Intestinal adaptation and rehabilitation in adults with short bowel syndrome.

PURPOSE OF REVIEW: Over the past decade, trophic gastrointestinal hormonal factors have been included in the intestinal rehabilitation programs for short bowel syndrome (SBS). Up today the only trophic factor approved for clinical practice is the glucagon-like peptide-2 (GLP-2) analogue, teduglutide. A literature review on the last 2-year data on GLP-2 analogues for the treatment of SBS in adults has been performed. RECENT FINDINGS: Several reports on real-world data on the efficacy and safety of teduglutide treatment for SBS, some case-reports on the use of teduglutide in non-SBS conditions as well as phase 2 trials on new GL-2 analogues on patients with SBS have been retrieved. SUMMARY: Real-world data confirmed the teduglutide efficacy not only in weaning off IVS in accurately selected patients but also increased the alert on the risk of development of gastrointestinal polyps related to the drug; the impact of the therapy on patients' QoL deserves further studies and the cost-utility of the treatment is still uncertain. Some case reports highlighted the potential benefit of treatment with teduglutide in non-SBS gastrointestinal diseases, such as graft-versus-host disease, primary amyloidosis and refractory microscopic colitis. Phase 2 RCTs on safety and efficacy of two new long-acting GLP-2 analogues, glepaglutide and apraglutide, were published, and phase 3 RCTs have been completed.

Pathophysiology of ascites: The importance of the intestine. A surgical contribution to the understanding of a medical problem.

The understanding of the mechanisms for the development of ascites has evolved over the years, involving the liver, peritoneum, heart, and kidneys as key responsible for its formation. In this article, we review the pathophysiology of ascites formation, introducing the role of the intestine as a major responsible for ascites production through "a game changer" case.

Bowel Stiffness Assessed by Shear-Wave Ultrasound Elastography Predicts Disease Behavior Progression in Patients With Crohn's Disease.

INTRODUCTION: There is a lack of reliable predictors of disease behavior progression in patients with Crohn's disease (CD). Real-time shear-wave elastography (SWE) is a novel method for evaluating tissue stiffness. However, its value for assessing CD has not yet been investigated. We aimed to explore the value of SWE and other ultrasound parameters at diagnosis in predicting CD behavior progression. METHODS: We retrospectively collected data from patients with CD with the nonstenotic nonpenetrating disease (B1 phenotype based on the Montreal classification). All patients underwent intestinal ultrasound at baseline and were followed up. The end point was defined as disease behavior progression to stricturing (B2) or penetrating (B3) disease. Cox regression analysis was performed for the association between baseline characteristics and subsequent end points. In addition, a multivariate nomogram was established to predict the risk of disease behavior progression quantitatively. RESULTS: A total of 130 patients with CD with B1 phenotype were enrolled. Twenty-seven patients (20.8%) developed B2 or B3 disease, with a median follow-up of 33 months. Multivariate analysis identified that SWE was the only independent predictor of disease behavior progression (hazard ratio 1.08, 95% confidence interval 1.03-1.12, P = 0.001). A reverse of the HR appeared at the cutoff 12.75 kPa. The nomogram incorporating SWE and other clinical characteristics showed a good prediction performance (area under the curve = 0.792). DISCUSSION: Intestinal stiffness assessed using SWE is an independent predictor of disease behavior progression in patients with CD. Patients with CD with SWE >12.75 kPa at diagnosis are prone to progress toward stricturing or penetrating diseases.

Bowel function and inflammation: Is motility the other side of the coin?

Digestion and intestinal absorption allow the body to sustain itself and are the emblematic functions of the bowel. On the flip side, functions also arise from its role as an interface with the environment. Indeed, the gut houses microorganisms, collectively known as the gut microbiota, which interact with the host, and is the site of complex immune activities. Its role in human pathology is complex and scientific evidence is progressively elucidating the functions of the gut, especially regarding the pathogenesis of chronic intestinal diseases and inflammatory conditions affecting various organs and systems. This editorial aims to highlight and relate the factors involved in the pathogenesis of intestinal and systemic inflammation.

Time to symptom onset and manual reduction outcomes as predictors of bowel viability in incarcerated obturator hernias.

