Falla hepática aguda como debut de hepatitis autoinmune desencadenada por dengue en una gestante: reporte de caso / Case report: liver failure as a debut of autoimmune hepatitis triggered by dengue virus in a pregnant woman

La hepatitis autoinmune (HAI) es una condición compleja con etiología poco clara, que engloba com-ponentes genéticos y ambientales que pueden desencadenar disfunción del sistema inmunológico. Pre-sentamos el caso de una gestante de una zona endémica de dengue que se presentó con ictericia, dolor abdominal y prurito, complicándose con insuficiencia hepática aguda. Los marcadores inmunológicos indicaron HAI desencadenada por la infección del virus del dengue, confirmada por una prueba positiva de IgM. El tratamiento con cuidados de soporte seguido de corticoterapia y azatioprina tuvo resultados clínicos y laboratoriales favorables, evitando la necesidad de un trasplante de hígado. Diversos virus han sido descritos como desencadenantes de HAI; sin embargo, el papel del virus del dengue en su patogénesis sigue siendo desconocido. El monitoreo clínico regular es vital para el manejo de la HAI, especialmente durante el embarazo, debido a las alteraciones inmunológicas y las diversas respuestas al tratamiento. Se necesita más investigación para dilucidar el vínculo entre la infección por dengue y el desarrollo de HAI. El tratamiento individualizado en estos pacientes es crucial, especialmente durante el embarazo, para disminuir el riesgo de complicaciones.

Epidemiology and risk factors for histopathologic characteristics of non-alcoholic fatty liver disease in South America.

BACKGROUND: The burden of non-alcoholic fatty liver disease (NAFLD) in South America is among the highest in the world. However, the epidemiology and risk factors for NAFLD are insufficiently described in the region. AIM: To explore the associations between clinical characteristics and histopathological features of NAFLD METHODS: This was a descriptive study of 2722 patients with NAFLD from 8 medical centres across 5 South American countries. We collected clinical, biochemical and histopathological data using a templated chart. Fibrosis was assessed by elastography or fibrosis scores and confirmed with biopsy when available. We examined associations between histopathological features and clinical characteristics with logistic regression models. Models were adjusted for country, age and sex. RESULTS: The median age was 53 years (IQR: 41-62), and 63% were women. Subjects from Brazil had the highest body mass index at 42 kg/m2 . Sixty-seven percent had dyslipidemia, 46% had obesity, 30% had hypertension, 17% had type 2 diabetes mellitus (T2DM) and 34% had metabolic syndrome. Biopsy reports were available for 948 (35%), of which 58% showed fibrosis, 91% steatosis and 65% inflammation; 25% showed significant fibrosis and 27% severe steatosis. Metabolic syndrome, T2DM and hypertension were significantly associated with significant fibrosis (OR = 1.94, p < 0.001; OR = 2.93, p < 0.001 and OR = 1.60, p = 0.003, respectively), severe steatosis (OR = 2.05, p < 0.001; OR = 1.91, p = 0.001 and OR = 2.17, p < 0.001, respectively) and liver inflammation (OR = 1.66, p = 0.007; OR = 2.00, p = 0.002; OR = 1.62, p = 0.001, respectively). CONCLUSIONS: In the largest NAFLD cohort study to date from South America, metabolic syndrome, hypertension and T2DM were independently associated with significant fibrosis, severe steatosis, and inflammation. The prevalence of T2DM was lower than the reported global prevalence.

Sorafenib for Treatment of Hepatocellular Carcinoma: A Survival Analysis From the South American Liver Research Network.

