[Use of the Scottish and Newcastle Anti-Emetic Pretreatment (SNAP) scheme in recovery from massive overdose of acetaminophen poisoning with acute liver failure - Case report]. / Uso del esquema Scottish and Newcastle Anti-Emetic Pretreatment (SNAP) en la recuperación de una intoxicación por sobredosis masiva de acetaminofén (paracetamol) con injuria hep ática aguda - Reporte de caso.

Acetaminophen is a drug widely used in the world and easily accessible due to its antipyretic, analgesics characteristics, among others (1); however, exposure to toxic doses causes organic damage and even death. We present the case of an 18-year-old female patient who ingested 40 grams of acetaminophen and developed severe liver dysfunction, being treated with N-acetylcysteine (NAC) antidotal therapy according to the simplified scheme: Scottish and Newcastle Anti-emetic Pretreatment Paracetamol Poisoning Study Regimen (SNAP), presenting improvement in the clinical course and decrease in liver profiles, coagulation disorder, INR and resolution of the condition.

[Pneumobilia, pneumoperitoneum and pneumowirsung of traumatic etiology: Case report and review of the literature]. / Neumobilia, neumoperitoneo y neumowirsung de etiología traum ática: Reporte de caso y revisión de la literatura.

Pneumobilia is a phenomenon associated with the presence of a biliary-enteric fistula or manipulation of the bile duct during procedures or surgical interventions that cause dysfunction of the sphincter of Oddi. A known, but infrequently reported event, is the increase in intraabdominal pressure after closed abdominal trauma, which causes pneumobilia due to a mechanism of retrograde air leakage towards the bile duct. Depending on the general compromise of each patient, the prognosis can vary from a benign condition that only requires conservative management, to being life threatening. We present the case of a 75-year-old male patient who, after suffering a closed thoraco-abdominal trauma, presented with rib fracture and, in addition, gallbladder wall rupture, pneumoperitoneum, pneumobilia, and pneumowirsung, having a favorable clinical course after receiving conservative management.

Pancreatitis aguda asociada a balón intragástrico: reporte de caso y revisión de la literatura

La obesidad es una patología de importancia a nivel mundial porque conlleva a una alta carga de mortalidad y morbilidad. El balón intragástrico representa una técnica no quirúrgica empleada cada vez con más frecuencia para lograr pérdida de peso. Si bien, este se considera un método seguro, se han reportado algunas complicaciones desde náuseas y vómitos, hasta eventos adversos graves, tales como perforación. La pancreatitis aguda constituye una complicación muy rara del balón intragástrico y se atribuye su efecto a la compresión directa que ejerce sobre el páncreas. Presentamos el caso de una paciente mujer de 21 años, quien después de 7 meses de colocación de balón intragástrico, cursó con dolor abdominal, náuseas y vómitos, asociados a elevación de enzimas pancreáticas. Se hizo diagnóstico de pancreatitis aguda y se corroboró compresión de la cola del páncreas mediante estudio tomográfico. Se decidió retiro del balón mediante endoscopía, cursando luego con evolución favorable.

Obesity is a pathology of importance worldwide because it leads to a high burden of mortality and morbidity. The intragastric balloon represents a non-surgical technique used more and more frequently to achieve weight loss. Although this is considered a safe method, some complications have been reported, from nausea and vomiting to serious adverse events, such as perforation. Acute pancreatitis is a very rare complication of the intragastric balloon, and its effect is attributed to the direct compression it exerts on the pancreas. We present the case of a 21-year-old female patient who, after 7 months of intragastric balloon placement, developed abdominal pain, nausea, and vomiting, associated with elevated pancreatic enzymes. A diagnosis of acute pancreatitis was made and compression of the tail of the pancreas was confirmed by tomographic study. It was decided to remove the balloon by endoscopy, which then progressed favorably.

Pneumobilia, pneumoperitoneum and pneumowirsung of traumatic etiology: Case report and review of the literature

Pneumobilia is a phenomenon associated with the presence of a biliary-enteric fistula or manipulation of the bile duct during procedures or surgical interventions that cause dysfunction of the sphincter of Oddi. A known, but infrequently reported event, is the increase in intraabdominal pressure after closed abdominal trauma, which causes pneumobilia due to a mechanism of retrograde air leakage towards the bile duct. Depending on the general compromise of each patient, the prognosis can vary from a benign condition that only requires conservative management, to being life threatening. We present the case of a 75-year-old male patient who, after suffering a closed thoraco-abdominal trauma, presented with rib fracture and, in addition, gallbladder wall rupture, pneumoperitoneum, pneumobilia, and pneumowirsung, having a favorable clinical course after receiving conservative management.

