Acute calculous cholecystitis: a real-life management study in a tertiary teaching hospital

Aim: to describe the management of acute calculous cholecystitis in a tertiary teaching hospital and the outcomes obtained. Material and methods: a retrospective single tertiary center cohort study. Results: medical records of 487 patients were analyzed. The mean follow-up was 44.5 +/- 17.0 months. Treatment alternatives were cholecystectomy (64.3%), conservative treatment (23.0%), endoscopic retrograde cholangiopancreatography (17.4%), percutaneous cholecystostomy (10.7%) and endoscopic ultrasound-guided gallbladder drainage (0.8%). Most cholecystectomies were delayed (88.8%). Recurrences occurred in 38.2% of patients. Although cholecystectomy was the therapeutic approach with the lowest recurrence rate once performed, 44.6% of patients that underwent delayed surgery had pre-surgical recurrences. Conclusions: delayed cholecystectomy is still commonly performed, even though it is related with a high frequency of preoperative recurrences

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Acute calculous cholecystitis: a real-life management study in a tertiary teaching hospital.

AIM: to describe the management of acute calculous cholecystitis in a tertiary teaching hospital and the outcomes obtained. MATERIAL AND METHODS: a retrospective single tertiary center cohort study. RESULTS: medical records of 487 patients were analyzed. The mean follow-up was 44.5 ± 17.0 months. Treatment alternatives were cholecystectomy (64.3%), conservative treatment (23.0%), endoscopic retrograde cholangiopancreatography (17.4%), percutaneous cholecystostomy (10.7%) and endoscopic ultrasound-guided gallbladder drainage (0.8%). Most cholecystectomies were delayed (88.8%). Recurrences occurred in 38.2% of patients. Although cholecystectomy was the therapeutic approach with the lowest recurrence rate once performed, 44.6% of patients that underwent delayed surgery had pre-surgical recurrences. CONCLUSIONS: delayed cholecystectomy is still commonly performed, even though it is related with a high frequency of preoperative recurrences.

Reuniones periódicas de gastroenterología y hepatología con atención primaria. Motivos de consulta / Periodic gastroenterology and hepatology meetings with primary care. Reasons for consultation

Introducción: la presión asistencial, el envejecimiento poblacional y el aumento de enfermedades crónicas incrementan las derivaciones desde atención primaria, pudiendo sobrecargar el sistema sanitario. Se han efectuado diversas intervenciones que intentan mejorar estos aspectos. Objetivos: valorar motivos de consulta más frecuentes de los médicos generales, tanto en consultas compartidas como en sesiones clínicas realizadas conjuntamente con un especialista consultor en atención primaria, en medios urbano y rural, y su repercusión sobre las derivaciones a primeras consultas de gastroenterología. Material y métodos: se efectúa una intervención de tipo fundamentalmente formativo, consistente en reuniones periódicas en dos centros de atención primaria (urbano y rural), con consultas compartidas y sesiones clínicas en relación con pacientes y temas de gastroenterología. El periodo de intervención (dividido en dos subperiodos) se comparó con un periodo control. Resultados: los problemas más comentados corresponden al tracto digestivo inferior, seguido de patología hepática y del tracto digestivo superior. Se encontraron diferencias significativas en la distribución de diagnósticos entre los dos centros en las consultas compartidas. Se detectó un descenso relativo o porcentual de las derivaciones a nivel global en ambos subperiodos, significativo solo en el primero (51,45 %), así como a nivel rural (45,24 %). Conclusión: los motivos de consulta habituales fueron similares en los medios urbano y rural, con cierto predominio del tracto digestivo inferior. La mayoría pueden ser resueltos desde atención primaria, con el apoyo del consultor especialista. Hay repercusión en las derivaciones a las consultas externas de la especialidad, sobre todo a nivel rural (AU)