GOALS: We aim to describe the efficacy, safety profile, and variables associated with survival in patients with hepatocellular carcinoma (HCC) treated with sorafenib in South America. BACKGROUND: Sorafenib has been shown to improve survival in patients with advanced HCC. There are few data on sorafenib use for HCC in South America. STUDY: We performed a retrospective analysis of HCC cases treated with sorafenib from 8 medical centers in 5 South American countries, between January 2010 and June 2017. The primary endpoint was overall survival (OS), which was defined as time from sorafenib initiation to death or last follow-up. Risk factors for decreased OS were assessed using Cox proportional hazard regression and log-rank tests. RESULTS: Of 1336 evaluated patients, 127 were treated with sorafenib and were included in the study. The median age of individuals was 65 years (interquartile range, 55 to 71) and 70% were male individuals. Median OS in all patients was 8 months (interquartile range, 2 to 17). Variables associated with survival on multivariate analysis were platelets >/<250,000 mm (2 vs. 8 mo, P=0.01) and Barcelona Clinic Liver Cancer (BCLC) stage (A/B, 13 vs. C/D, 6 mo; P=0.04). In a subanalysis of patients with BCLC stage C, platelets >/<250,000 mm were also independently associated with survival (2 vs. 5.5 mo, P=0.03). Patients lived longer if they experienced any side effects from sorafenib use (11 vs. 2 mo, P=0.009). Patients who stopped sorafenib because of side effects had shorter survival compared with patients who were able to tolerate side effects and continue treatment (7.5 vs. 13 mo, P=0.01). CONCLUSIONS: Pretreatment elevation of platelets and advanced BCLC stage were independently associated with poor survival on sorafenib in a South American cohort.

Percepción del gastroenterólogo sobre las necesidades de educación médica continua en el Perú / Perception of the gastroenterologist about the needs of continuing medical education in Peru

Objetivo: Determinar la percepción del gastroenterólogo sobre las necesidades de educación médica continua (EMC) en el Perú. Material y métodos: Estudio transversal y descriptivo. La muestra fue no probabilística. Se aplicó una encuesta a los gastroenterólogos miembros de la Sociedad de Gastroenterología del Perú. El cuestionario se elaboró en base al "Canadian Association of Gastroenterology Educational Needs Assessment Report" con una escala tipo Likert de 5 puntos (1= no necesario y 5= indispensable). Se determinó el promedio de los puntajes obtenidos en cada uno de los 33 ítems de las áreas clínica, endoscópica y métodos de aprendizaje. Resultados: Hubo 75 participantes y la edad promedio fue 43,40 años (DE ± 10,22 años). El lugar de trabajo principalmente fue Lima (68%) y la mayoría (50,67%) tuvo un tiempo de servicio menor de 5 años. La percepción de necesidades educativas en el área clínica fue mayor para el cáncer gástrico (4,37 ± 0,87) y el cáncer de colon (4,37 ± 0,83); en el área endoscópica fueron la polipectomía (4,15 ± 0,95) y las técnicas de emergencia (4,13 ± 0,99). Los principales métodos de aprendizaje para los gastroenterólogos fueron la asistencia a congresos (4,29 ± 0,83) y los talleres endoscópicos (4,19 ± 1,06). Conclusiones: La percepción del gastroenterólogo encuestado sobre las necesidades de EMC fue principalmente sobre temas de cáncer gástrico y de colon. La mayoría de ellos consideró la asistencia a congresos como el principal método de aprendizaje.

Objective: To determine the perception of the gastroenterologist about the needs of continuing medical education (CME) in Peru. Material and methods: Cross-sectional and descriptive study. The sample was not probabilistic. A survey was applied to the gastroenterologists members of the Society of Gastroenterology of Peru. The questionnaire was developed based on the "Canadian Association of Gastroenterology Educational Needs Assessment Report" with a Likert scale of 5 points (1 = not necessary and 5 = indispensable). The average of the scores obtained in each of the 33 items of the clinical, endoscopic and learning methods areas was determined. Results: There were 75 participants and the average age was 43.40 years (SD ± 10.22 years). The place of work was mainly Lima (68%) and the majority (50.67%) had a service time of less than 5 years. The perception of educational needs in the clinical area was higher for gastric cancer (4.37 ± 0.87) and colon cancer (4.37 ± 0.83); in the endoscopic area were polypectomy (4.15 ± 0.95) and emergency techniques (4.13 ± 0.99). The main learning methods for gastroenterologists were attendance at congresses (4.29 ± 0.83) and endoscopic workshops (4.19 ± 1.06). Conclusions: The perception of the gastroenterologist surveyed on the needs of CME was mainly on gastric and colon cancer issues. Most of them considered congress attendance as the main learning method.

HAP score as prognostic factor of hepatocellular carcinoma treated with transarterial chemoembolization in a Latin American center.

