¿Es la pancreatitis crónica una enfermedad rara en Chile?: ¿Subdiagnóstico, baja prevalencia o ambos? / Chronic pancreatitis: retrospective review of 121 cases

Background: Chronic pancreatitis (CP) is a rare disease in Chile, without a clear explanation for this low prevalence. Aim: To analyze the characteristics of our patients with pancreatitis. Material and Methods: Retrospective analysis of a database of patients with pancreatitis of a clinical hospital. Morphological proof of diagnosis (calcifications/calculi, alterations of ducts, local complication or histology) was obtained for every patient. History of acute pancreatitis was recorded and exocrine-endocrine function was assessed. Results: We retrieved information of 121 patients with pancreatitis (86 males) in a period of 20 years. The number of cases increased markedly every five years. The calculated incidence and prevalence was 0.8/100,000/year and 6/100,000, respectively. Pancreatic calcifications were initially observed in 93 patients and became evident during the follow-up in another six patients. Severe pain or local complications occurred in 27 patients, requiring surgery in 10 or endoscopic treatment in 15. During the years of follow-up, 55 patients were free of symptoms. Exocrine and endocrine insufficiency was demonstrated and treated in 81 and 67 patients, respectively. Alcoholic etiology was evident in 40% of patients. In 29% no etiology was identified. Mapuche origin was exceptional. Conclusions: Late diagnosis of CP is common, since most of our patients presented with advanced stages. Even though CP is increasingly diagnosed in our hospitals, the number of cases is still far fewer when compared to other countries. Underdiagnosis alone cannot explain this difference and genetic factors might be of importance.

[Chronic pancreatitis: Retrospective review of 121 cases]. / ¿Es la pancreatitis crónica una enfermedad rara en Chile?: ¿Subdiagnóstico, baja prevalencia o ambos?

BACKGROUND: Chronic pancreatitis (CP) is a rare disease in Chile, without a clear explanation for this low prevalence. AIM: To analyze the characteristics of our patients with pancreatitis. MATERIAL AND METHODS: Retrospective analysis of a database of patients with pancreatitis of a clinical hospital. Morphological proof of diagnosis (calcifications/calculi, alterations of ducts, local complication or histology) was obtained for every patient. History of acute pancreatitis was recorded and exocrine-endocrine function was assessed. RESULTS: We retrieved information of 121 patients with pancreatitis (86 males) in a period of 20 years. The number of cases increased markedly every five years. The calculated incidence and prevalence was 0.8/100,000/year and 6/100,000, respectively. Pancreatic calcifications were initially observed in 93 patients and became evident during the follow-up in another six patients. Severe pain or local complications occurred in 27 patients, requiring surgery in 10 or endoscopic treatment in 15. During the years of follow-up, 55 patients were free of symptoms. Exocrine and endocrine insufficiency was demonstrated and treated in 81 and 67 patients, respectively. Alcoholic etiology was evident in 40% of patients. In 29% no etiology was identified. Mapuche origin was exceptional. CONCLUSIONS: Late diagnosis of CP is common, since most of our patients presented with advanced stages. Even though CP is increasingly diagnosed in our hospitals, the number of cases is still far fewer when compared to other countries. Underdiagnosis alone cannot explain this difference and genetic factors might be of importance.

Hipertensión intra-abdominal: visión del gastroenterólogo / Intra-abdominal hypertension: perspective of the gastroenterologyst

Elevated intra-abdominal pressure (IAP) has deleterious effects in distant organ function. Sustained increase of IAP is known as intra-abdominal hypertension (IAH) and is associated with significant morbidity and mortality in critically ill patients. The aim of this article is to review basic pathophysiologic and clinical concepts about diagnosis and medical-surgical management of IAH and its most severe expression: the abdominal compartment syndrome, with emphasis on certain conditions as severe acute pancreatitis and end stage liver disease as these commonly associate with IAH.

El aumento de la presión intra-abdominal (PIA) se asocia a una serie de efectos deletéreos en la función de otros sistemas. El aumento sostenido de la PIA se denomina hipertensión intra-abdominal (HTIA) y es una entidad que aumenta la morbi-mortalidad en pacientes graves. La siguiente revisión expone los conceptos fisiopatológicos y clínicos básicos respecto al diagnóstico y manejo médico y quirúrgico de laHTIA y su grado máximo de expresión: el síndrome compartamental del abdomen, con énfasis en ciertas condiciones gastroenterológicas que se acompañan con frecuencia de HTIA como la pancreatitis aguda grave y el daño hepático crónico descompensado.