The current study aimed to identify the indications for manual reduction in incarcerated obturator hernias (OH). Further, whether time to symptom onset and manual reduction outcomes can be predictors of bowel viability and the need for bowel resection in incarcerated OH were examined. This retrospective study included 26 patients with incarcerated OH who underwent surgery. All patients underwent manual reduction, and computed tomography scan after manual reduction confirmed hernia release. Multivariate analyses were performed to determine the predictors of bowel resection. The bowel resection group had a significantly longer average time to symptom onset than the nonbowel resection group (88 vs 36 h). Further, the bowel resection group was more likely to have failed manual reduction than the nonbowel resection group. A time to symptom onset of ≥ 72 h and failed manual reduction were significant predictors of bowel viability. Age, sex, hernia localization, American Society of Anesthesiologists physical status score, and laboratory findings did not differ significantly between the bowel resection and nonbowel resection groups. Time to symptom onset and manual reduction outcomes are significant predictors of bowel viability in incarcerated OH. Patients with a time to symptom onset of ≥ 72 h and failed manual reduction require surgical evaluation due to a high risk of bowel nonviability. Therefore, a cautious approach is required in the management of OH, and further research on optimized treatment protocols should be conducted.

Prevalence of bowel symptoms in patients infected with human T-lymphotropic type 1 virus

Abstract INTRODUCTION: Bowel dysfunction is frequent in patients with spinal cord diseases, but little is known about the prevalence of bowel symptoms in human T-lymphotropic virus-(HTLV-1) infected individuals. The purpose of this study is to determine the frequency of bowel symptoms in HTLV-1 infected individuals and their correlation with the degree of neurologic disease. METHODS: This is a cross-sectional study comparing the frequency of bowel symptoms in HTLV-1-infected individuals* and seronegative donors (controls). Patients answered a questionnaire, the Rome III Criteria was applied, and stool consistency was evaluated by the Bristol Stool Form Scale. The individuals were classified as HTLV-1 carriers, probable HTLV-1 myelopathy and definitive HTLV-1 associated myelopathy or tropical spastic paraparesis (definitive HAM / TSP)**. RESULTS: We studied 72 HTLV-1 infected individuals and 72 controls with equal age and gender distribution. Constipation was the most frequent complaint, occurring in 38 % of HTLV-1 individuals and in 15 % of the controls. In comparison to the seronegative controls, the probability of constipation occurrence was approximately 18 times higher in definitive HAM / TSP patients. Straining, lumpy or hard stools, sensation of anorectal obstruction/blockage, fewer than 3 defecations per week, flatulence, soiling, evacuation pain, and bleeding were also more frequent in the HTLV-1 patients than in the controls. Moreover, bowel symptoms were more frequent in patients with definitive or probable HAM / TSP than in carriers. CONCLUSIONS: Bowel symptoms were more frequent in HTLV-1-infected patients than in seronegative controls and the frequency of bowel symptoms correlated with the severity of neurologic disease.

Radiographic predictors determined with an objective assessment tool for neonatal patients with necrotizing enterocolitis / Preditores radiográficos determinados com uso de ferramenta de avaliação objetiva para pacientes neonatais com enterocolite necrotizante

ABSTRACT Objective: The objective of this study was to develop and validate a computational tool to assist radiological decisions on necrotizing enterocolitis. Methodology: Patients that exhibited clinical signs and radiographic evidence of Bell's stage 2 or higher were included in the study, resulting in 64 exams. The tool was used to classify localized bowel wall thickening and intestinal pneumatosis using full-width at half-maximum measurements and texture analyses based on wavelet energy decomposition. Radiological findings of suspicious bowel wall thickening and intestinal pneumatosis loops were confirmed by both patient surgery and histopathological analysis. Two experienced radiologists selected an involved bowel and a normal bowel in the same radiography. The full-width at half-maximum and wavelet-based texture feature were then calculated and compared using the Mann-Whitney U test. Specificity, sensibility, positive and negative predictive values were calculated. Results: The full-width at half-maximum results were significantly different between normal and distended loops (median of 10.30 and 15.13, respectively). Horizontal, vertical, and diagonal wavelet energy measurements were evaluated at eight levels of decomposition. Levels 7 and 8 in the horizontal direction presented significant differences. For level 7, median was 0.034 and 0.088 for normal and intestinal pneumatosis groups, respectively, and for level 8 median was 0.19 and 0.34, respectively. Conclusions: The developed tool could detect differences in radiographic findings of bowel wall thickening and IP that are difficult to diagnose, demonstrating the its potential in clinical routine. The tool that was developed in the present study may help physicians to investigate suspicious bowel loops, thereby considerably improving diagnosis and clinical decisions.

