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The use of the faecal immunochemical test (FIT) to stratify the risk of colorectal cancer (CRC) in symptomatic patients in primary healthcare enables improved referrals to colonoscopy. However, its effect on diagnostic delays or the prognosis of patients has been poorly evaluated in this setting. We performed a retrospective cohort study that included symptomatic patients with outpatient CRC diagnosis between 2009 and 2017. We identified whether FIT had been analysed between initial healthcare contact and diagnostic confirmation. We included 589 patients (male = 65%, 71.7 ± 11.6 years, TNM IV = 17.1%) in the analysis. FIT was performed in 411 (69.8%) patients with a positive result (≥10 µg/g of faeces) in 96.4% of the evaluated patients. The use of FIT was associated with increased diagnostic delay (yes = 159 ± 277 days, no = 111 ± 172 days; p = 0.01). At five years follow up, 193 (32.8%) patients died (151 due to CRC). Mean survival was not modified by the use of FIT or its result (not performed = 46.8 ± 1.5 months, FIT+ = 48.9 ± 1 months, FIT- = 45.6 ± 5.5 months; p = 0.5) in Kaplan-Meier analysis, and was confirmed later in multivariate Cox regression analysis. In conclusion, FIT determination in symptomatic patients in primary healthcare did not modify CRC prognosis.
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Pólipos/complicaciones , Tracto Gastrointestinal/patología , Endoscopía , Adenocarcinoma/patología , Colectomía/métodos , Laparoscopía/métodosRESUMEN
Objetivo: Analizar el efecto de la demora atribuible al sistema sanitario en una cohorte consecutiva de pacientes diagnosticados de forma ambulatoria de cáncer colorrectal (CCR) en el área sanitaria de Ourense. Pacientes y métodos: Estudio observacional de cohortes retrospectivo en el que se incluyeron los pacientes diagnosticados entre 2009 y 2017. Se definió la demora atribuible al sistema sanitario como el tiempo entre la primera consulta por síntomas y la confirmación diagnóstica. Se determinó si existía una relación independiente entre la demora diagnóstica y el CCR estadio IV mediante una regresión logística. Finalmente, realizamos una regresión de riesgos proporcionales para determinar qué variables se asociaban con la mortalidad global y por CCR. Resultados: Se incluyeron 575 pacientes (hombres 64,5%, edad 71,9±11,5 años) con una demora atribuible al sistema sanitario de 115±153 días. Ninguna de las variables analizadas se asoció con el estadio tumoral al diagnóstico. Durante un seguimiento de 30,6±21 meses fallecieron 121 pacientes (79,3% en relación al CCR). Las variables asociadas de forma independiente con la mortalidad atribuible al CCR fueron el estadio IV al diagnóstico (HR 50,65; IC 95% 12,28-209), la edad (HR 1,04; IC 95% 1,02-1,05) y la solicitud de la colonoscopia desde Atención Primaria (HR 0,55; IC 95% 0,37-0,88). Conclusiones: La demora diagnóstica atribuible al sistema sanitario no se relacionó ni con el estadio ni con el pronóstico del CCR. Sin embargo, la solicitud de la colonoscopia desde Atención Primaria se asoció a una reducción en el riesgo de mortalidad
Objectives: To analyse the effect of a delay attributable to the healthcare system on a consecutive cohort of outpatients diagnosed with colorectal cancer in the healthcare area of Ourense (Spain). Patients and methods: We performed a retrospective cohort study that included patients diagnosed between 2009 and 2017. Delay attributable to the healthcare system was defined as the time between the first consultation with symptoms and the diagnostic confirmation. A logistic regression model was performed to evaluate the relationship between stage IV CRC and diagnostic delay. To analyse which variables were associated independently with overall mortality and mortality due to CRC we used a Cox regression model. Results: 575 patients were included (men 64.5%, age 71.9 ± 11.5 years), with a delay attributable to the healthcare system of 115 ± 153 days. None of the variables analysed were associated with tumour stage at diagnosis. With a mean follow-up of 30.6 ± 21 months, 121 patients died (79.3% due to CRC). The variables independently associated with CRC-related mortality were metastatic CRC (HR 50.65, 95% CI 12.28-209), age (HR 1.04, 95% CI 1.02-1.05) and colonoscopy requested from the Primary Healthcare level (HR 0.55, 95% CI 0.36-0.88). Conclusions: Diagnostic delay attributable to the healthcare system is not related to the prognosis or stage of CRC. However, a direct referral to colonoscopy from the Primary Healthcare level reduces the risk of mortality in our patients