INTRODUCTION: Hepatocellular carcinoma (HCC) in cirrhosis is diagnosed, most of times, when it is not susceptible to curative treatment. Transarterial chemoembolization (TACE) is a palliative therapeutic option with heterogeneous results. The HAP score stratifies patients who will benefit from the first TACE. OBJECTIVE: To evaluate if the HAP score is a prognostic factor of HCC treated with TACE. MATERIALS AND METHODS: Retrospective cohort study in cirrhotic patients with HCC and first TACE at the Edgardo Rebagliati Martins National Hospital, Lima-Peru, from June 2011 to June 20139. The HAP score was applied, mortality and survival were observed with a follow-up of 36 months. RESULTS: We included 54 patients with age of 67.7±9.9 years, 59.3% Child-Pugh A and 40.7% Child-Pugh B, MELD score of 11±2.7; 51.9 and 40.7% were BCLC A and B, respectively; 66.7% had a single tumor and 70.4% had a predominant tumor <5cm. The HAP score classified 8, 14, 26 and 6 patients as HAP A, B, C and D, respectively. The overall survival was 19.5±11.2 months and 32.8±6.5 months for HAP A, 24.9±14.8 months for HAP B, 13.9±5.2 months for HAP C and 14±6.6 months for HAP D. There were no deaths at 12 months in HAP A. At 24 months, mortality for HAP C and D was 100%. At 36 months, the survival rate for HAP A and B was 75 and 42.9%, respectively. CONCLUSIONS: The HAP score is a useful tool to guide the management decisions of cirrhotic patients with HCC requiring TACE due to its value in predicting mortality and survival.

HAP score as prognostic factor of hepatocellular carcinoma treated with transarterial chemoembolization in a Latin American center / HAP score como factor pronóstico del carcinoma hepatocelular tratado con quimioembolización transarterial en un centro de Latinoamérica

Introduction: Hepatocellular carcinoma (HCC) in cirrhosis is diagnosed, most of times, when it is not susceptible to curative treatment. Transarterial chemoembolization (TACE) is a palliative therapeutic option with heterogeneous results. The HAP score stratifies patients who will benefit from the first TACE. Objective: To evaluate if the HAP score is a prognostic factor of HCC treated with TACE. Materials and methods: Retrospective cohort study in cirrhotic patients with HCC and first TACE at the Edgardo Rebagliati Martins National Hospital, Lima-Peru, from June 2011 to June 20139. The HAP score was applied, mortality and survival were observed with a follow-up of 36 months. Results: We included 54 patients with age of 67.7±9.9 years, 59.3% Child-Pugh A and 40.7% Child-Pugh B, MELD score of 11±2.7; 51.9 and 40.7% were BCLC A and B, respectively; 66.7% had a single tumor and 70.4% had a predominant tumor <5cm. The HAP score classified 8, 14, 26 and 6 patients as HAP A, B, C and D, respectively. The overall survival was 19.5±11.2 months and 32.8±6.5 months for HAP A, 24.9±14.8 months for HAP B, 13.9±5.2 months for HAP C and 14±6.6 months for HAP D. There were no deaths at 12 months in HAP A. At 24 months, mortality for HAP C and D was 100%. At 36 months, the survival rate for HAP A and B was 75 and 42.9%, respectively. Conclusions: The HAP score is a useful tool to guide the management decisions of cirrhotic patients with HCC requiring TACE due to its value in predicting mortality and survival.

Introducción: El carcinoma hepatocelular (CHC) en cirrosis es diagnosticado, la mayoría de veces, cuando no es susceptible de tratamiento curativo. La quimioembolizacón transarterial (QETA) es una opción terapéutica paliativa con resultados heterogéneos. El HAP score estratifica a los pacientes que se beneficiarán con la primera QETA. Objetivo: Demostrar si el HAP score es un factor pronóstico del CHC tratado con QETA. Materiales y métodos: Estudio de cohortes retrospectivo en pacientes cirróticos con CHC y primera QETA en el Hospital Nacional Edgardo Rebagliati Martins, Lima-Perú, junio-2011 a junio-2013. Se aplicó el HAP score, y se observó la mortalidad y sobrevida con un seguimiento de 36 meses. Resultados: Se incluyeron 54 pacientes con edad de 67,7±9,9 años, 59,3% Child-Pugh A y 40,7% Child-Pugh B, MELD de 11±2,7; 51,9 y 40,7% fueron BCLC A y B, respectivamente; 66,7% tuvo tumor único y el 70,4% tumor predominante menor a 5 cm. Se clasificó como HAP A, B, C y D a 8, 14, 26 y 6 pacientes, respectivamente. La sobrevida general fue 19,5±11,2 meses; y 32,8±6,5 meses para HAP A, 24,9±14,8 meses para HAP B, 13,9±5,2 meses para HAP C y 14±6,6 meses para HAP D. A los 24 meses, la mortalidad para HAP C y D fue 100%. A los 36 meses, la sobrevida para HAP A y B fue 75 y 42,9%, respectivamente. Conclusiones: El HAP score es una herramienta útil que orienta al manejo del CHC tributario de QETA por su valor pronóstico de mortalidad y sobrevida.