RESUMO Objetivo: O objetivo deste estudo foi desenvolver e validar uma ferramenta computacional para auxiliar as decisões radiológicas na enterocolite necrotizante. Metodologia: Pacientes que exibiam sinais clínicos e evidências radiográficas do estágio 2 ou superior de Bell foram incluídos no estudo, que resultou em 64 exames. A ferramenta foi usada para classificar o aumento localizado da espessura da parede intestinal e a pneumatose intestinal com medidas de largura total a meia altura e análises de textura baseadas na decomposição da energia wavelet. Os achados radiológicos de aumento suspeito da espessura da parede intestinal e das alças na pneumatose intestinal foram confirmados pela cirurgia e análise histopatológica do paciente. Dois radiologistas experientes selecionaram um intestino afetado e um intestino normal na mesma radiografia. A largura total a meia altura e a característica da textura baseada em wavelet foram então calculadas e comparadas com o uso do teste U de Mann-Whitney. Foram calculados a especificidade, sensibilidade, valores preditivos positivos e negativos. Resultados: Os resultados da largura total a meia altura foram significativamente diferentes entre a alça normal e a distendida (mediana de 10,30 e 15,13, respectivamente). Medidas de energia wavelet horizontal, vertical e diagonal foram avaliadas em oito níveis de decomposição. Os níveis 7 e 8 na direção horizontal apresentaram diferenças significativas. Para o nível 7, as medianas foram 0,034 e 0,088 para os grupos normal e com pneumatose intestinal, respectivamente, e para o nível 8, as medianas foram 0,19 e 0,34, respectivamente. Conclusões: A ferramenta desenvolvida pode detectar diferenças nos achados radiográficos do aumento da espessura da parede intestinal e PI de difícil diagnóstico, demonstra seu potencial na rotina clínica. A ferramenta desenvolvida no presente estudo pode ajudar os médicos a investigar alças intestinais suspeitas e melhorar consideravelmente o diagnóstico e as decisões clínicas.

Aspectos fisiopatológicos da síndrome pós-ressecção anterior do reto para o tratamento de câncer retal / Pathophysiological aspects of the low anterior resection syndrome for treatment of rectal cancer

RESUMO O número de pacientes com distúrbios funcionais intestinais em decorrência das operações para o tratamento do câncer retal tem aumentado durantes as últimas décadas. Alterações anatômicas e funcionais após a retirada do reto provocam aumento da frequência evacuatória, urgência evacuatória, evacuações múltiplas e incontinência para fezes e flatos, caracterizando a síndrome da ressecção anterior baixa ou LARS - "low anterior resection syndrome". Este artigo apresenta uma revisão geral do tema, com ênfase para conceitos atuais e aspectos fisiopatológicos de distúrbios funcionais do intestino após o tratamento cirúrgico do câncer retal. É fundamental que o cirurgião compreenda esses mecanismos, para melhor abordagem dos pacientes e restabelecimento da sua qualidade de vida.

ABSTRACT The number of patients with bowel dysfunction due to the treatment of rectal cancer has increased during the recent decades. Anatomical and functional disorders after the removal of the rectum are followed by increased stool frequency, urgency, multiple evacuations and flatus or stool incontinence characterizing the low anterior resection syndrome - LARS. The purpose of this article is to present a review of the literature on current concepts and pathophysiological aspects of bowel dysfunction after resection of rectal cancer. It is essential to understand these mechanisms for a better management of patients and recovery of their quality of life.

