Metástasis a duodeno de cáncer renal de células claras con patrón sarcomatoide: reporte de caso / Duodenal metastases from sarcomatoid renal cell carcinoma: Case report

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Use and overuse of proton pump inhibitors in cirrhotic patients.

BACKGROUND: There are several indications for the use of proton pump inhibitors (PPIs) but little evidence to support their use in patients with chronic liver disease. Moreover, the pattern of clinical use is unknown. The aim of the present study was to analyze the use of PPIs in patients with chronic liver disease in an ambulatory setting. MATERIAL/METHODS: This was a retrospective study in a clinical setting. Clinical variables, severity indexes, and endoscopic findings were assessed. Management of PPIs was classified according to proven indication as: G1, proven indication and a prescription; G2, no proven indication and prescription; G3, proven indication and no prescription; and G4, no proven indication and no prescription. G1+G4 were considered proper use of PPIs. The classification was used to identify variables associated with proper use. RESULTS: The study included 243 patients (mean age: 55.82+/-12.9 years). The most common etiologies of chronic liver disease were hepatitis C virus infection and chronic alcoholic liver disease. PPIs were indicated in 46.1% patients. Multivariate analysis showed that a MELD score < or =8 points (OR: 2.6, 95% CI: 1.3-5.3), esophageal varices (OR: 0.38, 95% CI: 0.16-0.90), and previous in-hospital use of PPIs (OR: 0.78, 95% CI: 0.6-0.9) were associated with G1+G4. CONCLUSIONS: Clinical use of PPIs in chronic liver disease was inappropriate in nearly one half of all patients. A less severe disease was associated with proper use and previous in-hospital use was associated with inappropriate use. Future research into the clinical use of PPIs in cirrhotic patients is mandatory.

Microscopic colitides: a single center experience in Mexico.

BACKGROUND/AIM: Microscopic colitis is characterized by chronic diarrhea and specific microscopic changes in a macroscopically normal colonic mucosa. In this paper, we report the clinical and histological features of a group of Mexican patients with microscopic colitis. MATERIALS AND METHODS: Patients were identified from 10 years of data in the pathology database of our institution. A pathologist reassessed all biopsy material. We included only patients who met strict histopathological criteria. Clinical data were obtained from medical records. RESULTS: Microscopic colitis was diagnosed in 26 cases. The female/male ratio was 1.8:1. The median age at diagnosis was 56.5 +/- 15.7 (range, 26-85) years. The most frequent symptoms were diarrhea in all, weight loss in 22 (84%), and abdominal pain in 18 (69%) patients. Sixteen (61%) patients reported associated diseases; autoimmune thyroid disorders were the most common. Drug-induced microscopic colitis was suspected in 12 (46%) patients. More than 80% of the treated patients improved or had clinical remission. CONCLUSION: Microscopic colitis is an uncommon colonic disease at our institution, representing less than 1% of the final diagnoses in mucosal colonic biopsies. It is the largest case series of microscopic colitis in the Mexican population.

Response of negative estrogen-receptor hepatocarcinoma to tamoxifen, and survival of non-resectable patients.

Hepatocellular carcinoma is the fifth most common malignant neoplasm worldwide. Most patients are not candidates to surgical treatment. The prognosis of this neoplasm is poor, with an overall survival rate of 8 weeks in unresectable tumors. Estrogen receptors have been found in up to 33% of this tumors, reason why treatment with tamoxifen or progesterone compounds have been tried to diminish this neoplasm's progression but its use remains controversial. In our institution, thirteen patients were treated with tamoxifen (20- 40 mg/day) and 26 received supportive measures only. The clinical and tumoral characteristics were similar in both groups. Survival in the Tamoxifen group was of 5.5 +/- 1.7 months while in the supportive measures group was of 2.1 +/- 0.5 months (p = 0.018). Other factors related to an increased survival were: female gender and the Okuda score; age, TNM and alphaFP were not related to survival. The multivariate analysis showed that treatment with tamoxifen duplicates survival independently of the tumoral stage and functional hepatic reserve. It seems that the benefit of treatment with tamoxifen is limited and is not associated to the presence of estrogen receptors. In our study a 69 year-old man with diagnosis of non-resectable hepatocellular carcinoma and negative estrogen receptors, was treated with tamoxifen with a partial response and an overall survival of 4 years until November 2005. Despite some case reports that have shown tumoral regression, while other studies do not report any survival benefits. It is important to identify patients that would benefit from treatment with tamoxifen.

Hepatoblastoma in adult age. A case report and literature review.