La neumobilia es un fenómeno asociado a presencia de fístula bilioentérica o manipulación de la vía biliar durante procedimientos o intervenciones quirúrgicas que condicionan disfunción del esfínter de Oddi. Un evento poco reportado, pero ya conocido, es el aumento de la presión intraabdominal tras un trauma abdominal cerrado, que condiciona neumobilia por un mecanismo retrógrado de fuga de aire hacia la vía biliar. Según el compromiso general de cada paciente, el pronóstico puede variar desde un cuadro benigno, que solo requiere un manejo conservador, hasta ser amenazante para la vida. Se presenta el caso de un paciente varón de 75 años, quien después de presentar un trauma toracoabdominal cerrado cursa con fractura costal y, además, ruptura de pared vesicular, neumoperitoneo, neumobilia, y neumowirsung, cursando con evolución favorable tras recibir manejo conservador.

Neutropenic Enterocolitis: Case report and literature review

Typhlitis, is also known as neutropenic enterocolitis, affects the cecum and distal ileum. It was frequently encountered in pediatric patients who were undergoing treatment for leukemia. Nonetheless, it can affect adult patients, regardless of the cause of the immunosuppression. We report the case of a 20-year-old patient who was receiving chemotherapy for Osteosarcoma, who had a 6-day history of nausea and vomiting, fever sensation, diarrhea, and diffuse abdominal pain. Physical examination was relevant for hemodynamic instability, a distended and tender abdomen predominantly in the right iliac fossa. The laboratory workup showed severe neutropenia, thrombocytopenia, and electrolyte disturbances. The image studies evidenced edema of the ascending colon and cecum. Treatment was started with vasopressor support, correction of electrolyte alterations, blood cell and platelet transfusion, G-CSF, hydration, broad spectrum antibiotic therapy, initially with adequate clinical and laboratory response. After a few days, he presented lower gastrointestinal bleeding which was treated by conservative management. In conclusion, typhlitis must be suspected in every patient developing neutropenia as a reaction to chemotherapy and who also presents gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and intense abdominal pain.

La tiflitis o también denominada enterocolitis neutropénica afecta el ciego e íleon distal. Fue descrita comúnmente en pacientes pediátricos sometidos a tratamiento para leucemia; sin embargo, puede afectar al paciente adulto independiente de la causa que origine la inmunosupresión. Presentamos el caso de un paciente de 20 años con antecedente de osteosarcoma, quien acude con tiempo de enfermedad de 6 días caracterizado por náuseas y vómitos, sensación de alza térmica, diarrea y dolor abdominal difuso. Al examen físico se encuentra hemodinámicamente inestable, abdomen distendido y se corrobora el dolor abdominal a predominio en fosa iliaca derecha. Los exámenes de laboratorio mostraron neutropenia severa, trombocitopenia y alteraciones hidroelectrolíticas. En los estudios de imágenes la TC evidenció edema de asas delgadas, así como edema de pared del colon ascendente y ciego. Se inició tratamiento con soporte vasopresor, corrección de alteraciones hidroelectrolíticas, transfusión de paquetes globulares y plaquetas, G-CSF, hidratación, terapia antibiótica de amplio espectro, inicialmente con adecuada respuesta clínica y laboratorial. Al cabo de unos días presentó hemorragia digestiva baja como complicación que fue tratada mediante manejo conservador. En conclusión, la tiflitis debe sospecharse en todo paciente que desarrolla neutropenia luego de quimioterapia y que presenta síntomas gastrointestinales como náuseas, vómitos, diarrea y dolor abdominal intenso. El manejo conservador, en pacientes con hemorragia digestiva y tiflitis, que involucra corrección de coagulopatía, transfusión de paquetes globulares e hidratación, puede ser el adecuado en pacientes que no cursan con inestabilidad hemodinámica y logran controlar el sangrado.

Neutropenic Enterocolitis: Case report and literature review.

Typhlitis, is also known as neutropenic enterocolitis, affects the cecum and distal ileum. It was frequently encountered in pediatric patients who were undergoing treatment for leukemia. Nonetheless, it can affect adult patients, regardless of the cause of the immunosuppression. We report the case of a 20-year-old patient who was receiving chemotherapy for Osteosarcoma, who had a 6-day history of nausea and vomiting, fever sensation, diarrhea, and diffuse abdominal pain. Physical examination was relevant for hemodynamic instability, a distended and tender abdomen predominantly in the right iliac fossa. The laboratory workup showed severe neutropenia, thrombocytopenia, and electrolyte disturbances. The image studies evidenced edema of the ascending colon and cecum. Treatment was started with vasopressor support, correction of electrolyte alterations, blood cell and platelet transfusion, G-CSF, hydration, broad spectrum antibiotic therapy, initially with adequate clinical and laboratory response. After a few days, he presented lower gastrointestinal bleeding which was treated by conservative management. In conclusion, typhlitis must be suspected in every patient developing neutropenia as a reaction to chemotherapy and who also presents gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and intense abdominal pain.