Insuficiencia intestinal secundaria a síndrome de intestino corto: resultados de un programa multidisciplinario de rehabilitación intestinal / Intestinal failure due to short bowel syndrome: impact of a multidisciplinary intestinal rehabilitation program

Background: In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. Aim: To report the results of our program in patients suffering intestinal failure. Patients and Methods: A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. Results: Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. Conclusions: Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.

Changes in mast cell infiltration: a possible mechanism in detrusor overactivity induced by visceral hypersensitivity

ABSTRACT Objective: To establish the detrusor overactivity (DO) model induced by visceral hypersensitivity (VH) and investigate the relationship between mast cell (MC) infiltration and DO. Materials and Methods: Sixty rats are divided into 4 groups randomly: Group 1:Baseline group; Group 2: DO group; Group 3: CON group; Group 4: VH group. The colorectal distension (CRD) and abdominal withdral reflex (AWR) scores are performed to evaluate VH. The cystometric investigation and histological test of MC infiltration are assessed. Results: The threshold pressure of CRD in the VH group is significantly lower than that in the CON group (P<0.001). At the distension pressure ≥20 mmHg, the AWR scores of the VH group are significantly higher than those of the CON group (10 mmHg: P=0.33; 20 mmHg: P=0.028; 40 mmHg: P<0.001; 60 mmHg: P<0.001; 80 mmHg: P<0.001). DO model is successfully established in the VH group (DO rate=100%). Compared with the CON group, the numbers of MC infiltration are significantly increased in the VH group, including submucosa of bladder (P<0.001), mucosa lamina propria/mesentery of small intestine (P<0.001), and mucosa lamina propria/mesentery of large intestine (P<0.001). Furthermore, more MC activation as well as degranulation are observed in the VH group. Conclusions: It is indicated that DO model can be established in the VH rats. The MC infiltration may play an important role in DO induced by VH, and may be helpful to understand the mechanisms of DO in VH patients.

Enterografia por tomografia computadorizada: experiência inicial na avaliação das doenças do intestino delgado / CT enterography: a preliminary experience in the evaluation of small bowel diseases

OBJETIVO: O objetivo deste estudo é demonstrar a importância da enterografia por tomografia computadorizada (entero-TC) e como este exame pode contribuir na elucidação diagnóstica e avaliação clínica de pacientes com doenças do intestino delgado. MATERIAIS E MÉTODOS: Análise retrospectiva de 35 pacientes submetidos a entero-TC realizadas em aparelho multidetector de 16 canais, entre maio de 2008 e março de 2009. Utilizou-se meio de contraste iodado venoso e oral neutro (polietilenoglicol). As principais indicações foram avaliação de doença de Crohn, diarreia de origem indeterminada e suspeita de neoplasias. RESULTADOS: Houve boa correlação dos achados à entero-TC relacionados à atividade da doença em pacientes com doença de Crohn, quando comparados com dados clínicos, laboratoriais e endoscópicos. Em 15 casos identificaram-se alterações compatíveis com doença de Crohn, 9 deles sugerindo atividade. Dos pacientes com diarreia, o exame elucidou a maioria dos casos. Identificaram-se dois casos de tumor carcinoide. CONCLUSÃO: A entero-TC é método simples e eficaz para estudo das doenças inflamatórias/neoplásicas do intestino delgado, sobretudo na avaliação da doença de Crohn, indicando atividade da doença. Uma de suas principais vantagens é a possibilidade de avaliação de alterações mesentéricas e extraintestinais associadas.

OBJECTIVE: The present study was aimed at demonstrating the value of computed tomography enterography (CT enterography) and how this imaging method can be useful in the diagnostic elucidation and assessment of patients with small bowel diseases. MATERIALS AND METHODS: Retrospective evaluation of 35 patients submitted to CT enterography in a 16-row multidetector CT equipment from May/2008 to March/2009. All the patients received intravenous and neutral oral iodinated contrast agents (polyethylene glycol). Main indications were: Crohn's disease, diarrhea of undetermined origin and suspicion of neoplasia. RESULTS: A good correlation was observed between CT enterography findings and clinical, laboratory and endoscopic data related to the disease activity in patients with Crohn's disease. In 15 cases alterations compatible with Crohn's disease were identified, nine of them suggesting disease activity. A diagnosis was achieved in the majority of the patients with diarrhea. Carcinoid tumors were identified in two patients. CONCLUSION: CT enterography is a simple and effective method in the evaluation of inflammatory/neoplastic small bowel diseases, particularly in cases of Crohn's disease, indicating disease activity. One of the main advantages of this method is the possibility of evaluating associated mesenteric and extraintestinal alterations.