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Humanos , Masculino , Femenino , Anciano , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/mortalidad , Diagnóstico Tardío/efectos adversos , Sector de Atención de Salud , Factores de Edad , Colonoscopía/estadística & datos numéricos , Neoplasias Colorrectales/patología , Estudios de Seguimiento , Modelos Logísticos , Pronóstico , Estudios Retrospectivos , Factores de TiempoRESUMEN
OBJECTIVES: To analyse the effect of a delay attributable to the healthcare system on a consecutive cohort of outpatients diagnosed with colorectal cancer in the healthcare area of Ourense (Spain). PATIENTS AND METHODS: We performed a retrospective cohort study that included patients diagnosed between 2009 and 2017. Delay attributable to the healthcare system was defined as the time between the first consultation with symptoms and the diagnostic confirmation. A logistic regression model was performed to evaluate the relationship between stage IV CRC and diagnostic delay. To analyse which variables were associated independently with overall mortality and mortality due to CRC we used a Cox regression model. RESULTS: 575 patients were included (men 64.5%, age 71.9 ± 11.5 years), with a delay attributable to the healthcare system of 115 ± 153 days. None of the variables analysed were associated with tumour stage at diagnosis. With a mean follow-up of 30.6 ± 21 months, 121 patients died (79.3% due to CRC). The variables independently associated with CRC-related mortality were metastatic CRC (HR 50.65, 95% CI 12.28-209), age (HR 1.04, 95% CI 1.02-1.05) and colonoscopy requested from the Primary Healthcare level (HR 0.55, 95% CI 0.36-0.88). CONCLUSIONS: Diagnostic delay attributable to the healthcare system is not related to the prognosis or stage of CRC. However, a direct referral to colonoscopy from the Primary Healthcare level reduces the risk of mortality in our patients.
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Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/mortalidad , Diagnóstico Tardío/efectos adversos , Sector de Atención de Salud , Factores de Edad , Anciano , Colonoscopía/estadística & datos numéricos , Neoplasias Colorrectales/patología , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Pronóstico , Estudios Retrospectivos , Factores de TiempoAsunto(s)
Pólipos Adenomatosos/diagnóstico , Neoplasias del Colon/diagnóstico , Pólipos del Colon/diagnóstico , Endoscopía Gastrointestinal/métodos , Pólipos/diagnóstico , Procedimientos Innecesarios , Adenocarcinoma/prevención & control , Pólipos Adenomatosos/cirugía , Anciano , Anciano de 80 o más Años , Neoplasias del Colon/prevención & control , Neoplasias del Colon/cirugía , Pólipos del Colon/cirugía , Neoplasias Duodenales/diagnóstico , Neoplasias Duodenales/cirugía , Endoscopía Gastrointestinal/educación , Femenino , Humanos , Pólipos Intestinales/diagnóstico , Pólipos Intestinales/cirugía , Masculino , Persona de Mediana Edad , Pólipos/cirugía , Neoplasias del Recto/diagnóstico , Neoplasias del Recto/cirugía , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/cirugía , Grabación en VideoRESUMEN
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Humanos , Neoplasias Colorrectales/epidemiología , Detección Precoz del Cáncer/métodos , Atención Primaria de Salud , Análisis Costo-Eficiencia , Tamizaje Masivo/métodos , Pautas de la Práctica en MedicinaAsunto(s)
Humanos , Linfoma de Células del Manto/complicaciones , Linfoma de Células del Manto/diagnóstico , Linfoma de Células del Manto/cirugía , Enfermedades Intestinales/complicaciones , Enfermedades Intestinales/diagnóstico , Enfermedades Intestinales/cirugía , Linfoma de Células del Manto/tratamiento farmacológico , Linfoma de Células del Manto/fisiopatología , Linfoma de Células del Manto , Enfermedades Intestinales/fisiopatología , Enfermedades IntestinalesRESUMEN