Introduction: care overload, aging of population, and increased chronic diseases lead to increased referrals from primary care, which may sometimes overload the health system. Thus, different interventions have been carried out attempting to improve these aspects. Objectives: to assess the most frequent causes of consultation of general physicians, both in joint consultations and clinical sessions held jointly with specialist consultant in primary care, in the urban and rural setting, and the influence on referrals to first consultations of gastroenterology. Material and methods: a mainly training type of intervention was carried out, consisting of regular meetings in both urban and rural primary care center, to perform joint consultations and clinical sessions on patients and topics related to the specialty of gastroenterology. The intervention period (divided in two subperiods) was compared with a control period. Results: most reasons for consultation were those corresponding to lower gastrointestinal tract, followed by liver disease and upper gastrointestinal tract. Significant differences were only found in distribution of diagnoses between the two centers in joint consultations. There was a relative (percent) decrease in referrals at the global level in both subperiods, only significant in the first (51.45 %), as well as in rural setting (45.24 %). Conclusion: common consultations motifs were similar in urban and rural settings, with some relevance of lower gastrointestinal tract disease. Most of them can be solved at primary care, with the help of consultant specialist. There is impact on referrals to the outpatient first consultations of gastroenterology, mainly in rural setting (AU)

Periodic gastroenterology and hepatology meetings with primary care. Reasons for consultation.

INTRODUCTION: care overload, aging of population, and increased chronic diseases lead to increased referrals from primary care, which may sometimes overload the health system. Thus, different interventions have been carried out attempting to improve these aspects. OBJECTIVES: to assess the most frequent causes of consultation of general physicians, both in joint consultations and clinical sessions held jointly with specialist consultant in primary care, in the urban and rural setting, and the influence on referrals to first consultations of gastroenterology. MATERIAL AND METHODS: a mainly training type of intervention was carried out, consisting of regular meetings in both urban and rural primary care center, to perform joint consultations and clinical sessions on patients and topics related to the specialty of gastroenterology. The intervention period (divided in two subperiods) was compared with a control period. RESULTS: most reasons for consultation were those corresponding to lower gastrointestinal tract, followed by liver disease and upper gastrointestinal tract. Significant differences were only found in distribution of diagnoses between the two centers in joint consultations. There was a relative (percent) decrease in referrals at the global level in both subperiods, only significant in the first (51.45 %), as well as in rural setting (45.24 %). CONCLUSION: common consultations motifs were similar in urban and rural settings, with some relevance of lower gastrointestinal tract disease. Most of them can be solved at primary care, with the help of consultant specialist. There is impact on referrals to the outpatient first consultations of gastroenterology, mainly in rural setting.

Perfiles de expresión génica en las primeras doce semanas de tratamiento en pacientes con hepatitis C crónica / Gene expression profiling in the first twelve weeks of treatment in chronic hepatitis C patients

Introducción Los perfiles de expresión génica (PEG) en las primeras semanas de tratamiento de pacientes con hepatitis C crónica pueden servir para evaluar la eficacia de la terapia basada en interferón. El objetivo de este trabajo fue estudiar los PEG de pacientes respondedores y no respondedores precoces antes y tras 12 semanas de tratamiento con peginterferón alfa y ribavirina. Métodos Estudio observacional donde se analizaron los PEG de 12 pacientes con hepatitis C crónica candidatos a recibir tratamiento con peginterferón alfa y ribavirina. Resultados De los 12 pacientes estudiados, seis mostraron una respuesta virológica precoz completa, mientras que seis no lograron controlar la viremia. En respondedores precoces, el tratamiento con peginterferón y ribavirina indujo un aumento de la expresión de un mayor número de genes de respuesta al interferón (ISG15, IFI6, IFI44L, IFI27, MX1, OASL, IRF7, IFIT3, IFITM1, EIF2AK2, HERC5 y APOBEC3A) que en no respondedores (ISG15, IFI44L, IFI27, IRF7, USP18) (p<0,05). En ambos grupos, se observaron cambios en los niveles de algunos genes hasta ahora escasamente descritos en el tratamiento de la hepatitis C.Conclusiones Los PEG descritos en este trabajo pueden ayudar a comprender mejor la patogénesis de la infección, así como las bases fisiológicas de la respuesta al tratamiento. Así, el mayor efecto del tratamiento sobre la expresión de genes de respuesta al interferón observado en respondedores podría explicar su mejor control de la carga viral (AU)