Epidemiology and associated factors of irritable bowel syndrome in an Andean community from Peru.

INTRODUCTION: Irritable bowel syndrome (IBS) is a chronic functional bowel condition with an average world prevalence of 11.2%. Is associated with multiple factors as female sex, young age, stress, anxiety and depression which can have a negative impact on quality of life. IBS in Peru is not investigated at all specially in the Andean region. The objective of this study is to determine the prevalence and associated factors of IBS in an Andean community from Peru using the Rome IV criteria. MATERIALS AND METHODS: Cross-sectional study in a rural community dedicated to livestock and agriculture in Peru at 3,235 meters above sea level. Questionnaires provided by the Rome Foundation as the Rome IV - Diagnostic questionnaire for adults, Irritable Bowel Syndrome - Symptom Severity Scale and Bristol stool scale were used. RESULTS: 130 residents met the inclusion criteria. 46.9% were males with an average age of 54 years old. 11.54% presented red flags and were not included in the analysis. 13.1% were diagnosed with IBS and 52.9% presented constipation as predominant bowel pattern. 52.9% presented a mild course of the disease. In the chi-square analysis, factors as depression, anxiety, female sex, younger age, liquefied petroleum gas exposure for cooking and education achievement were statistically significant associated to IBS. In the logistic regression analysis, anxiety was the unique independent predictor factor with an OR of 9.6 (95% IC: 1.78-51.82). CONCLUSION: IBS is a prevalent condition in the Andean region and should be managed as a public health issue to improve quality of life.

Epidemiology and associated factors of irritable bowel syndrome in an Andean community from Peru

Introduction : Irritable bowel syndrome (IBS) is a chronic functional bowel condition with an average world prevalence of 11.2%. Is associated with multiple factors as female sex, young age, stress, anxiety and depression which can have a negative impact on quality of life. IBS in Peru is not investigated at all specially in the Andean region. The objective of this study is to determine the prevalence and associated factors of IBS in an Andean community from Peru using the Rome IV criteria. Materials and methods : Cross-sectional study in a rural community dedicated to livestock and agriculture in Peru at 3,235 meters above sea level. Questionnaires provided by the Rome Foundation as the Rome IV - Diagnostic questionnaire for adults, Irritable Bowel Syndrome - Symptom Severity Scale and Bristol stool scale were used. Results : 130 residents met the inclusion criteria. 46.9% were males with an average age of 54 years old. 11.54% presented red flags and were not included in the analysis. 13.1% were diagnosed with IBS and 52.9% presented constipation as predominant bowel pattern. 52.9% presented a mild course of the disease. In the chi-square analysis, factors as depression, anxiety, female sex, younger age, liquefied petroleum gas exposure for cooking and education achievement were statistically significant associated to IBS. In the logistic regression analysis, anxiety was the unique independent predictor factor with an OR of 9.6 (95% IC: 1.78-51.82). Conclusion : IBS is a prevalent condition in the Andean region and should be managed as a public health issue to improve quality of life.

Introducción : El síndrome del intestino irritable (SII) es una enfermedad intestinal funcional crónica con una prevalencia mundial promedio del 11,2%. Se asocia a múltiples factores como el sexo femenino, la juventud, el estrés, la ansiedad y la depresión que pueden tener un impacto negativo en la calidad de vida. El SII en Perú, no es investigado a profundidad, especialmente en la región andina. El objetivo de este estudio es determinar la prevalencia y factores asociados del SII en una comunidad andina de Perú utilizando los criterios de Roma IV. Materiales y métodos : Estudio transversal en una comunidad rural dedicada a la ganadería y la agricultura en Perú a 3 235 metros sobre el nivel del mar. Se utilizaron cuestionarios proporcionados por la Fundación de Roma como Rome IV - Cuestionario de diagnóstico para adultos, Síndrome del intestino irritable - Escala de gravedad de los síntomas y Escala de heces de Bristol. Resultados : 130 residentes cumplieron los criterios de inclusión. El 46,9% eran varones con una edad media de 54 años. El 11,54% presentó señales de alerta y no fueron incluidos en el análisis. El 13,1% fueron diagnosticados de SII y el 52,9% presentó estreñimiento como patrón intestinal predominante. El 52,9% presentó un curso leve de la enfermedad. En el análisis de chi-cuadrado, factores como depresión, ansiedad, sexo femenino, edad más joven, exposición a gas licuado de petróleo para cocinar y logros educativos fueron estadísticamente significativos asociados con el SII. En el análisis de regresión logística, la ansiedad fue el único factor predictor independiente con una OR de 9,6 (IC del 95%: 1,78-51,82). Conclusión : El SII es una condición prevalente en la región andina y debe ser manejado como un problema de salud pública para mejorar la calidad de vida.