[Perception of the gastroenterologist about the needs of continuing medical education in Peru]. / Percepción del gastroenterólogo sobre las necesidades de educación médica continua en el Perú.

OBJECTIVE: To determine the perception of the gastroenterologist about the needs of continuing medical education (CME) in Peru. MATERIAL AND METHODS: Cross-sectional and descriptive study. The sample was not probabilistic. A survey was applied to the gastroenterologists members of the Society of Gastroenterology of Peru. The questionnaire was developed based on the "Canadian Association of Gastroenterology Educational Needs Assessment Report" with a Likert scale of 5 points (1 = not necessary and 5 = indispensable). The average of the scores obtained in each of the 33 items of the clinical, endoscopic and learning methods areas was determined. RESULTS: There were 75 participants and the average age was 43.40 years (SD ± 10.22 years). The place of work was mainly Lima (68%) and the majority (50.67%) had a service time of less than 5 years. The perception of educational needs in the clinical area was higher for gastric cancer (4.37 ± 0.87) and colon cancer (4.37 ± 0.83); in the endoscopic area were polypectomy (4.15 ± 0.95) and emergency techniques (4.13 ± 0.99). The main learning methods for gastroenterologists were attendance at congresses (4.29 ± 0.83) and endoscopic workshops (4.19 ± 1.06). CONCLUSIONS: The perception of the gastroenterologist surveyed on the needs of CME was mainly on gastric and colon cancer issues. Most of them considered congress attendance as the main learning method.

Hepatocellular carcinoma in South America: Evaluation of risk factors, demographics and therapy.

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide. Most studies addressing the epidemiology of HCC originate from developed countries. This study reports the preliminary findings of a multinational approach to characterize HCC in South America. METHODS: We evaluated 1336 HCC patients seen at 14 centres in six South American countries using a retrospective study design with participating centres completing a template chart of patient characteristics. The diagnosis of HCC was made radiographically or histologically for all cases according to institutional standards. Methodology of surveillance for each centre was following AASLD or EASL recommendations. RESULTS: Sixty-eight percent of individuals were male with a median age of 64 years at time of diagnosis. The most common risk factor for HCC was hepatitis C infection (HCV, 48%), followed by alcoholic cirrhosis (22%), Hepatitis B infection (HBV, 14%) and NAFLD (9%). We found that among individuals with HBV-related HCC, 38% were diagnosed before age 50. The most commonly provided therapy was transarterial chemoembolization (35% of HCCs) with few individuals being considered for liver transplant (<20%). Only 47% of HCCs were diagnosed during surveillance, and there was no difference in age of diagnosis between those diagnosed incidentally vs by surveillance. Nonetheless, being diagnosed during surveillance was associated with improved overall survival (P = .01). CONCLUSIONS: Our study represents the largest cohort to date reporting characteristics and outcomes of HCC across South America. We found an important number of HCCs diagnosed outside of surveillance programmes, with associated increased mortality in those patients.

Pseudotumor inflamatorio por Fasciola hepática: a propósito de un caso / Inflammatory pseudotumor by Fasciola hepática: a case report

Introduction: Fasciola hepatica is a parasite of the class Trematoda. It commonly has been found in developing countries. When it infects humans is characterized by a triad of fever, pain in right upper quadrant and peripheral eosinophilia. We present a 67-year-old female from a rural town of the north of Lima, Peru, it was found abdominal pain, eosinophilia and focal hepatic lesions. For this reason, a hepatic mass was the initial suspicion. The hepatic biopsy was performed and one of the findings was eosinophilia. Fasciola hepatica infection should be considered as part of differential diagnosis in hepatic tumors with eosinophilia when the origin of the patient is from endemic areas of F. hepatica.