Introduction: Gene expression profiling in the first weeks of treatment of patients with chronic hepatitis C may contribute to better evaluate the response to interferon-based therapy. The objective of this study was to evaluate the gene expression profiles of early responders and non-responders before, and after12 weeks of treatment with peginterferon alfa and ribavirin. Methods: Gene expression profiles were analysed in 12 patients with chronic hepatitis C, and scheduled for treatment with peginterferon alpha and ribavirin. Results: Of the 12 patients studied, six showed a complete early virological response, while six failed tocontrol viremia. In early responders, treatment with peginterferon and ribavirin induced an increasedexpression of a larger number of interferon-induced genes (ISG15, IFI6, IFI44L, IFI27, MX1, OASL, IRF7,IFIT3, IFITM1, EIF2AK2, HERC5 and APOBEC3) than in non-responders (ISG15, IFI44L, IFI27, IRF7, USP18)in the first twelve weeks of treatment (P<0.05). In both groups, there were changes in the levels of certaingenes poorly described in the treatment of hepatitis C so far (AU)

EUS-guided single-incision needle-knife biopsy: description and results of a new method for tissue sampling of subepithelial GI tumors (with video).

BACKGROUND: The diagnostic efficacy of current tissue sampling techniques for upper GI subepithelial tumors (SETs) appears to be limited. Better tissue acquisition techniques are needed to improve the diagnostic yield in this setting. OBJECTIVE: Our purpose was to determine the safety and diagnostic yield of EUS-guided needle-knife incision and forceps biopsy (SINK biopsy) of upper GI SETs. DESIGN: Retrospective database review. SETTING: Academic tertiary-care referral center. PATIENTS: This study involved 14 consecutive patients referred for EUS evaluation of upper GI SETs with previous unsuccessful attempts at tissue diagnosis by conventional forceps biopsy. INTERVENTION: EUS-guided needle-knife incision and forceps biopsy. MAIN OUTCOME MEASUREMENTS: The safety and diagnostic yield of this method, compared with EUS-guided fine-needle aspiration (EUS-FNA), when possible. RESULTS: SINK biopsy provided tissue samples that were sufficient for definite histologic diagnosis in 13 of 14 cases (diagnostic yield 92.8%). There were 8 gastric GI stromal tumors. In 7 of 8, the size of SINK specimens allowed immunohistochemical analysis, and the evaluation of malignant potential was carried out by means of mitotic index determination in 5 cases (71.42%). SINK biopsies determined the pathological diagnosis of all (4 of 4) nonmesenchymal lesions. Eight patients underwent both EUS-FNA and SINK, with final histologic diagnosis determined in 6 of 8 cases (75%) by SINK versus 1 of 8 cases (12.5%) by EUS-FNA (Fisher exact test, P = .023). There were no procedure-related complications. LIMITATIONS: A single-center, retrospective analysis with small sample size. CONCLUSION: SINK biopsy appears to be an easy, safe, and effective technique for determining the definitive pathological diagnosis, evaluation of the malignant potential, and planning management of SETs. It could be a reliable alternative to conventional FNA, providing larger samples that improve the histologic yield.

[Gene expression profiling in the first twelve weeks of treatment in chronic hepatitis C patients]. / Perfiles de expresión génica en las primeras doce semanas de tratamiento en pacientes con hepatitis C crónica.