[Independent risk factors for severity and mortality in lower gastrointestinal bleeding]. / Hemorragia digestiva baja, factores predictores de severidad y mortalidad en un hospital p úblico de Lima.

In lower gastrointestinal bleeding (LGIB), it is very important to stratify the risk of LGIB for a proper management. OBJECTIVE: Identity the independent risk factors to mortality and severity (require critical care, prolonged hospitalization, reebleding, re hospitalization, politrasfusion, surgery for bleeding control) in LGIB. MATERIALS AND METHODS: It is an analytic prospective cohort study, performed between June 2016 and April 2018 in a tertiary care hospital. Independent factors were determined using binomial logistic regression. RESULTS: A total of 98 patients were included, of which 13 patients (13,3%) died, and 56 (57,1%) met severity criteria. The independent risk factor for mortality was Glasgow scale under 15, and for severe bleeding were: Systolic blood pressure under 100 mm Hg, albumin lower than 2,8 g/dL. CONCLUSIONS: The frequency of mortality and severe LGIB is high in our population, the principal risk factors were systolic blood pressure under than 100 mm Hg, Glasgow score lower than 15, albumin lower than 2,8 g/dL. Identifying these associated factors would improve the management of LGB in the emergency room.

Hemorragia digestiva baja, factores predictores de severidad y mortalidad en un hospital público de Lima

En hemorragia digestiva baja (HDB) es muy importante estratificar el riesgo de la misma para brindar un manejo adecuado. Objetivo: Identificar los factores predictores de mortalidad y severidad en pacientes con HDB (definida como: requerimiento de unidad de cuidados críticos, control de hemorragia en sala de operaciones, estancia prolongada mayor a 9 días, resangrado, reingreso, o politransfusión más de 5 paquetes globulares). Materiales y métodos: Es un estudio observacional analítico de cohorte prospectivo, realizado entre junio del 2016 y abril del 2018 en un hospital de nivel III. Se determinó los factores predictores de mortalidad y severidad. Se evalúo la sobrevida hasta los 30 días Resultados: Se incluyó un total de 98 pacientes de los cuales 13 pacientes (13,3%) fallecieron y 56 (57,1%) cumplen criterios de severidad. El factor predictor independiente de mortalidad fue escala de Glasgow menor a 15 y los factores independientes de severidad fueron un valor de albúmina menor a 2,8 g/dl y la presión arterial sistólica menor a 100 mmhg. Conclusiones: La frecuencia de mortalidad y HDB severa es alta en nuestro estudio. La presión arterial sistólica, la escala de Glasgow y la albúmina sérica son evaluaciones que pueden permitirnos predecir durante la primera evaluación en emergencia el riesgo de severidad y mortalidad de un paciente con HDB.

In lower gastrointestinal bleeding (LGIB), it is very important to stratify the risk of LGIB for a proper management. Objective: Identity the independent risk factors to mortality and severity (require critical care, prolonged hospitalization, reebleding, re hospitalization, politrasfusion, surgery for bleeding control) in LGIB. Materials and methods: It is an analytic prospective cohort study, performed between June 2016 and April 2018 in a tertiary care hospital. Independent factors were determined using binomial logistic regression. Results: A total of 98 patients were included, of which 13 patients (13,3%) died, and 56 (57,1%) met severity criteria. The independent risk factor for mortality was Glasgow scale under 15, and for severe bleeding were: Systolic blood pressure under 100 mm Hg, albumin lower than 2,8 g/dL. Conclusions: The frequency of mortality and severe LGIB is high in our population, the principal risk factors were systolic blood pressure under than 100 mm Hg, Glasgow score lower than 15, albumin lower than 2,8 g/dL. Identifying these associated factors would improve the management of LGB in the emergency room.

Hypoxic hepatitis in an extensive aortic disecction: case report.

Hypoxic hepatitis is an uncommon cause of hepatic damage characterized by a centrolobular necrosis. Its pathophysiology remains unclear. Aortic dissection is a rare but frequently catastrophic event. It is caused by an aortic intimal tear with propagation of a false channel in the media. Depending on the site and extension, it can cause hypoperfusion of any organ leading to cellular ischemia and necrosis. We are presenting a case of hypoxic hepatitis in a patient with an extensive aortic dissection who present to the emergency department.

Hypoxic hepatitis in an extensive aortic disecction: case report / Hepatitis hipóxica en una disección aórtica extensa: reporte de caso

Hypoxic hepatitis is an uncommon cause of hepatic damage characterized by a centrolobular necrosis. Its pathophysiology remains unclear. Aortic dissection is a rare but frequently catastrophic event. It is caused by an aortic intimal tear with propagation of a false channel in the media. Depending on the site and extension, it can cause hypoperfusion of any organ leading to cellular ischemia and necrosis. We are presenting a case of hypoxic hepatitis in a patient with an extensive aortic dissection who present to the emergency department.