Objetivo Analizar el efecto de la puesta en marcha de una consulta de alta resolución (CAR) y de un programa de aumento de la capacidad resolutiva de atención primaria (PACRAP) en las derivaciones a las consultas de gastroenterología desde atención primaria y en los recursos utilizados. Métodos Estudio observacional retrospectivo basado en la revisión de las hojas de derivación y de las bases de datos de documentación clínica. Se analizaron el número y el motivo de las derivaciones, los tiempos de demora y el consumo de recursos en dos periodos: anterior (primer cuatrimestre de 2007) y posterior (primer cuatrimestre de 2009) a la puesta en marcha de la CAR y el PACRAP. Resultados Se evaluaron 881 derivaciones en el periodo anterior y 1076 en el posterior, y se halló una disminución de los tiempos de demora en el segundo periodo (80,8±64,34 días frente a 36,1±29,12 días, p<0,001). Las causas de derivación más frecuentes fueron dispepsia (27,7%), alto riesgo de cáncer colorrectal (17,1%), alteración del ritmo intestinal (18,2%), dolor (16%) y reflujo gastroesofágico (11,2%), sin diferencias entre ambos periodos. En el segundo periodo, los tiempos de demora fueron menores en las derivaciones a la CAR (primera consulta: 10,8±9,03 días frente a 42,8±28,67 días, p<0,001; alta: 39,6±80,65 días frente a 128,6±135,34 días, p<0,001). Sin embargo, el número de citas (3,6±2,20 frente a 3,2±1,95, p=0,015) y el coste por derivación (592,7±421,50 frente a 486,0±309,66 , p<0,001) fueron más altos. Conclusiones En el periodo estudiado aumentó el número de derivaciones evaluadas con una reducción en la demora. La CAR reduce los tiempos de atención, incrementando los recursos sanitarios utilizados(AU)
Objectives To analyze the effect of implementing a high-resolution clinic (HRC) and an increasing resolution capacity program in primary care (IRCPPC) for referrals to a gastroenterology outpatient clinic from primary care and the resources used. Methods A retrospective and observational study based on a review of referral sheets and databases was performed. We analyzed the number and reason for referrals, delay times and resource consumption in two periods: before (first 4 months of 2007) and after (first 4 months of 2009) the launch of the IRCPPC and HRC. Results In the first and second periods, 881 and 1076 patients, respectively, referred from primary health care were evaluated in the gastroenterology clinic, with a decrease in the delay time in the second period (80.8±64.34 days vs 36.1±29.12 days, p<0.001). The most frequent reasons for referral were dyspepsia (27.7%), high-risk of colorectal cancer (17.1%), disturbance of bowel rhythm (18.2%), abdominal pain (16%), and gastroesophageal reflux (11.2%), with no differences between the two periods. Although delay times until the first visit (10.8±9.03 days vs 42.8±28.67 days, p<0.001) and until discharge (39.6±80.65 days vs 128.6±135.34 days, p<0.001) were lower in referrals to the HRC, the number of visits (3.6±2.20 vs 3.2±1.95, p=0.015) and the cost of referrals (592.7±421.50 vs 486.0±309.66 , p<0.001) was higher. Conclusions In the study period the number of referrals increased, while the delay time decreased. Although the HRC reduces delay times, it is associated with an increase in health resource use(AU)
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Humanos , Derivación y Consulta/estadística & datos numéricos , Enfermedades Gastrointestinales/epidemiología , Atención Primaria de Salud/estadística & datos numéricos , Asignación de Recursos para la Atención de Salud/estadística & datos numéricos , Pautas de la Práctica en Medicina , Endoscopía GastrointestinalRESUMEN
OBJECTIVES: To analyze the effect of implementing a high-resolution clinic (HRC) and an increasing resolution capacity program in primary care (IRCPPC) for referrals to a gastroenterology outpatient clinic from primary care and the resources used. METHODS: A retrospective and observational study based on a review of referral sheets and databases was performed. We analyzed the number and reason for referrals, delay times and resource consumption in two periods: before (first 4 months of 2007) and after (first 4 months of 2009) the launch of the IRCPPC and HRC. RESULTS: In the first and second periods, 881 and 1076 patients, respectively, referred from primary health care were evaluated in the gastroenterology clinic, with a decrease in the delay time in the second period (80.8 ± 64.34 days vs 36.1 ± 29.12 days, p < 0.001). The most frequent reasons for referral were dyspepsia (27.7%), high-risk of colorectal cancer (17.1%), disturbance of bowel rhythm (18.2%), abdominal pain (16%), and gastroesophageal reflux (11.2%), with no differences between the two periods. Although delay times until the first visit (10.8 ± 9.03 days vs 42.8 ± 28.67 days, p < 0.001) and until discharge (39.6 ± 80.65 days vs 128.6 ± 135.34 days, p < 0.001) were lower in referrals to the HRC, the number of visits (3.6 ± 2.20 vs 3.2 ± 1.95, p = 0.015) and the cost of referrals (592.7 ± 421.50 vs 486.0 ± 309.66 , p < 0.001) was higher. CONCLUSIONS: In the study period the number of referrals increased, while the delay time decreased. Although the HRC reduces delay times, it is associated with an increase in health resource use.