Fasciola hepática es un parásito de la clase Trematoda común en países en desarrollo. La infección en el ser humano se caracteriza por la triada de fiebre, dolor abdominal en el cuadrante superior derecho y eosinofilia. Se presenta el caso de una mujer de 67 años procedente de una zona rural al norte de Lima, con historia de dolor abdominal de seis meses de evolución, con una imagen hipodensa hepática en el TAC abdominal y eosinofilia. La biopsia hepática mostró un infiltrado inflamatorio con eosinofilia. En el diagnóstico diferencial en pacientes con un tumor hepático y eosinofilia, se deben incluir infecciones parasitarias como F. hepatica; sobre todo en pacientes que proceden de áreas endémicas.

[Inflammatory pseudotumor by Fasciola hepática: a case report]. / Pseudotumor inflamatorio por Fasciola hepática: a propósito de un caso.

INTRODUCTION: Fasciola hepatica is a parasite of the class Trematoda. It commonly has been found in developing countries. When it infects humans is characterized by a triad of fever, pain in right upper quadrant and peripheral eosinophilia. We present a 67-year-old female from a rural town of the north of Lima, Peru, it was found abdominal pain, eosinophilia and focal hepatic lesions. For this reason, a hepatic mass was the initial suspicion. The hepatic biopsy was performed and one of the findings was eosinophilia. Fasciola hepatica infection should be considered as part of differential diagnosis in hepatic tumors with eosinophilia when the origin of the patient is from endemic areas of F. hepatica.

Suplemento de probióticos a la terapia erradicadora de Helicobacter pylori para mejorar la efectividad y disminuir sus efectos adversos. Estudio multicéntrico Lima-Perú / Supplement with probiotics to the eradication therapy of Helicobacter pylori to improve effectiveness and reduce its adverse effects. Multicenter study, Lima-Peru

Determinar si el suplemento de probióticos a la terapia erradicadora convencional mejora la efectividad y disminuye los efectos adversos. Material y métodos: Ensayo Clínico aleatorizado Multicéntrico se randomizaron 102 pacientes dispépticos con Biopsia (+) que requirieron tratamiento para Helicobacter Pylori los pacientes fueron distribuidos en 2 grupos para recibir tratamiento convencional (omeprazol+amoxicilina+claritromicina) o tratamiento convencional más Biolactol Probiótico Acidophilus 10 ml (Lactobacillus Acidophilus cepa LMB 021) c/12h por 10 días la erradicación fue corroborada con test de aliento con C-13 los efectos adversos fueron recogidos mediante encuesta directa en una ficha de recolección de datos. El análisis de los datos se realizó a través de: T de student, Chi Cuadrado y OR. El procesamiento de datos se realizó con SPSS 12.0 y EPIINFO-2000. Resultados: el grupo de pacientes con probiótico erradicó la infección en 80 por ciento comparado con 82,7 por ciento de pacientes sin probióticos los efectos adversos más frecuentes fueron sabor metálico, diarrea, nauseas y vómitos. Todos los efectos adversos fueron menos frecuentes en el grupo que recibió probiótico pero estas diferencias sólo fueron significativas para diarrea, dolor y distensión abdominal, 10 por ciento de pacientes sin probiótico descontinuó el tratamiento. Conclusiones. Los probióticos disminuyen los efectos adversos de la terapia erradicadora, pero no logran mejorar la efectividad del tratamiento. La descontinuación del tratamiento se observó en el grupo que no recibió probiótico...

