Long-term remission with rituximab in a patient with severe hepatitis C virus-induced mixed cryoglobulinemia.

Mixed cryoglobulinemia (MC) is a small-vessel systemic vasculitis characterized by the presence of cryoglobulins, immunoglobulin complexes that precipitate at low temperatures ( < 37 ºC) inducing the inflammatory process. The most frequent etiology is hepatitis C infection (HCV) (1). Rituximab (RTX), an anti-CD20 monoclonal antibody, has recently emerged as the treatment of choice for severe MC (2). We present a case of severe hepatitis C virus-induced MC that was controlled and maintained in remission with RTX for 26 months, a remarkable prolonged period of time.

Remisión a largo plazo con rituximab en paciente con crioglobulinemia grave asociada al virus de la hepatitis C / Long-term remission with rituximab in a patient with severe hepatitis C virus-induced mixed cryoglubulinemia

La crioglobulinemia (CG) es una vasculitis sistémica de pequeño vaso caracterizada por la presencia de crioglobulinas, las cuales son inmunocomplejos circulantes que, a bajas temperaturas (< 37 °C), precipitan desencadenando el proceso inflamatorio. La etiología más frecuente es la infección por el virus de la hepatitis C (VHC) (1). En los últimos años el anticuerpo monoclonal anti-CD20 rituximab (RTX) se ha ido posicionando como el tratamiento de primera línea en las CG de presentación agresiva (2). Presentamos el caso de una paciente con brote grave de una CG asociada al VHC que respondió al tratamiento con RTX, manteniéndose posteriormente en remisión de manera inusualmente prolongada durante 26 meses (AU)

Mixed cryoglobulinemia (MC) is a small-vessel systemic vasculitis characterized by the presence of cryoglobulins, immunoglobulin complexes that precipitate at low temperatures (< 37 °C) inducing the inflammatory process. The most frequent etiology is hepatitis C infection (HCV) (1). Rituximab (RTX), an anti-CD20 monoclonal antibody, has recently emerged as the treatment of choice for severe MC (2). We present a case of severe hepatitis C virus-induced MC that was controlled and maintained in remission with RTX for 26 months, a remarkable prolonged period of time (AU)

Esofagitis aguda necrosante asociada a coma diabético hiperosmolar / Acute necrotizing esophagitis associated with hyperglycemic hyperosmolar ketotic coma

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Gastrostomía endoscópica percutánea: nuestra experiencia / Percutaneous endoscopic gastrostomy: our experience

Fundamento y objetivo: En pacientes con disfagia, la gastrostomía endoscópica percutánea (GEP) es superior a la sonda nasogástrica en cuanto a una mayor recuperación de peso y masa corporal. Por su utilidad, seguridad, bajo coste y fácil mantenimiento es, en estos momentos, de elección en pacientes con problemas de deglución. Pacientes y método: Se incluyó a 77 pacientes en este estudio, a quienes se administró profilaxis antibiótica previamente al procedimiento. Las indicaciones para la colocación de la GEP fueron: enfermedad neurológica (46%), neoplasias de cabeza y cuello (26%) y un tercer grupo de miscelánea (29%). Resultados: En el seguimiento posterior a la colocación de la GEP se detectó la aparición de complicaciones mayores en el 1,3% de los pacientes, y en el 18,18% de ellos aparecieron complicaciones menores; la infección del estoma representó el 15%. Conclusiones: La gastrostomía endoscópica percutánea es el método de elección para facilitar una nutrición enteral prolongada (AU)

Background and objective: In patients with dysphagia, percutaneous endoscopic gastrostomy (PEG) is more effective in increasing body weight and mass than the nasogastric tube. Because of its safety, efficacy, low cost and easy maintenance, PEG is currently the method of choice in patients with difficulties in swallowing. Patients and method: Seventy-seven patients were included in this study. Antibiotic prophylaxis was administered prior to the procedure. The indications for PEG were neurological disorders in 46%, neoplasms located in the oropharynx, neck or esophagus in 26%, and miscellaneous in 29%. Results: Major complications were detected in 1.3% of the patients and minor complications in 18.18%. The rate of wound infection was 15%. Conclusions: PEG is the method of choice to achieve long-term enteral nutrition (AU)

Manometric findings in adult eosinophilic oesophagitis: a study of 12 cases.