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Gastroenterología/organización & administración , Servicio Ambulatorio en Hospital/organización & administración , Atención Primaria de Salud/organización & administración , Derivación y Consulta/organización & administración , Adulto , Anciano , Atención Ambulatoria/economía , Atención Ambulatoria/organización & administración , Atención Ambulatoria/estadística & datos numéricos , Bases de Datos Factuales , Grupos Diagnósticos Relacionados , Técnicas de Diagnóstico del Sistema Digestivo/economía , Técnicas de Diagnóstico del Sistema Digestivo/estadística & datos numéricos , Endoscopía Gastrointestinal/economía , Endoscopía Gastrointestinal/estadística & datos numéricos , Femenino , Adhesión a Directriz , Recursos en Salud/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Servicio Ambulatorio en Hospital/economía , Servicio Ambulatorio en Hospital/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Evaluación de Programas y Proyectos de Salud , Derivación y Consulta/economía , Derivación y Consulta/estadística & datos numéricos , Estudios Retrospectivos , España , Factores de TiempoRESUMEN
INTRODUCTION: Within a program to improve referrals by primary care (PC) in Ourense (Spain), we implemented practice guidelines on dyspepsia and rectal bleeding. Our aim was to evaluate the reasons for referral to endoscopy, the appropriateness of these referrals, and wait times. MATERIAL AND METHODS: We performed a retrospective cohort study in the Ourense health area between February 2009 and January 2010. The endoscopies performed with the indications of dyspepsia and rectal bleeding requested directly from PC were compared with those referred initially to specialist care (SC). The reasons for the referral, the priority of the endoscopy, compliance with the protocol, endoscopic finding and the wait time from referral were gathered. RESULTS: During the period analyzed, 158 upper gastrointestinal endoscopies (SC: 121; PC: 37) and 243 colonoscopies (SC: 193; PC: 50) were performed with the indications of dyspepsia and rectal bleeding. Among endoscopies, 34.5% and 77.7% were requested with high priority from PC and SC, respectively (p<0.001). The criteria for referral were met in 86.5% of upper gastrointestinal endoscopies and in 82% of colonoscopies requested from PC. No differences were found in endoscopic findings. The median wait time from referral was lower in upper gastrointestinal endoscopy (PC: 105±5.5 days, SC: 174±17.8 days; p: 0.003) and colonoscopies (PC: 101±11.8 days, SC: 187±9.6 days; p<0.001) referred from PC. CONCLUSIONS: The use of the program for improved referrals by PC reduces wait times. The examinations requested complied with the indications.