To demonstrate if adding a probiotic supplement to conventional Helicobacfer pylori therapy improves its efficacy and decreases its adverse effects. Methods: randomized, multicentric clinical trial 102 dyspeptic patients with positive biopsy to Helicobacfer pylori were randomized to receive either conventional therapy alone (omeprazole, amoxicilin and clarytromicine) or conventional therapy plus Biolactol Probiotic Acidophilus (Lactobacillus Acidophilus cepa LMB 021) 10 ml e/12h during 10 days. Erradication of Helicobacter pylori was confirmed with C-13 breath test. Adverse effects were registered by a direct survey. The data was analized with t student, chi square and odds ratio, in SPSS 12.0 and EPIINFO-2000 software. Results: Patients who received treatment with probiotic obtained erradication in 80 per cent versus 82.7 per cent obtained by the group without probiotics metalic taste, diarrhea, nausea and vomits were the most frequent adverse effects registered. All the adverse effects were less frequent in the group who received probiotics, but this was significative only for diarrhea, abdominal pain and distension. 10 per cent of patients without probitics discontinued the therapy. Conclusion: Probiotics decreases the adverse effects of H pylori therapy, but do not improve the therapy efficacy. Lack of therapy compliance was observed only in the group who did not receive probiotics...

Adición de subsalicilato de Bismuto a la terapia triple erradicadora de la infección por Helicobacter pylori: efectividad y efectos adversos / Addition of Bismuth subsalicylate to triple eradication therapy for Helicobacter pylori infection: efficiency and adverse events

Determinar la eficacia y los efectos adversos de la adición del Subsalicilato de bismuto a la terapia triple en la erradicación de la infección del Helicobacter Pylori. Materiales y métodos: Estudio experimental controlado doble ciego. Se trabajó con 54 pacientes con diagnóstico de Helicobacter Pylori atendidos entre febrero-marzo 2012. El grupo experimental tuvo 29 pacientes a los que se les agregó subsalicilato de bismuto, a la terapia triple convencional y 24 pacientes a los que se añadió placebo. Resultados: La edad promedio fue 47 +/- 14,9 años, el 66,7% fueron mujeres. Se realizó test de aliento en ambos grupos para el control post tratamiento, obteniendo un test de aliento negativo en el 89.7% en el grupo de estudio y 80% en el grupo placebo (p=0,319). Los efectos adversos de los pacientes que recibieron tanto subsalicilato de Bismuto como aquellos que fueron tratados con Placebo fueron: diarrea en ambos grupos (10,3% primer grupo y 16% en el segundo grupo) p=0,537, Heces oscuras 37,9% en el primer grupo mientras que en el segundo grupo no hubo este tipo de consecuencia, (p=0,001). El dolor abdominal se presentó en el 20,7% del primer grupo y en el 52% del segundo grupo (p=0,016). Las náuseas se presentaron solo en el 3% del grupo placebo. (p=0,055). Conclusiones: No se encontró diferencias estadísticas con la adición de Bismuto al esquema de la terapia triple para erradicar el Helicobacter Pylori Comparado con placebo. (p=0,319).Los efectos adversos fueron menores en el grupo que recibió bismuto...

To establish the efficiency and adverse effects of the addition of bismuth subsalicylate to triple eradication therapy for Helicobacter pylori infection. Material and methods: Double blind controlled experimental trial. The study population consisted of 54 patients with Helicobacter pylori infection: 29 were allocated to the experimental group, who received the usual triple plus bismuth subsalicylate therapy, and 24 received the triple therapy plus placebo. Results: The average age was 47+/-14.9 years, 66.7% of the patients were women. Both groups underwent the breath test: it was negative in 89.7% of the patients from the experimental group and 80% of the patients from the placebo group (p=0.319). The adverse events of both groups were: diarrhea (10.3% in the experimental group vs 16% in the placebo group; p=0.537), dark feces (37.9% in the experimental group vs 0% in the placebo group; p=0.001), abdominal pain (20.7% in the experimental group vs 52% in the placebo group; p=0.016). Nausea only were present in 3% of the patients of placebo group p=0.055). Conclusions: The association of bismuth subsalicylate to the triple therapy scheme for the erradication of Helicobacter pylori was effective in 89.7% of patients, whereas 80% of efficiency was obtained in the placebo group (p=0.319). The adverse events were lesser in the experimental group...

Actualización en el tratamiento de la Hepatitis C / An update in the therapy of Hepatitis C

La hepatitis C es una enfermedad infecto contagiosa causada por 6 genotipos del virus del mismo nombre que puede responder de manera distinta al tratamiento. El virus de 30 a 38 nm de tamaño, posee una envoltura y una sola cadena de ARN (+), pertenece a la familia Flaviviridae. La hepatitis C constituye un grave problema de salud pública se calcula que las tasas de infectados en la mayoría de los países se encuentra entre el 1,5 y el 3 %, siendo su tratamiento complejo.