The air-breathing cycle of Hoplosternum littorale (Hancock, 1828)(Siluriformes: Callichthyidae)

Hoplosternum littorale is a continuous air breather, which uses a portion of its intestine to extract oxygen from inspired air. Its air-breathing behavior occurs in four phases: 1) ascent to the water surface; 2) mouth emergence with expansion of the oral cavity for air inspiration; 3) downward swimming and oral cavity compression resulting in air swallowing and the expiration of old air from the anus; 4) return to bottom. The time required to complete the air-breathing cycle was significantly shorter for small fish compared to large fish.

Hoplosternum littorale é um peixe de respiração aérea contínua que utiliza parte de seu intestino para a extração do oxigênio do ar. Este comportamento de respiração aérea realiza-se em quatro etapas: 1) Subida para a superfície da água; 2) Emergência da boca com a simultânea expansão da cavidade oral e inspiração; 3) Giro do corpo para baixo com compressão da cavidade oral e expiração do ar pelo ânus; 4) Retorno ao fundo. O tempo necessário para a realização do ciclo respiratório aéreo completo foi significativamente mais curto em indivíduos de menor tamanho quando comparados aos de maior massa corpórea.

Lactente com dor abdominal / Abdominal pain in an infant

Objetivo: Descrever um caso de intussuscepção intestinal em lactente de apresentação atípica e realizar uma revisão da literatura acerca dos pontos chave relacionados ao diagnóstico e ao tratamento da intussuscepção em crianças. Relato de caso: Lactente de 4 meses levado ao pronto atendimento por quadro de choro havia uma hora. O exame físico inicial revelou apenas palidez e ruídos hidroaéreos aumentados ao exame do abdomen.Após admissão, evoluiu com resolução completa de todos os sintomas e não apresentou novos episódios de dor durante sete horas de observação. Uma hora após a alta, apresentou evacuação com sangue,que levou ao diagnóstico de intussuscepção intestinal.Conclusão: A intussuscepção intestinal pode ter formas de apresentação variáveis que dificultam o diagnóstico. Elevado índice de suspeição, reavaliações frequentes e investigação radiológica são necessários para o diagnóstico precoce dos casos atípicos.

Objective: To report a case of intestinal intussusception with atypical presentation in an infant, and to provide a review of the key points of the literature related to diagnosis and treatment of intussusception in children. Case report: A four months old infant was brought to the Emergency Department due to crying beginning one hour before. Physical examination on admission revealed paleness and increased abdominal sounds. After admission the patient exhibited a complete resolution of all the symptoms, and no new onset of pain during a seven hours period of observation. One hour after discharge the infant had one single episode of bloody stools, which led to the diagnosis of intestinal intussusception. Conclusion: The initial presentation of intestinal intussusception may be variable, making difficult its diagnosis. A high index of suspicion, repeated re-evaluations and radiological investigation are necessary to establish an early diagnosis of atypical cases.

Fisiopatología de la diarrea aguda / Physiopathology of acute diarrhea

Es un artículo de revisión de los aspectos importantes de la fisiopatología de la diarrea. Se hace una descripción de la fisiopatología intestinal que incluye la anatomía del intestino y de su superficie de absorción y la estructura funcional de la mucosa intestinal. La fisiopatología normal de los líquidos intestinales. Mecanismo de absorción del agua y los electrólitos. Absorción de sodio por difusión electrogénica, unido al ion cloro, intercambio con el ion hidrógeno y unido a sustancias orgánicas como glucosa, aminoácidos y algunos oligopéptidos; secreción intestinal de agua y electrólitos. Control intracelular de la secreción. Mediadores y moduladores extracelulares del transporte intestinal. Factores que aumentan la absorción y reducen la secreción. Factores que estimulan la secreción y reducen la absorción Mecanismo fisiopatológico de la diarrea. Clasificación de la diarrea infecciosa aguda: acuosa secretoria y osmótica; diarrea con sangre invasiva y no invasiva

Importância da microflora intestinal / Importance of the intestinal microflora

Objetivo: avaliar a instalação e evolução da microflora intestinal, assim como o impacto nas condições de saúde e doença. Fontes Pesquisadas: a base de dados Medline. Síntese dos dados: na maior parte, a microflora bacteriana intestinal é benéfica ao hospedeiro, com função...

