) and in the need for intubation (ICU, OR = 0.18; 95% CI, 0.10 to 0.35; n= 219; p < 0,00001; ward, OR = 0.43; IC 95%, 0.24-0.78; n = 270; p = 0.006). Length of stay was lower in the NIV group upon ICU trials (WMD, 3.7 days; 95% CI, 5.46 to 1.93 days). Only one ward RCT showed significant differences in the length of stay. Published data did not allow a meta-analysis for length of stay. CONCLUSIONS: NIV decreases mortality and the need for intubation in COPD patients with acute respiratory failure both in ICU and ward. In ICU non-invasive ventilation decreases the length of stay too.