OBJECTIVE: To describe the manometric findings detected in adult patients with dysphagia that were diagnosed of eosinophilic oesophagitis, and to compare with the cases of eosinophilic infiltration of the oesophagus reported in the literature. PATIENTS AND METHODS: We present 12 adult patients diagnosed as suffering from this disorder in our department in a 1.5-year period, according to histological criteria and discarding any other cause of eosinophilic infiltration of the oesophagus. Stationary oesophageal manometry using a hydropneumocapillary perfusion system was performed in every case. The recommendations of the Spanish Group of Digestive Motility were followed for the interpretation of the results. In seven patients who presented motor disorder in manometric evaluation, treatment with steroid oesophageal lavage using fluticasone propionate was carried out and these patients were subsequently re-evaluated. RESULTS: All patients were young predominantly men, and the first endoscopic examination showed regular concentric stenosis or a 'ring oesophagus'. Six patients had a severe nonspecific oesophageal motor disorder characterized by up to 80% of nontransmitted or very low-amplitude waves in the lower two-thirds of the organ. Three patients presented a manometric disturbance characterized by hyperkinetic peristaltic waves in distal oesophageal third. One patient had an alteration of the oesophageal motor dynamics characterized by 80% of deglutory complexes formed by a primary simultaneous wave in the two lower oesophageal thirds followed by a secondary peristaltic wave in 50% of cases that had a normal duration and amplitude. The remaining two patients had normal oesophageal motility. The upper oesophageal sphincter showed no alterations, and the manometric evaluation of the lower oesophageal sphincter tone proved normal in 10 patients, with slight hypotension in two cases. In seven of the nine patients who presented an oesophageal motor disorder, treatment with steroid oesophageal lavage using fluticasone propionate was administered and a new oesophageal manometry was performed afterwards, in which the motor disorder was clearly improved as soon as dysphagia, endoscopic lesions and histopathologic alteration disappeared. DISCUSSION: In the literature, 61 cases of eosinophilic infiltration of the oesophageal mucosa subjected to oesophageal manometric study had been described, and 60.6% of them showed evidence of different types of manometric alterations, mainly with spastic or hypercontractility characteristics. Although six of our cases showed very deficient peristalsis with very low-amplitude or nontransmitted waves, and in another three high-amplitude peristaltic waves were recorded. Motor disorders improved parallel to the disappearance of the eosinophilic infiltration of the mucosa. These data suggest that motor disorders in eosinophilic oesophagitis are a consequence of eosinophil infiltration of the oesophagus and should be considered in the differential diagnosis of dysphagia. These manometric alterations could be considered as primary nonspecific disorders and included in the 'ineffective oesophageal motility' group.

Food allergies and eosinophilic esophagitis--two case studies.

Eosinophilic esophagitis (EE) is a clinical-pathological disorder which is being increasingly diagnosed. It is etiologically associated with hypersensitivity to airborne allergens and/or dietary components. However, immediate hypersensitivity to foods has rarely been proven as the etiologic cause of the disorder. Two patients are presented with a history of rhinoconjunctivitis, allergic asthma, atopic dermatitis and food allergies which are currently under control and who show specific IgE to pulses and chicken respectively. These patients developed acute dysphagia and vomiting immediately after ingesting these foods and following appropriate examination were diagnosed as suffering from EE. The study also showed signs of blood hypereosinophilia while the esophageal manometry revealed a motor disorder characterized by aperistalsis and non-propulsive simultaneous waves affecting the lower two-thirds of the organ composed of smooth muscle. Topical treatment with fluticasone propionate was administered over a period of 3 months, in addition to a diet abstaining from the aforementioned foods and this led to remission of dysphagia and normalization of the endoscopic, histological and manometric studies of the esophagus. This situation remained stable for a considerable length of time after steroid treatment was discontinued, which showed that exposure to foods seemed to be the cause of the esophageal disorder. Similarly, allergies to inhalants and other digestive symptoms which appear upon immediate ingestion of the foods involved would not justify the sudden onset of dysphagia. We offer a pathophysiological explanation for the mechanisms of the disease based on the activation of eosinophils and mast cells by IgE and their ability to disturb the dynamic behavior of the neural and muscle components of the esophageal wall.

Radiofrequency ablation for hepatocellular carcinoma and liver metastases: experience in Hospital La Paz.