La hepatitis hipóxica es una causa poco frecuente de daño hepático caracterizada por una necrosis centrolobular. Su fisiopatología sigue siendo poco clara. La disección aórtica es un evento raro pero con frecuencia catastrófico. Dependiendo del sitio y la extensión, puede causar hipoperfusión de cualquier órgano lo que conduce a una isquemia celular y necrosis. Nosotros presentamos un caso de hepatitis hipóxica en un paciente con disección aórtica extensa que se presenta al servicio de emergencia.

Histoplasmosis-induced ileal perforation in a patient with acquired immune deficiency syndrome: Case report.

Intestinal involvement with disseminated histoplasmosis is common in some populations infected with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), especially in those who come from tropical zones. We report the case of a 29-year-old male patient, from a tropical zone, with HIV infection and a CD4 value less than 50 cells/mm3, with a history of abdominal pain, fever, diarrhea, and weight loss. On presentation, he was pale, sweaty, and had abdominal rebound tenderness. Laboratory findings demonstrated microcitic hipocromic anemia, azoemia, and hypoalbuminemia. Abdominal-X-rays revealed pneumoperitoneum and air fluid levels. He underwent surgery, and a 1-cm perforation proximal to ileocecal valve was found. A resection and an ileostomy were performed. Histopathology identified caseating granulomas with yeast, compatible with histoplasmosis. He was treated with anfotericin B plus itraconazol with clinical improvement.

Frecuencia, perfil clínico y mortalidad de la insuficiencia hepática crónica reagudizada en un hospital público de Lima - Perú / Frequency, clinical profile and mortality of acute-on-chronic liver failure in a public hospital of Lima - Peru

Introducción: Una condición de alta mortalidad a corto plazo en el cirrótico es la Insuficiencia hepática crónica reagudizada (ACLF por sus siglas en inglés), caracterizada por la falla de órgano(s) y precedida habitualmente por una descompensación aguda (DA). Objetivo: Determinar la frecuencia, el perfil clínico y la mortalidad en los cirróticos hospitalizados con ACLF. Materiales y métodos: Estudio analítico observacional realizado de julio 2016 a junio 2017. Se estableció la condición de ACLF según los criterios del estudio CANONIC. Resultados: Se reclutaron 118 pacientes cirróticos, 34 (28,8%) de los cuales presentaron ACLF, con grado 1: 14 (41%), grado 2: 16 (47%) y grado 3: 4 (12%) pacientes. La edad promedio fue 61,5 años; siendo la etiología más frecuente el alcoholismo en 18 pacientes (53%) y la mayoría no tenían historia previa de DA (64,7%). Los factores precipitantes más frecuentes fueron: la hemorragia digestiva (41%) y las infecciones (29,4%). Los grupos con y sin ACLF tuvieron una diferencia estadísticamente significativa en el puntaje Child-Turcotte-Pugh (CTP) (11,4 ± 1,8 vs 8,69 ± 2,04; p<0,0001), puntaje MELD (26,4 ± 8,1 vs 14,4 ± 4,6; p<0,0001), leucocitos (11 809,7 ± 6906,3/mm3 vs 8434,01 ± 5434,9/mm3; p: 0,006) y mortalidad a 28 días (76,5% vs 21,4%; p<0,0001), con un riesgo relativo (RR) de 3,5. Conclusiones: La frecuencia de ACLF fue 28,8%, similar a la del estudio CANONIC (30,9%). El principal factor precipitante fue la hemorragia digestiva. Los puntajes CTP, MELD y leucocitos fueron más altos en el grupo con ACLF, observándose una mortalidad a 28 días de 76,5% (3,5 veces mayor que en los pacientes sin ACLF).

Introduction: A condition of high short-term mortality in the cirrhotic patient is Acute-on-Chronic Liver Failure (ACLF), characterized by organ failure (s) and usually preceded by acute decompensation (AD). Objective: To determine the frequency, clinical profile, and mortality in cirrhotic patients hospitalized with ACLF. Materials and methods: This is an observational analytical study conducted from July 2016 to June 2017. We established the ACLF condition through the criteria of the CANONIC study. Results: The study population was 118 patients, of whom 34 (28.8%) presented ACLF, 14 (41%) were Grade 1, 16 (47%) Grade 2 and 4 (11.9%) Grade 3. The average age was 61.5 years old, alcoholism being the most frequent etiology with 18 patients (53%) and mostly without episodes of AD (64.7%). The most frequent precipitating factors were: Digestive hemorrhage (41%) and infections (29.4%). The groups with and without ACLF were statistically significant in the Child-Turcot- Pugh score (CTP) (11.4 ± 1.8 vs. 8.69 ± 2.04; p < 0.0001), MELD score (26.4 ± 8.1 vs. 14.4 ± 4.6; p < 0.0001), leukocytes (11,809.7 +/- 6,906.3 per mm3 vs. 8,434.01 ± 5,434.9 per mm3; p: 0.006) and 28-day mortality (76.5% vs. 21.4%, p < 0.0001), with a relative risk (RR) of 3.5. Conclusions: The frecuency of ACLF was 28.8%, similar to that of the CANONIC study (30.9%). The digestive hemorrhage being the main precipitating factor. The CTP, MELD and leukocyte scores were highest in this group. Mortality in patients with ACLF was 3.5 times more frequent than in patients without ACLF.