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Endoscopía Gastrointestinal/estadística & datos numéricos , Gastroenterología/organización & administración , Implementación de Plan de Salud , Atención Primaria de Salud/organización & administración , Derivación y Consulta/organización & administración , Adulto , Anciano , Protocolos Clínicos , Estudios de Cohortes , Colonoscopía/estadística & datos numéricos , Dispepsia/diagnóstico , Femenino , Hemorragia Gastrointestinal/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Recto , Derivación y Consulta/estadística & datos numéricos , Regionalización , Estudios Retrospectivos , España , Listas de EsperaRESUMEN
IntroducciónDentro del programa de aumento de capacidad resolutiva de atención primaria (AP) en Ourense se han implementado las guías de práctica clínica en dispepsia y rectorragia. Nuestro objetivo es evaluar los motivos de solicitud de las exploraciones, el nivel de adecuación de las solicitudes, los hallazgos endoscópicos y los tiempos de demora.Material y métodosEstudio de cohortes retrospectivo en el área sanitaria de Ourense entre febrero de 2009 y enero de 2010. Se analizaron las endoscopias realizadas con las indicaciones de dispepsia y rectorragia solicitadas directamente desde AP frente a las derivadas inicialmente a atención especializada (AE). Se recogieron los motivos de solicitud, el nivel de prioridad, la adecuación al protocolo, los hallazgos endoscópicos y los tiempos de demora desde la derivación.ResultadosEn el periodo analizado, se realizaron 158 endoscopias digestivas altas (EDA) (AE 121, AP 37) y 243 colonoscopias (AE 193, AP 50). Se solicitaron de forma preferente el 34,5% de las endoscopias de AP y el 77,7% de AE (p<0,001). El 86,5% de las EDA y el 82% de las colonoscopias solicitadas desde AP cumplieron los criterios de derivación. No se encontraron diferencias en los hallazgos. La mediana del tiempo de demora desde la derivación fue inferior tanto en la EDA (AP: 105±5,5 días; AE: 174±17,8 días; p: 0,003) como en la colonoscopia (AP: 101±11,8 días; AE: 187±9,6 días; p<0,001) solicitada desde AP.ConclusionesLa utilización del programa de aumento de capacidad resolutiva reduce los tiempos de demora. Las exploraciones solicitadas se han adecuado a las indicaciones (AU)
Introduction: Within a program to improve referrals by primary care (PC) in Ourense (Spain),we implemented practice guidelines on dyspepsia and rectal bleeding. Our aim was to evaluatethe reasons for referral to endoscopy, the appropriateness of these referrals, and wait times.Material and methods: We performed a retrospective cohort study in the Ourense health areabetween February 2009 and January 2010. The endoscopies performed with the indications ofdyspepsia and rectal bleeding requested directly from PC were compared with those referredinitially to specialist care (SC). The reasons for the referral, the priority of the endoscopy,compliance with the protocol, endoscopic finding and the wait time from referral were gathered.Results: During the period analyzed, 158 upper gastrointestinal endoscopies (SC: 121; PC: 37)and 243 colonoscopies (SC: 193; PC: 50) were performed with the indications of dyspepsiaand rectal bleeding. Among endoscopies, 34.5% and 77.7% were requested with high priorityfrom PC and SC, respectively (p < 0.001). The criteria for referral were met in 86.5% of uppergastrointestinal endoscopies and in 82% of colonoscopies requested from PC. No differenceswere found in endoscopic findings. The median wait time from referral was lower in uppergastrointestinal endoscopy (PC: 105±5.5 days, SC: 174±17.8 days; p: 0.003) and colonoscopies(PC: 101±11.8 days, SC: 187±9.6 days; p < 0.001) referred from PC.Conclusions: The use of the program for improved referrals by PC reduces wait times. Theexaminations requested complied with the indications (AU)
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Humanos , Refuerzo Biomédico/métodos , Implementación de Plan de Salud/métodos , Endoscopía del Sistema Digestivo/estadística & datos numéricos , Hemorragia Gastrointestinal/diagnóstico , Dispepsia/diagnóstico , Atención Primaria de Salud/tendencias , Guías de Práctica Clínica como Asunto , Listas de Espera , Estudios RetrospectivosRESUMEN