Hepatoblastoma (HB) rarely occurs in adults. We report herein the unusual case of a 19-year-old, otherwise healthy woman with no history of liver disease who presented with upper abdominal pain and hepatomegaly. Tests for hepatitis B virus (HBV), hepatitis C virus (HCV) were negative, and AFP was normal. There was no evidence of liver cirrhosis. A welldemarcated solid mass of 14 cm in diameter, which was lobulated and partly necrotic, was detected in the liver by computed tomography (CT). At surgical exploration a large liver mass was detected occupying the entire right lobe. A right trisegmentectomy was performed with tumor grossly resected with microscopic residual disease (i.e positive margins). On microscopic examination the tumor was composed mainly of two components which were intermingled: epithelial and mesenchymal elements. The epithelial component was formed of small embryonal cells, grouped into nodules, scattered in cellular mesenchymal tissue. The diagnosis was mixed hepatoblastoma. The patient received 4 cycles of systemic chemotherapy with cisplatinum and adriamycin. Post-chemotherapy evaluation revealed recurrence of the hepatoblastoma in the remaining liver. She died 6 months later.

Clinical and pathologic factors associated with survival in young adult patients with fibrolamellar hepatocarcinoma.

BACKGROUND: Fibrolamellar Carcinoma (FLC), a subtype of hepatocellular carcinoma (HCC), is a rare primary hepatic malignancy. Several aspects of the clinic features and epidemiology of FLC remain unclear because most of the literature on FLC consists of case reports and small cases series with limited information on factors that affect survival. METHODS: We did a retrospective analysis of the clinical and histological characteristics of FLC. We also determined the rate of cellular proliferation in biopsies of these tumors. We assessed whether these variables were associated with survival. RESULTS: We found 15 patients with FLC out of 174 patients with HCC (8.6%). Between patients with these neoplasms, we found statistically significant survival, age at onset, level of alpha fetoprotein, and an earlier stage of the disease. The 1, 3 and 5 year survival in patients with FLC was of 66, 40 and 26% respectively. The factors associated with a higher survival in patients with FLC were age more than 23 years, feasibility of surgical resection, free surgical borders, absence of thrombosis or invasion to hepatic vessels and the absence of alterations in liver enzymes. The size of the tumor, gender, cellular proliferation and atypia did not affect the prognosis. CONCLUSION: We concluded that FLC patients diagnosed before 23 years of age have worse prognosis than those diagnosed after age 23. Other factors associated with worse prognosis in this study are: lack of surgical treatment, presence of positive surgical margins, vascular invasion, and altered hepatic enzymes.

Electrocardiographic abnormalities in patients with acute pancreatitis.

BACKGROUND: Electrocardiographic abnormalities may be associated with acute pancreatitis (AP). GOALS: To describe the electrocardiographic disturbances present in patients with AP and to assess differences in electrolyte and pancreatic enzyme levels among patients with and without these abnormalities. STUDY: Fifty-one consecutive patients with AP and without preexisting heart disease underwent a standard 12-lead electrocardiogram (EKG) and a serum electrolyte profile. EKG abnormalities were summarized in terms of frequencies, means, and standard deviations. Electrolyte and enzyme levels were summarized as medians. Differences were analyzed using the Mann-Whitney U test. RESULTS: Twenty-eight patients (55%) had an abnormal EKG. Nonspecific changes of repolarization (20%), sinus tachycardia (12%), and left anterior hemiblock (10%) were the most frequent disturbances. Patients with sinus tachycardia had lower levels of phosphorus (2.3 vs. 3.4 mEq/L, P < 0.004) and calcium (8.4 vs. 9.1 mg/dL, P < 0.02). A tendency to higher levels of potassium and lower levels of phosphorus was found in patients with sinus tachycardia and nonspecific changes of repolarization, respectively. No differences were found in amylase, pancreatic amylase, or lipase among patients with normal and abnormal EKG. CONCLUSIONS: More than 50% of the patients with AP had EKG abnormalities, and these changes could be related to electrolyte alterations.

[Antibodies and physiopathogeny of autoimmune hepatitis]. / Anticuerpos y fisiopatogenia de la hepatitis autoinmune.

Autoimmune hepatitis (AIH) is an inflammatory disease of unknown cause characterized by periportal hepatitis, increased serum globulins and the presence of certain antibodies. The disorder can be classified in three types. Type 1 AIH is characterized by the presence of antinuclear antibodies (ANA) and smooth muscle autoantibodies (SMA) in up to 70-80% of patients. ANA and SMA can be the only antibodies present in 13 and 33% of cases respectively. Type 2 AIH is defined by the presence of liver and kidney antimicrosomal antibodies (LKM1). Type 2 AIH is the only form of the disease in which the autoantigen has been identified: cytochrome mono-oxygenase (P-450 IID6) CYP2D6. In type 3 AIH the presence of anti-SLA/LP (soluble liver antigen/liver pancreas) targets a cytosolic protein involved in the incorporation of selenocysteine into peptidic chains. The pathophysiology of AIH is complex and involves genetic predisposition, previous exposure to antigens (autoantigens), presence of triggering factors and defects in immunoregulation. In spite of the advances in the understanding of AIH, the role of autoantibodies in the pathophysiology of this disease has not been fully established and their presence does not clearly distinguish any prognostic groups. Further investigations will help in the diagnosis of this disorder, the comprehension of its origins and the establishment of new forms of treatment.