[Accuracy of ASGE predictors in diagnosis of coledocolithiasis in a public hospital of Lima, Peru]. / Precisión de los predictores de la ASGE en el diagnóstico de coledocolitiasis en un hospital público de Lima, Perú.

BACKGROUND: The predictors proposed by the American Society of Gastrointestinal Endoscopy (ASGE) are commonly used topredict the presence and management of choledocholithiasis. OBJECTIVE: To evaluate the performance and precision of thepredictors of choledocholithiasis proposed by ASGE. MATERIALS AND METHODS: Prospective and longitudinal study performed ata third level hospital during January 2015 to June 2017. All patients with high and intermediate probability of choledocholithiasiswho underwent endoscopic retrograde cholangiopancreatography (ERCP) were included according to the criteria proposedby the ASGE. RESULTS: A total of 246 patients with suspected choledocholithiasis were analyzed. Of the 228 patients withhigh probability criteria 144 (63.2% = performance) had choledocholithiasis in ERCP with an accuracy of 62% (sensitivity:94.1% and specificity: 9.7%). Among the 18 patients with intermediate probability criteria, 9 (50% = performance) hadcholedocholithiasis with an accuracy of 38% (sensitivity: 5.9% and specificity: 90.3%). In the multivariate analysis, the presenceof stone in the bile duct by ultrasonography (OR: 1.937, 95% CI 1.048-3.580, p=0.035) and age 55 and over (OR: 2.121, 95%CI, 1.101-4.088, p=0.025) were the strongest predictors for choledocholithiasis. CONCLUSIONS: The application of the criteriaof the ASGE to predict the probability of choledocholithiasis, in our population has a performance greater than 50%, however,it is necessary to improve these parameters to avoid an unnecessary performance of ERCP.

Precisión de los predictores de la ASGE en el diagnóstico de coledocolitiasis en un hospital público de Lima, Perú / Accuracy of ASGE predictors in diagnosis of coledocolithiasis in a public hospital of Lima, Peru

Antecedentes: Habitualmente se utilizan los predictores propuestos por la Sociedad Americana de Endoscopía Gastrointestinal (ASGE) para predecir la presencia y manejo de coledocolitiasis. Objetivo: Evaluar el rendimiento y precisión de los predictores de coledocolitiasis propuestos por la ASGE. Materiales y métodos: Estudio prospectivo y longitudinal realizado en un hospital de tercer nivel desde enero del 2015 hasta junio del 2017. Se incluyeron a todos los pacientes con probabilidad alta e intermedia de coledocolitiasis y que fueron sometidos a colangiopancreatografía retrógrada endoscópica (CPRE) según los criterios propuestos por la ASGE. Resultados: Se analizó un total de 246 pacientes con sospecha de coledocolitiasis. De los 228 pacientes con criterios de alta probabilidad, 144 (63,2% = rendimiento) tenían coledocolitiasis en la CPRE con una precisión de 62% (sensibilidad: 94,1% y especificidad: 9,7%). Entre los 18 pacientes con criterios de probabilidad intermedia: 9 (50% = rendimiento) tenían coledocolitiasis con una precisión de 38% (sensibilidad: 5,9% y especificidad: 90,3%). En el análisis multivariado la presencia de cálculo en el colédoco por ecografía (OR: 1,937; IC 95% 1,048- 3,580; p=0,035) y la edad mayor de 55 años (OR: 2,121; IC 95% 1,101-4,088; p=0,025) fueron los predictores más fuertes para coledocolitiasis. Conclusiones: La aplicación de los criterios de la ASGE para predecir probabilidad de coledocolitiasis, en nuestra población tiene un rendimiento mayor del 50%; sin embargo, se necesita mejorar estos parámetros para evitar una realización innecesaria de CPRE.