Objective: to evaluate the intetinal microflora installment and evolution as its impact on health and disease. Data source: medline data basis. Data synthesis: most of the intestinal bacterial microflora is beneficial for the host, with digestive functions...

Manejo das lesões intestinais em cirurgia ginecológica / Intestinal injury management in gynecological surgery

As lesões iatrogênicas do intestino podem ocorrer em qualquer procedimento cirúrgico ginecológico, independente da via de acesso usada para realização da cirurgia. São pouco freqüentes, mas podem ter conseqüências drásticas para as pacientes quando não forem diagnosticadas ou reparadas da maneira adequada. Deve-se atentar para as pacientes que apresentam fatores de risco para complicações intestinais intra-operatórias, principalmente a possível ocorrência de aderências intestinais aos órgãos do sistema reprodutor feminino, e tomar medidas preventivas em relação às mesmas. O diagnóstico precoce destas iatrogenias propicia normalmente reparo simples das lesões, não sendo necessário colostomia, o que diminui a morbimortalidade destas pacientes.

Lesões intestinais decorrentes de isquemia e reperfusão: fisiopatologia e modelos experimentais / Reperfusion injury intestinal ischemia: pathophysiology and experimental models

A isquemia intestinal é uma emergência pouco frequente em cirurgia vascular. As principais causas dessa doença são as embolias e as tromboses arteriais. A isquemia, por si só, é bastante lesiva, mas a reperfusão do tecido isquêmico pode levar a uma série de complicações, que podem aumentar as lesões teciduais e, associado às complicações sistêmicas, colocar em risco a vida do paciente. As lesões decorrentes da isquemia e reperfusão em tecido intestinal foram demonstradas em estudos clínicos e experimentais, nos quais estudou-se também a fisiopatologia e os tratamentos adequados. Esses estudos foram feitos em grande variedade de modelos experimentais, e, consequentemente, os resultados encontrados foram bastante contraditórios...

Esquistossomose mansônica experimental: estudo morfométrico e histoquímico das células caliciformes intstinais / Experimental schistosomiasis mansoni: Morphometric and histochemistry study of the intestinal caliciforme cells

Com o objetivo da avaliar a repercussão da esquistossomose mansônica sobre as células caliciformes do intestino delgado de camudongos, estudaram-se, através da histoquímica e morfometria, 48 animais (40 infectados com cercárias de S. mansoni, cepa SLM, e oito controles). O tempo de evolução da infecção variou de 40 a 75 dias. Para o estudo histólogico e histoquímico, cortes teciduais foram corados,respectivamente, com hematoxilina-eosina e alcian blue, pH2,5. As medidas morfométricas foram realizadas em um analisador de imagens, constituído por um microcomputador, com mesa digitalizadora, acoplado a um microscópio. O estudo histólogico mostrou alterações estruturais decorrentes principalmente da presença de granulomas periovulares, além da congestão, edema, e infiltrado inflamatório difuso. A histoquímica permitiu caracterizar as células caliciformes produtoras de mucina ácida. A morfometria evidênciou aumento estatisticamente significativo tanto de número dessas células como quantidade de mucina por vilosidade à medida que a infeção evoluiu. Essas alterações são provavelmente medidas por mecanismos imunológicos

La homeostasis intestinal / The intestinal homeostasis

se revisan los principales aspectos fisiológicos que llevan a la homeostasis intestinal y que permiten la absorción adecuada de nutrientes, analizando también los factores fisiopatológicos en pacientes con inmunosupresión o falla multisistémica y señalando los posibles métodos para corregirlos.