INTRODUCTION: Gene expression profiling in the first weeks of treatment of patients with chronic hepatitis C may contribute to better evaluate the response to interferon-based therapy. The objective of this study was to evaluate the gene expression profiles of early responders and non-responders before, and after 12 weeks of treatment with peginterferon alfa and ribavirin. METHODS: Gene expression profiles were analysed in 12 patients with chronic hepatitis C, and scheduled for treatment with peginterferon alpha and ribavirin. RESULTS: Of the 12 patients studied, six showed a complete early virological response, while six failed to control viremia. In early responders, treatment with peginterferon and ribavirin induced an increased expression of a larger number of interferon-induced genes (ISG15, IFI6, IFI44L, IFI27, MX1, OASL, IRF7, IFIT3, IFITM1, EIF2AK2, HERC5 and APOBEC3) than in non-responders (ISG15, IFI44L, IFI27, IRF7, USP18) in the first twelve weeks of treatment (P<0.05). In both groups, there were changes in the levels of certain genes poorly described in the treatment of hepatitis C so far. CONCLUSIONS: The gene expression profiles described in this study provide a new insight to understanding the pathogenesis of the disease and treatment effect. The more marked effect of the treatment on the expression of interferon-response genes observed in early responders could explain their better control of viral load.

Hemorragia digestiva masiva por úlcera gástrica en un paciente con amiloidosis / Massive gastrointestinal bleeding due to gastric ulcer in a patient with amyloidosis

La amiloidosis gastrointestinal se puede presentar como parte de las manifestaciones sistémicas de una amiloidosis primaria o de manera localizada. Los síntomas y signos que pueden aparecer son múltiples e inespecíficos por lo que es difícil de sospechar clínicamente cuando la enfermedad todavía no ha sido diagnosticada. Las úlceras gástricas que se manifiestan con hemorragia masiva constituyen una manifestación infrecuente de esta enfermedad. Presentamos el caso clínico de un paciente con amiloidosis primaria que desarrolló, como complicación de esta enfermedad, hemorragia digestiva masiva por una úlcera gástrica que precisó de cirugía de urgencia para control del sangrado (AU)

Gastrointestinal amyloidosis may occur as part of the systemic manifestations of primary amyloidosis or in a localized form. The symptoms and signs that may occur are numerous and nonspecific, hampering clinical suspicion when this disease has not already been diagnosed. Gastric ulcers presenting as massive bleeding are an uncommon manifestation of this disease. We report the case of a patient with primary amyloidosis who developed massive gastrointestinal bleeding complicated by an amyloid gastric ulcer. Emergency surgery was required to control the bleeding (AU)

[Massive gastrointestinal bleeding due to gastric ulcer in a patient with amyloidosis]. / Hemorragia digestiva masiva por úlcera gástrica en un paciente con amiloidosis.

Gastrointestinal amyloidosis may occur as part of the systemic manifestations of primary amyloidosis or in a localized form. The symptoms and signs that may occur are numerous and nonspecific, hampering clinical suspicion when this disease has not already been diagnosed. Gastric ulcers presenting as massive bleeding are an uncommon manifestation of this disease. We report the case of a patient with primary amyloidosis who developed massive gastrointestinal bleeding complicated by an amyloid gastric ulcer. Emergency surgery was required to control the bleeding.

Increased Th1, Th17 and pro-fibrotic responses in hepatitis C-infected patients are down-regulated after 12 weeks of treatment with pegylated interferon plus ribavirin.