Background: The predictors proposed by the American Society of Gastrointestinal Endoscopy (ASGE) are commonly used to predict the presence and management of choledocholithiasis. Objective: To evaluate the performance and precision of the predictors of choledocholithiasis proposed by ASGE. Materials and methods: Prospective and longitudinal study performed at a third level hospital during January 2015 to June 2017. All patients with high and intermediate probability of choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included according to the criteria proposed by the ASGE. Results: A total of 246 patients with suspected choledocholithiasis were analyzed. Of the 228 patients with high probability criteria 144 (63.2% = performance) had choledocholithiasis in ERCP with an accuracy of 62% (sensitivity: 94.1% and specificity: 9.7%). Among the 18 patients with intermediate probability criteria, 9 (50% = performance) had choledocholithiasis with an accuracy of 38% (sensitivity: 5.9% and specificity: 90.3%). In the multivariate analysis, the presence of stone in the bile duct by ultrasonography (OR: 1.937, 95% CI 1.048-3.580, p=0.035) and age 55 and over (OR: 2.121, 95% CI, 1.101-4.088, p=0.025) were the strongest predictors for choledocholithiasis. Conclusions: The application of the criteria of the ASGE to predict the probability of choledocholithiasis, in our population has a performance greater than 50%, however, it is necessary to improve these parameters to avoid an unnecessary performance of ERCP.

[Frequency, clinical profile and mortality of acute-on-chronic liver failure in a public hospital of Lima - Peru]. / Frecuencia, perfil clínico y mortalidad de la insuficiencia hepática crónica reagudizada en un hospital público de Lima ­ Perú.

INTRODUCTION: A condition of high short-term mortality in the cirrhotic patient is Acute-on-Chronic Liver Failure (ACLF), characterized by organ failure (s) and usually preceded by acute decompensation (AD). OBJECTIVE: To determine the frequency, clinical profile, and mortality in cirrhotic patients hospitalized with ACLF. MATERIALS AND METHODS: This is an observational analytical study conducted from July 2016 to June 2017. We established the ACLF condition through the criteria of the CANONIC study. RESULTS: The study population was 118 patients, of whom 34 (28.8%) presented ACLF, 14 (41%) were Grade 1, 16 (47%) Grade 2 and 4 (11.9%) Grade 3. The average age was 61.5 years old, alcoholism being the most frequent etiology with 18 patients (53%) and mostly without episodes of AD (64.7%). The most frequent precipitating factors were: Digestive hemorrhage (41%) and infections (29.4%). The groups with and without ACLF were statistically significant in the Child-Turcot-Pugh score (CTP) (11.4 ± 1.8 vs. 8.69 ± 2.04; p < 0.0001 ). MELD score (26.4 ± 8.1 vs. 14.4 ± 4.6; p < 0.0001), leukocytes (11,809.7 +/- 6,906.3 per mm3 vs. 8,434.01 ± 5,434.9 per mm3; p: 0.006) and 28-day mortality (76.5% vs. 21.4%, p < 0.0001), with a relative risk (RR) of 3.5. CONCLUSIONS: The frecuency of ACLF was 28.8%, similar to that of the CANONIC study (30.9%). The digestive hemorrhage being the main precipitating factor. The CTP, MELD and leukocyte scores were highest in this group. Mortality in patients with ACLF was 3.5 times more frequent than in patients without ACLF.

[Autoimmune pancreatitis type 1: a case report]. / Pancreatitis autoinmune tipo 1: reporte de caso.

Autoimmune pancreatitis type 1 (AIP) is the pancreatic manifestation of IgG4-related disease. The most frequent presentation of AIP is with obstructive jaundice. For definite diagnosis of type 1 Autoimmune pancreatitis international consensus diagnosis criteria (ICDC) for AIP are used. ICDC criteria include pancreatic parenchymal imaging, ductal imaging, serology, other organ involvement, histology, and response to steroid. We report a 52-years-old woman with rheumatoid arthritis without treatment presented with two months of abdominal pain in up-right quadrant with moderate intensity. She also presented jaundice, acholia, xerophtalmia, xerostomia, and a weight loss of 5 pounds. On examination jaundice, symmetrically enlarged submandibular glands, and epigastric pain was observed. On laboratory, a cholestasis pattern and conjugated bilirubin predominance was found. CT Abdominal, CMR revealed a dilated common bile duct with a diffuse pancreatic enlargement with delayed enhancement. Immunological studies show a IgG4 610 u/l and ANA 1/640. The patient responds to steroid clinically and in the laboratorial values. In conclusion, autoimmune pancreatitis type 1 should be suspected in case of an obstructive jaundice with a pancreatic inflammatory image, and complete ICDC criteria for a definite diagnosis.

