Acute necrotizing pancreatitis and severe hepatic failure: description of three cases.

INTRODUCTION: Acute pancreatitis is not uncommon in fulminant hepatic failure (FHF) as confirmed by histology or serology. A few reports exist of symptomatic pancreatitis in the setting of acute viral hepatitis; the diagnosis is usually made intraoperatively or postmortem. We report three cases of liver transplant (OLT) recipients with severe acute liver failure and severe acute pancreatitis as an intraoperative finding. METHODS: We undertook a retrospective review among a large cohort of liver transplant recipients to define the impact of this problem. RESULTS: Between 1999 and 2007, 293. LTs were performed including 15 (5%) who had severe acute liver failure (nine with FHF and six with an emergency retransplantation [ER]). Among this group, three patients were diagnosed intraoperatively with acute necrotizing pancreatitis (ANP): two patients with associated FHF and one with an ER due to ABO incompatibility. None of the patients had symptoms of pancreatitis. In all, ANP was classified as Balthazar CT grade D-E, which determined the outcome. All the patients developed a pseudocyst and abscess, which required surgical drains. CONCLUSION: ANP was diagnosed as an intraoperative finding in patients with FHF. The mechanism of pancreatitis in patients with FHF is unknown. It may be multifactorial (virus, acute liver failure, hypotension, infection, drug-induced lesion,). This association leads to a worse outcome due to the complications.

Historia natural / Natural history

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[The diagnostic performance of echography and CT in pancreatic diseases producing extrahepatic cholestasis]. / Rendimiento diagnóstico de la ecografía y TC en las enfermedades del páncreas productoras de colestasis extrahepática.

A hundred and fifty patients with jaundice and analytical suspicion of extrahepatic cholestasis were studied prospectively; history, laboratory investigation and ultrasound examination were realized. Computerized tomography was performed in 146 patients. Ultrasonography and computerized tomography findings were confirmed by CPRE o CPTH and surgery. Ultrasonography has a sensitivity of 92.6% while that of computerized tomography was 87.2% for the identification of dilated biliary ducts. The accuracy of ultrasonography was higher than the one obtained in computerized tomography in cholangiocarcinoma (sensitivity: 77.7%) and gallbladder carcinoma (sensitivity: 100%). Computerized tomography recognized choledocholithiasis (sensitivity: 83.3%) and ampullary carcinoma (sensitivity: 88.8%) with better accuracy. However for pancreatic carcinoma (sensitivity: 88.8%) and pancreatitis (sensitivity: 83.3%) both examinations had the same accuracy.

[Hypothyroidism as a complication of the treatment of hepatitis C with interferon]. / Hipotiroidismo como complicación del tratamiento con interferón de la hepatitis C.

Interferon is becoming the most important therapy for chronic hepatitis due to hepatitis C virus. Secondary effects are frequent and sometimes so important to stop the therapy. Autoimmune disorders, specially autoimmune thyroid diseases may occur. We report two out of 69 chronic hepatitis C patients treated with interferon who developed hypothyroidism, that required definitive substitutive therapy.

[Hepatitis C following administration of intravenous immunoglobulins]. / Hepatitis C tras administración de inmunoglobulinas intravenosas.

Five patients with hepatitis C virus infection of different severity and evolution following the administration of intravenous (i.v.) immunoglobulins (Igs) are presented. The important morbidity of hepatitis C virus infection and the need for adequate donor screening are discussed, as is accurate indication of these drugs in the management of patients with immunosuppression and other diseases.

[Hemorrhagic diathesis as initial clinical manifestation of celiac disease]. / Diátesis hemorrágica como manifestación clínica inicial de la enfermedad celíaca.

Coeliac disease is the most frequent malabsortive syndrome in daily practice. However, its true prevalence is not exactly known. The symptoms vary from patient to patient, ranging from the classic presentation with diarrhea, weight loss and fatigue to oligosymptomatic forms, being the latter more common in adults. We report two patients in which urinary and skin spontaneous hemorrhage were the only symptoms, and led to the diagnosis. We insist on the importance of considering the diagnosis of coeliac disease in patients with this kind of clinical manifestations. The early diagnosis will allow us to reduce both the morbidity and mortality in coeliac patients.

[Extrahepatic cholestasis: the echographic and CT findings]. / Colestasis extrahepática: hallazgos mediante ecografía y TC.

One hundred and fifty patients with jaundice and analytical suspicion of extrahepatic cholestasis were studied prospectively; history laboratory investigation and ultrasound examination were done in all. Computerized tomography was performed in 46 patients. Ultrasonography has a sensitivity of 92.6% while that of computerized tomography was 87.2% for the identification of dilated biliary ducts. Computerized tomography demonstrated the level of obstruction with a sensitivity of 89.1%, being most useful at the suprapancreatic and ampullary levels, while ultrasound examination had a sensitivity of 80%. The accuracy of ultrasonography was higher than the one obtained in computerized tomography in cholangiocarcinoma (sensitivity: 77%) and gallbladder carcinoma (sensitivity: 100%). Computerized tomography recognized choledocholithiasis (sensitivity: 83%) and ampullary carcinoma (sensitivity: 75%) with better accuracy. However for pancreatic carcinoma (sensitivity: 87%) and pancreatitis (sensitivity: 88%) both examinations had the same accuracy.

[Whipple's disease with gastric and duodenal involvement. A new case]. / Enfermedad de Whipple con afectación gástrica y duodenal. Un nuevo caso.

Whipple's disease (WD) is a chronic multisistemic process in which the gastrointestinal tract is almost invariably affected. It is believed to be bacterial in origin, although a causative agent has not yet been isolated. Antibiotic treatment is usually quickly effective. We report a case of Whipple's disease in a 69-year-old man with typical clinical history and laboratory data. However, an associated allergic vasculitis not yet described in WD, the characteristical endoscopic appearance, and a partial response to treatment with persistence of histological lesions, made us consider of interest the report of the case.

Endoscopic retrograde cholangiography (E.R.C.P.) and complicated hepatic hydatid cyst in the biliary tract.

A complicated hepatic hydatid cyst in the biliary tract is a cause of cholestasis that we must consider in an endemic geographical area. ERCP is a valuable technique for its diagnosis. In our experience, this eventuality represents 2.6% of the indications for ERCP in biliary diseases.