Hepatitis C virus causes significant morbidity and mortality worldwide. The infection induces up-regulation of cytokine and chemokines commonly linked to the development of cellular and pro-inflammatory antiviral responses. The current standard in hepatitis C treatment consists of combination regimens of pegylated interferon-alpha plus ribavirin. The impact of combined treatment in the host immune response is still poorly understood. In the present study, we profiled 27 cytokines, chemokines and growth factors involved in the innate and adaptive responses to the virus in the serum of 27 hepatitis C virus-infected patients, before and after 12 weeks of combined treatment, and compared them to 10 healthy controls. Hepatitis C virus infection induced not only the secretion of chemokines and cytokines participating in Th1 responses (MIP-1 alpha, IP-10, TNF-alpha, IL-12p70, IL-2), but also cytokines involved in the development of Th17 responses (IL-6, IL-8, IL-9 and IL-17) and two pro-fibrotic factors (FGF-b, VEGF). The most important increases included MIP-1 alpha (4.7-fold increase compared to the control group), TNF-alpha (3.0-fold), FGF-b (3.4-fold), VEGF (3.5-fold), IP-10 (3.6-fold), IL-17 (107.0-fold), IL-9 (7.5-fold), IL-12p70 (7.0-fold), IL-2 (5.6-fold) and IL-7 (5.6-fold). Combined treatment with pegylated interferon-alpha plus ribavirin down-modulated the secretion of key Th1 and Th17 pro-inflammatory mediators, and pro-fibrotic growth factors as early as 12 weeks after treatment initiation. MIP-1 alpha, FGF-b, IL-17 decreased in a more dramatic manner in the group of responder patients than in the group of non-responders (fold-change in cEVR; fold-change in NcEVR): MIP-1 alpha (4.72;1.71), FGF-b (4.54;1.21), IL-17 (107.1;1.8). Correlation studies demonstrated that the decreases in the levels of these mediators were significantly associated with each other, pointing to a coordinated effect of the treatment on their secretion (r coefficient; p value): [ FGF-b versus IL-17 (0.90; 0.00), IL-17 versus VEGF (0.88; 0.00), MIP-1 alpha versus IL-17 (0.84;0.00), FGF-b versus MIP-1 alpha (0.96;0.00), FGF-b versus IL-12p70 (0.90; 0.00), VEGF versus IL-12p70 (0.89; 0.00)]. Th17 immunity has been previously associated with autoimmune diseases and asthma, but this is the first work reporting a role for this profile in viral hepatitis. These results provide an opportunity to evaluate the impact of the treatment with Peg-INF-alpha and RBV on the prevention of immune-driven tissue damage in infected patients.

[Immunity against hepatitis A virus in patients with chronic hepatitis C]. / Inmunidad frente al virus de la hepatitis A en los pacientes con infección crónica por el virus de la hepatitis C.

BACKGROUND AND OBJECTIVE: Because of high fatality rate associated with acute infection by hepatitis A virus (HAV) in chronic hepatitis C patients, it is of interest to know the prevalence of immunization against HAV in these patients. PATIENTS AND METHOD: Immunoglobulin G (IgG) IgG HAV antibodies (IgG anti-HAV) were determined in 313 hepatitis C virus antibodies (anti-HCV) positive patients and in 313 anti-HCV negative subjects (control group). Several epidemiological factors were recorded (age, sex, rural vs urban precedence, tattoos, parenteral drugs use, alcohol consumption and surgery). RESULTS: The prevalence of IgG anti-HAV was identical in both groups: 81.2%. However, in those younger than 41 years, this prevalence was greater in those anti-HCV positive than in the control group. Parenteral drugs use and tattoos were more frequent in the first group. The presence of IgG anti-HAV was associated with age and the rural origin in both groups. CONCLUSIONS: The prevalence of IgG anti-HAV increases with age, and is more frequent in individuals with rural origin. It was also greater in young anti-HCV positive patients, when compared with controls of the same age. This finding can be due to the poor standards of hygiene probably associated with some practices more common in this population, such as parenteral drugs use, tattoos and others.

Octreótida en el sangrado por angiodisplasias intestinales / No disponible

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Acalculous cholecystitis due to Salmonella enteritidis.

Acute acalculous cholecystitis (AAC) is defined as an acute inflammation of the gallbladder in the absence of stones. We herein report a case of a young man who developed AAC after a Salmonella enteritidis gastrointestinal infection.

Inmunidad frente al virus de la hepatitis A en los pacientes con infección crónica por el virus de la hepatitis C / Immunity against hepatitis A virus in patients with chronic hepatitis C