Hepatitis C is a communicable disease caused by 6 genotypes of the hepatitis C virus, and this condition may have a variable response to therapy. Viral particles are 30-38 nm long, they have an envelope and single-stranded RNA. The virus belongs to the Flaviviridae family. Hepatitis C is a severe public health problem. It has been estimated that the rate of infected persons in most of the countries lies between 1,5 to 3 per cent, and its therapy is quite complex.

Utilidad del suplemento de probioticos (Lactobacillus acidophilus y bulgaricus) en el tratamiento del Síndrome de Intestino Irritable / Probiotic supplement (Lactobacillus acidophilus and bulgaricus) utility in the treatment of irritable bowel syndrome

El Sindrome de Intestino Irritable (SII), es un transtorno funcional muy común y causa frecuente de consulta en gastroenterología, su fisiopatología es multifactorial y se caracteriza por dolor abdominal, distensión y alteración de los hábitos defecatorios, su terapia es básicamente sintomática (loperamida, antiespasmódicos, antidepresivos,etc).Recientemente se ha incorporado al tratamiento, el uso de probióticos que podrían mejorar su sintomatología. POBLACIÓN Y MÉTODO: Ensayo Clínico doble ciego aleatorizado simple, multicentrico que incluyó pacientes con diagnóstico de SII basado en criterios de Roma III. A estos se les administró Bromuro de Pinaverio mas placebo o Bromuro de Pinaverio mas Probiótico. La intensidad de los síntomas y el efecto del tratamiento fue valorado de acuerdo a Score de Francis antes y al final del tratamiento. Los cálculos fueron hechos con el programa SPSS 12.0.IC 95% RESULTADO. Se evaluaron 51 pacientes con promedio de edad de 43 años, mayoritariamente mestizos, 75%(38) casados y 55%(28) del sexo femenino, se encontró diferencias significativas en 4 variables de comparación: Dolor abdominal, Severidad del dolor, Días de dolor, y el Score total al final del tratamiento. CONCLUSIONES Los Probióticos utilizados como suplemento son efectivos en mejorar la sintomatología del SII.

Background: Irritable bowel syndrome (IBS) is a very common functional condition and a frequent cause of consultation in gastroenterology. With a multifactorial pathophysiology IBS is characterized by abdominal pain, distension and altered bowel habits. Loperamide, antispasmodics and antidepressants are symptomatic relievers of this disorder. Recently probiotics were incorporated to therapy, and could improve the symptomatology. Methods: multicenter randomized placebo-controlled trial that included IBS patients, diagnosed with Rome III criteria. The patients were given pinaverium bromure and placebo or pinaverium bromure and probiotics for 3 weeks. The intensity of symptoms and the effect of therapy were evaluated with the Francis Score, before and after the treatment. Statistics were done with SPSS 12.0 (C.I 95%). Results: 51 patients were evaluated, with an average age of 43 years old, mostly mestizo, 75% (38) married and 55% (28) female. There were statistical differences in four variables: abdominal pain, intensity of pain, days of pain and total score at the end of therapy. Conclusions: Probiotics used as supplement are effective in improving symptomatology of IBS.

Rebrote virológico en el tratamiento de hepatitis B con entecavir: ¿resistencia? / Virological breakthrough in treating hepatitis B with entecavir: It means resistance?

Paciente varón de 45 años natural de Lima, casado con antecedentes de , múltiples parejas sexuales y operado de fimosis, que debuta con eritema nodoso y diagnosticado de hepatitis B crónica en Agosto del 2008, en controles por consultorio se realiza diagnóstico de cirrosis hepática child A y hepatocarcinoma. Inicia tratamiento para la hepatitis B con Entecavir 0,5mg y luego se realiza hepatectomía del segmento V, En Febrero 2009 en controles de imágenes se evidencia recidiva de hepatocarcinoma en el segmento VI (lesión de 14mm) con AFP de 68 ng/dl, se realiza etanolización, con evolución final favorable. Durante el seguimiento no se observa evidencia de recidiva de HCC, continua con Entecavir 0,5 mg /d y en abril 2010, luego de 72 semanas de tratamiento con adecuada adherencia al tratamiento presenta rebrote virológico (carga viral positiva de 646 UI/dl), y se decide agregar a la terapia Tenofovir. Actualmente paciente con buena evolución con última carga viral de Abril del 2012 negativa recibiendo terapia doble para VHB. Reportamos el caso por ser uno de los primeros en nuestro país de resistencia probable a Entecavir y donde se pone de manifiesto la necesidad de examenes complementarios que confirmen dicha sospecha.