Tratamiento exitoso con los nuevos antivirales de acción directa en paciente infectado con el virus de la hepatitis C con fibrosis avanzada y dos recaídas previas: Reporte de caso / Successful treatment with new direct acting antiviral in an infected patient with hepatitis C virus with advanced liver fibrosis in a treatment experienced patient: Case report

El tratamiento del virus de la hepatitis C ha presentado grandes cambios en los últimos años. El esquema base utilizado era Interferón Pegylado y Ribavirina, con el que se lograba respuesta viral sostenida (RVS) de alrededor del 50%. Con la adición de los inhibidores de proteasa Telaprevir y Boceprevir al esquema "esqueleto" de Interferon Pegylado y Ribavirina, la tasa de RVS mejoró hasta valores cercanos a 70%; sin embargo, ocurren efectos colaterales importantes y difícil adherencia. Los nuevos antivirales de acción directa (AAD) (inhibidores de la polimerasa NS5A y NS5B), tienen altas tasas de RVS alcanzando valores mayores de 95% en los diferentes genotipos, en pacientes que recibieron tratamiento previo o no, incluyendo cirróticos. Se presenta el caso de un paciente que recibió dos esquemas terapéuticos previos y con fibrosis hepática avanzada que presentó RVS al ser tratado con los nuevos AAD (Sofosbuvir y Ledipasvir). (AU)

The treatment of hepatitis C virus utilized was Pegylated Interferon and Ribavirin, achieving a sustained virological response (SVR) of about 50 %. With the addition of the first-generation protease inhibitors Telaprevir and Boceprevir to the Pegylated Interferon/Ribavirin backbone the SVR rates rose up to approximately 70%, but with important side effects and a difficult adherence. The new direct acting antivirals (NS5A and NS5B polymerase inhibitors) improved SVR rates to 95 % or greater in the different genotypes, in the treatment-naive and treatment experienced patients including patients with cirrhosis. We report the case of a patient with advanced fibrotic stage, who failed to respond to 2 regimens and was subsequently treated with Ledipasvir/Sofosbuvir and achieved virogical cure. (AU)

Pancreatitis autoinmune tipo 1: reporte de caso / Autoimmune pancreatitis type 1: a case report

La pancreatitis autoinmune tipo 1 es una enfermedad de baja prevalencia siendo más frecuente en varones, se encuentra incluida dentro de las enfermedades relacionadas a IgG4. Esta patología puede debutar como un síndrome colestásico y el diagnóstico se realiza según los criterios del consenso internacional para pancreatitis autoinmune (ICDC) que incluye una imagen típica, serología, compromiso de otros órganos, histología y respuesta al tratamiento con corticoides. Presentamos el caso de una mujer de 52 años con antecedente de artritis reumatoide sin tratamiento que acude con tiempo de enfermedad de 2 meses caracterizado por dolor abdominal en hipocondrio derecho de moderada intensidad asociado a ictericia, coluria, hipocolia, xeroftalmia, xerostomía y pérdida de peso de 3 kg. Al examen físico se evidencia ictericia, hipertrofia simétrica de glándulas submandibulares, leve dolor en epigastrio. En los exámenes auxiliares existe patrón colestásico con hiperbilirrubinemia a predominio directo. En los estudios de imágenes se evidencia colédoco dilatado, con aumento difuso del volumen del páncreas con captación tardía de contraste. En el estudio inmunológico se evidenció IgG4 en 610 u/L y ANA 1/640. Se inició tratamiento con corticoides con respuesta clínica y de laboratorio favorable. En conclusión, se debe sospechar de pancreatitis autoinmune ante un cuadro de dolor abdominal y colestasis extrahepática con imágenes sugestivas de páncreas inflamatorio, en el que se deben complementar los criterios ICDC para confirmar el diagnóstico

Autoimmune pancreatitis type 1 (AIP) is the pancreatic manifestation of IgG4-related disease. The most frequent presentation of AIP is with obstructive jaundice. For definite diagnosis of type 1 Autoimmune pancreatitis international consensus diagnosis criteria (ICDC) for AIP are used. ICDC criteria include pancreatic parenchymal imaging, ductal imaging, serology, other organ involvement, histology, and response to steroid. We report a 52-years-old woman with rheumatoid arthritis without treatment presented with two months of abdominal pain in up-right quadrant with moderate intensity. She also presented jaundice, acholia, xerophtalmia, xerostomia, and a weight loss of 5 pounds. On examination jaundice, symmetrically enlarged submandibular glands, and epigastric pain was observed. On laboratory, a cholestasis pattern and conjugated bilirubin predominance was found. CT Abdominal, CMR revealed a dilated common bile duct with a diffuse pancreatic enlargement with delayed enhancement. Immunological studies show a IgG4 610 u/l and ANA 1/640. The patient responds to steroid clinically and in the laboratorial values. In conclusion, autoimmune pancreatitis type 1 should be suspected in case of an obstructive jaundice with a pancreatic inflammatory image, and complete ICDC criteria for a definite diagnosis