AIM: To ascertain the role of cardiovascular risk factors, cardiovascular diseases, standard treatments and other diseases in the development of ischemic colitis (IC). METHODS: A retrospective, case-control study was designed, using matched data and covering 161 incident cases of IC who required admission to our hospital from 1998 through 2003. IC was diagnosed on the basis of endoscopic findings and diagnostic or compatible histology. Controls were randomly chosen from a cohort of patients who were admitted in the same period and required a colonoscopy, excluding those with diagnosis of colitis. Cases were matched with controls (ratio 1:2), by age and sex. A conditional logistic regression was performed. RESULTS: A total of 483 patients (161 cases, 322 controls) were included; mean age 75.67 ± 10.03 years, 55.9% women. The principal indications for colonoscopy in the control group were lower gastrointestinal hemorrhage (35.4%), anemia (33.9%), abdominal pain (19.9%) and diarrhea (9.6%). The endoscopic findings in this group were hemorrhoids (25.5%), diverticular disease (30.4%), polyps (19.9%) and colorectal cancer (10.2%). The following variables were associated with IC in the univariate analysis: arterial hypertension (P = 0.033); dyslipidemia (P < 0.001); diabetes mellitus (P = 0.025); peripheral arterial disease (P = 0.004); heart failure (P = 0.026); treatment with hypotensive drugs (P = 0.023); angiotensin-converting enzyme inhibitors; (P = 0.018); calcium channel antagonists (P = 0.028); and acetylsalicylic acid (ASA) (P < 0.001). Finally, the following variables were independently associated with the development of IC: diabetes mellitus [odds ratio (OR) 1.76, 95% confidence interval (CI): 1.001-3.077, P = 0.046]; dyslipidemia (OR 2.12, 95% CI: 1.26-3.57, P = 0.004); heart failure (OR 3.17, 95% CI: 1.31-7.68, P = 0.01); peripheral arterial disease (OR 4.1, 95% CI: 1.32-12.72, P = 0.015); treatment with digoxin (digitalis) (OR 0.27, 95% CI: 0.084-0.857, P = 0.026); and ASA (OR 1.97, 95% CI: 1.16-3.36, P = 0.012). CONCLUSION: The development of an episode of IC was independently associated with diabetes, dyslipidemia, presence of heart failure, peripheral arterial disease and treatment with digoxin or ASA.
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Enfermedades Cardiovasculares/complicaciones , Colitis Isquémica , Diabetes Mellitus Tipo 2/complicaciones , Hipertensión/complicaciones , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Colitis Isquémica/etiología , Colitis Isquémica/patología , Colitis Isquémica/fisiopatología , Femenino , Humanos , Curva ROC , Estudios Retrospectivos , Factores de RiesgoRESUMEN
La pancreatitis aguda (PA) se asocia con una frecuencia variable al desarrollo de complicaciones locales: colecciones, necrosis, seudoquistes y abscesos abdominales. Aunque el desarrollo de abscesos hepáticos se ha relacionado con la obstrucción de la vía biliar o cirugía abdominal en pacientes con pancreatitis crónica, son escasas las descripciones de abscesos hepáticos asociados a un episodio de PA. A continuación se presenta el caso de un varón de 45 años con un primer episodio de PA grave de etiología alcohólica, complicada con trombosis de la rama portal derecha, absceso intrahepático y fístula biliar, así como el abordaje y el tratamiento realizados (AU)
Acute pancreatitis is frequently associated with the development of local complications: collections, necrosis, pseudocysts and abdominal abscesses. Although the development of liver abscesses has been linked to bile duct obstruction or abdominal surgery in patients with chronic pancreatitis, there are few descriptions of liver abscesses associated with an episode of acute pancreatitis. We report the case of a 45-year-old man with a first episode of severe acute alcoholic pancreatitis, complicated with thrombosis of the right portal branch, liver abscess and intrahepatic biliary fistula. The approach and treatment are described (AU)
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Humanos , Masculino , Persona de Mediana Edad , Absceso Hepático/complicaciones , Fístula Biliar/complicaciones , Pancreatitis Aguda Necrotizante/complicaciones , Trombosis de la Vena/complicaciones , Vena PortaRESUMEN
Acute pancreatitis is frequently associated with the development of local complications: collections, necrosis, pseudocysts and abdominal abscesses. Although the development of liver abscesses has been linked to bile duct obstruction or abdominal surgery in patients with chronic pancreatitis, there are few descriptions of liver abscesses associated with an episode of acute pancreatitis. We report the case of a 45-year-old man with a first episode of severe acute alcoholic pancreatitis, complicated with thrombosis of the right portal branch, liver abscess and intrahepatic biliary fistula. The approach and treatment are described.