FUNDAMENTO Y OBJETIVO: Debido a la mayor morbimortalidad de la hepatitis aguda por el virus dela hepatitis A (VHA) cuando ocurre en pacientes con infección crónica por el virus de la hepatitisC (VHC), interesa conocer la prevalencia de inmunización frente al VHA en estos pacientes.PACIENTES Y MÉTODO: Se determinaron los anticuerpos de tipo inmunoglobulina G (IgG) frente alVHA (IgG anti-VHA) en 313 pacientes con infección crónica por el VHC (anti-VHC) y en 313 individuosanti-VHC negativo.RESULTADOS: La prevalencia de IgG anti-VHA encontrada fue idéntica en ambos grupos: un81,2%. Sin embargo, entre los menores de 41 años esta prevalencia era mayor en los anti-VHCpositivo que en los individuos del grupo control. La adicción a drogas por vía parenteral y lostatuajes fueron más frecuentes en el primer grupo. La presencia de IgG anti-VHA se asoció conla edad y con la procedencia del medio rural en ambos grupos.CONCLUSIONES: La prevalencia de IgG anti-VHA aumenta con la edad y es más elevada entre losindividuos de procedencia rural. También podría ser mayor entre los pacientes jóvenes anti-VHC positivo, en comparación con los controles de edad similar. Este hallazgo puede deberse alas peores condiciones higiénicas probablemente asociadas con ciertas prácticas más comunesentre estos individuos, como la adicción a drogas por vía parenteral y los tatuajes

BACKGROUND AND OBJECTIVE: Because of high fatality rate associated with acute infection by hepatitisA virus (HAV) in chronic hepatitis C patients, it is of interest to know the prevalence of immunizationagainst HAV in these patients.PATIENTS AND METHOD: Immunoglobulin G (IgG) IgG HAV antibodies (IgG anti-HAV) were determinedin 313 hepatitis C virus antibodies (anti-HCV) positive patients and in 313 anti-HCV negativesubjects (control group). Several epidemiological factors were recorded (age, sex, rural vsurban precedence, tattoos, parenteral drugs use, alcohol consumption and surgery).RESULTS: The prevalence of IgG anti-HAV was identical in both groups: 81.2%. However, in thoseyounger than 41 years, this prevalence was greater in those anti-HCV positive than in thecontrol group. Parenteral drugs use and tattoos were more frequent in the first group. The presenceof IgG anti-HAV was associated with age and the rural origin in both groups.CONCLUSIONS: The prevalence of IgG anti-HAV increases with age, and is more frequent in individualswith rural origin. It was also greater in young anti-HCV positive patients, when comparedwith controls of the same age. This finding can be due to the poor standards of hygiene probablyassociated with some practices more common in this population, such as parenteraldrugs use, tattoos and others

Enfermedad de Crohn esofágica / Esophageal Crohn’s disease

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Terapia endoscópica combinada para el tratamiento de angiodisplasias de colon / Combined endoscopic therapy for the treatment of angiodysplasias of the colon

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[Cytokines and other immunological parameters as markers of distant organ involvement in acute pancreatitis]. / Citocinas y otros parámetros inmunológicos como marcadores de alteración de órganos a distancia en la pancreatitis aguda.

BACKGROUND AND OBJECTIVE: There is a role of immunologic proinflammatory mediators in pathogenesis of distant organ disfunction in acute pancreatitis (AP). The aim is to evaluate the relationship between those mediators and liver, kidney and lung disfunction in patients with AP. PATIENTS AND METHOD: On the day of admission in 34 patients with AP, biochemical parameters of liver function, creatinine and arterial partial pressure of oxygen (PO2) were determined, and cut points were established. Soluble tumor necrosis factor receptor I (sTNFRI), interleukin (IL) 1 receptor antagonist (IL-1Ra), IL-6, soluble IL-6 receptor (sIL-6R), IL-18, and intercellular adhesion molecule-1 (ICAM-1) were determined on days 1, 2, 3 and 7, and were compared between patients with biochemical parameters and PO2 on admission higher or lower than an established cut point. RESULTS: Levels of sTNFRI, IL-18 and ICAM-1 were significantly higher and sustained, and IL-6 only the first day, in patients with parameters of liver function above the cut point. sTNFRI, IL-1Ra and ICAM-1 early showed significantly higher levels in relation with serum creatinine, and these and also IL-6 in those with PO2 below 60 mmHg. CONCLUSIONS: sTNFRI, IL-6, IL-18 and ICAM-1 behaved as early markers of hepatic alteration, sTNFRI, IL-1Ra and ICAM-1 of renal disfunction and these and IL-6 of lung injury.