A 45 year- old - married man, with several sexual partners, initiated symptoms with nodosum erythema and in August 2008, is diagnosed of chronic hepatitis due to hepatitis B virus (HBV). Later he was diagnosed of Child A cirrhosis and hepatocarcinoma. He began HBV treatment with Entecavir 0,5 mg; then he underwent a V segment hepatectomy. In February 2009 he presented a relapse with a tumor of 14 mm on VI segment with AFP values of 68 ng/dl, so he underwent an ethanolization with good evolution. During the follow up, he has not presented evidence of relapse of hepatocarcinoma and continued with Entecavir 0,5 mg/d. In April 2010, after 72 weeks of therapy with good compliance, the patient presented a virological breakthrough (viral load 646 UI/dl) and Tenofovir was added to his therapy. Nowadays the patient is receiving double therapy for HBV and his last viral load, April 2012, was negative. This could be the first case in our country of a probable resistance to Entecavir; complementary tests are needed in order to rule out this suspicion.

[Virological breakthrough in treating hepatitis B with entecavir: it means resistance?]. / Rebrote virológico en el tratamiento de hepatitis B con entecavir ¿resistencia?

A 45 year-old married man, with several sexual partners, initiated symptoms with nodosum erythema and in August 2008, is diagnosed of chronic hepatitis due to hepatitis B virus (HBV). Later he was diagnosed of Child A cirrhosis and hepatocarcinoma. He began HBV treatment with Entecavir 0.5 mg; then he underwent a V segment hepatectomy. In February 2009 he presented a relapse with a tumor of 14 mm on VI segment with AFP values of 68 ng/dl, so he underwent an ethanolization with good evolution. During the follow up, he has not presented evidence of relapse of hepatocarcinoma and continued with Entecavir 0.5 mg/d. In April 2010, after 72 weeks of therapy with good compliance, the patient presented a virological breakthrough (viral load 646 UI/dl) and Tenofovir was added to his therapy. Nowadays the patient is receiving double therapy for HBV and his last viral load, April 2012, was negative. This could be the first case in our country of a probable resistance to Entecavir; complementary tests are needed in order to rule out this suspicion.

[Clinical - Epidemiological characteristics of the Hepatocellular Carcinoma and treatment in the departament of digestive system diseases of the National Hospital "Eduardo Rebagliatti Martins" (HNERM) - ESSALUD]. / Características clínico - epidemiológicas del Carcinoma Hepatocelular y su tratamiento en el departamento del aparato digestivo del HNERM ES-SALUD.

UNLABELLED: Hepatocellular carcinoma (CHC) is one of the leading causes of worldwide cancer mortality. The aim of this study is to describe the clinical and epidemiological characteristics, as well as treatment prescribed in patients with this diagnosis. METHODS: Longitudinal and prospective study that included patients with diagnosis of CHC in the Department of Digestive System at the HNERM-EsSalud between august 2007 and august 2008. RESULTS: We included 36 patients, median age was 60,1 years and 61,1% were male. Cirrhosis was present in 69,1% and median age in this group was 68,9 years, the median age in those without cirrhosis was 40 years (p<0,001). The most frequent associated cause was hepatitis B (38,9%) and 60% had AFP higher than 200 ng/ml. In cirrhotic patients, 80% were Child-Pugh score B or C. Symptomatic treatment was prescribed in 44,4% of the patients. CONCLUSIONS: Epidemiological features are different between patients with or without cirrhosis. In the first case their characteristics are similar to those described in areas of low risk for CHC; in the second group the characteristics are similar to those described in areas with high risk population. CHC has frequent association with hepatitis B virus. High percentage of patients is diagnosed with an advanced stage of HCC.