INTRODUCTION: Radiofrequency ablation for patients presenting with non-resectable primary or metastatic liver tumours seems to be a valid therapeutic alternative. In the present study, we show a descriptive list of indications, results and complications of Radiofrequency Ablation Technique for treating non-resectable solid hepatic tumours. MATERIALS AND METHODS: Twenty two patients were included in this study; eleven of them (50%) sustained liver metastases from colorectal adenocarcinoma, ten patients (45.5%) had hepatocellular carcinoma and 1 patient had insulinoma. RESULTS: Local recurrence rate of hepatocellular carcinoma was 22.7% and 27.3% for colorectal carcinoma, after a respective median follow-up of 21 and 14 months. Complications rate was 6.9% and technique-associated mortality rate was 0%. CONCLUSIONS: Radiofrequency ablation is an easy to make, safe and useful technique for the treatment of primary and metastatic liver tumours.

[Secondary prophylaxis with elastic band ligation in esophageal-gastric varices]. / Profilaxis secundaria mediante ligadura con bandas elásticas en varices esofagogástricas.

The aim of the present study was to determine the usefulness of elastic band ligation in the prevention of hemorrhage recurrence due to esophageal-gastric varices. Sixty-five patients who survived an episode of variceal hemorrhage were included in the study. Twenty-nine patients (45%) were Child-Pugh class A, 25 (38%) were class B, and 11 (17%) were class C. The cause of cirrhosis was hepatitis C virus and alcohol in 45% and 31% of the patients, respectively. The first ligation session was performed between the third and fifth day after the hemorrhagic episode and subsequent sessions were carried out at intervals of 3-4 weeks. The ligation sessions were performed with antibiotic prophylaxis. A mean of 2.7 bands were placed per session (range 1-5), and the mean number of sessions required per patient to achieve variceal eradication was 2.5 (range 1-6). The rate of bleeding recurrence was 24.6% (16 episodes). In conclusion, endoscopic elastic band ligation is a useful technique for the eradication of esophageal varices and for the prevention of bleeding recurrence.

Profilaxis secundaria mediante ligadura con bandas elásticas en varices esofagogástricas / Secondary prophylaxis with elastic band ligation in esophageal-gastric varices

El objetivo del presente estudio fue determinar la utilidad de la ligadura con bandas elásticas en la prevención de la recidiva hemorrágica por varices esofagogástricas. Se incluyó a 65 pacientes que sobrevivieron a un episodio hemorrágico por varices. Veintinueve (45%) eran Child A, 25 (38%) B y 11 (17%) C; el virus C y el alcohol fueron la etiología de la cirrosis en el 45 y el 31% de los casos, respectivamente. La primera sesión de ligadura se realizó entre el tercer y el quinto día después del episodio hemorrágico, y las sesiones posteriores a intervalos de 3-4 semanas. Las sesiones de ligadura se realizaron con profilaxis antibiótica. Se aplicó una media de 2,7 bandas por sesión (rango, 1-5), y la media de sesiones por paciente hasta erradicar las varices fue de 2,5 (rango, 1-6). La tasa de recidiva hemorrágica fue del 24,6% (16 episodios). En conclusión, la ligadura endoscópica con bandas elásticas es una técnica útil para la erradicación de varices esofágicas y en la prevención de recidiva hemorrágica

The aim of the present study was to determine the usefulness of elastic band ligation in the prevention of hemorrhage recurrence due to esophageal-gastric varices. Sixty-five patients who survived an episode of variceal hemorrhage were included in the study. Twenty-nine patients (45%) were Child­Pugh class A, 25 (38%) were class B, and 11 (17%) were class C. The cause of cirrhosis was hepatitis C virus and alcohol in 45% and 31% of the patients, respectively. The first ligation session was performed between the third and fifth day after the hemorrhagic episode and subsequent sessions were carried out at intervals of 3-4 weeks. The ligation sessions were performed with antibiotic prophylaxis. A mean of 2.7 bands were placed per session (range 1-5), and the mean number of sessions required per patient to achieve variceal eradication was 2.5 (range 1-6). The rate of bleeding recurrence was 24.6% (16 episodes). In conclusion, endoscopic elastic band ligation is a useful technique for the eradication of esophageal varices and for the prevention of bleeding recurrence