[Autoimmune pancreatitis: Report of 10 cases]. / Pancreatitis autoinmune: Experiencia clínica y revisión de la literatura.

BACKGROUND: Autoimmune pancreatitis is a special form of chronic pancreatitis, more common in men and usually presenting as obstructive jaundice or abdominal pain. It may be associated with other immunological disorders and sometimes it is possible to find positive serological markers. Typical images show pancreatic enlargement with focal or diffuse stenosis of the pancreatic duct but sometimes it presents as a focal pancreatic mass that is difficult to differentiate from pancreatic carcinoma. AIM: To report ten cases of autoimmune pancreatitis. MATERIAL AND METHODS: Retrospective review of clinical records of 10 patients aged 26 to 56 years (six males) with autoimmune pancreatitis. RESULTS: The clinical presentation was obstructive jaundice in six cases, acute pancreatitis in two, persistent increase in serum amylase and Upase in one, and permanent abdominal pain and weight loss in one. On imaging studies, a circumscribed mass was founded in six patients. An endoscopic retrograde colangiopancreatography was performed in four patients showing an abnormal pancreatic duct in all. Six patients were operated and tissue for pathological study was obtained in five, showing inflammatory infiltration. Vive patients were treated with steroids with a good clinical response. CONCLUSIONS: Autoimmune pancreatitis must be borne in mind in the differential diagnosis of pancreatic lesions.

Causas y complicaciones infecciosas de la pancreatitis aguda / Infectious complications in acute pancreatitis

La pancreatitis aguda es una enfermedad prevalente. En los últimos años hemos asistido a un progresivo aumento de la sobrevida conforme a los avances en el manejo intensivo. El grupo de pacientes con infección de la necrosis mantiene una elevada mortalidad (30-50 por ciento). Las estrategias preventivas de la infección de la necrosis se basan en el soporte nutricional y la profilaxis antibiótica. El manejo se fundamenta en el soporte general y en técnicas de drenaje desde las mínimamente invasivas, que se han desarrollado en los últimos años, hasta la cirugía tradicional. Se discute en detalle la profilaxis, diagnóstico y manejo de la necrosis infectada.

Acute pancreatitis is a prevalent disease that has experienced a progressive decline in mortality in last years due to intensive supportive care. Patients with necrosis infection still have worse prognosis with mortality ranging between 30-50 percent. Strategies to prevent necrosis infection include early enteral nutrition and antibiotic prophylaxis. Management is based on general support and removal of infected necrotic debris, including recently developed minimally invasive techniques and traditional surgery. This article discusses in detail topics on prophylaxis, diagnosis and treatment of infected necrosis.

Pancreatitis autoinmune: experiencia clínica y revisión de la literatura / Autoimmune pancreatitis: report of 10 cases

Background: Autoimmune pancreatitis is a special form of chronic pancreatitis, more common in men and usually presenting as obstructive jaundice or abdominal pain. It may be associated with other immunological disorders and sometimes it is possible to find positive serological markers. Typical images show pancreatic enlargement with focal or diffuse stenosis of the pancreatic duct but sometimes it presents as a focal pancreatic mass that is difficult to differentiate from pancreatic carcinoma. Aim: To report ten cases of autoimmune pancreatitis. Material and Methods: Retrospective review of clinical records of 10 patients aged 26 to 56 years (six males) with autoimmune pancreatitis. Results: The clinical presentation was obstructive jaundice in six cases, acute pancreatitis in two, persistent increase in serum amylase and Upase in one, and permanent abdominal pain and weight loss in one. On imaging studies, a circumscribed mass was founded in six patients. An endoscopic retrograde colangiopancreatography was performed in four patients showing an abnormal pancreatic duct in all. Six patients were operated and tissue for pathological study was obtained in five, showing inflammatory infiltration. Vive patients were treated with steroids with a good clinical response. Conclusions: Autoimmune pancreatitis must be borne in mind in the differential diagnosis of pancreatic lesions.

[Small intestine bacterial overgrowth in patients with chronic pancreatitis]. / Sobrecrecimiento bacteriano intestinal en pacientes con pancreatitis crónica.

BACKGROUND: Previous reports describe 30-40% of small intestine bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP), SIBO is a cause of persistent symptoms in this group of patients even when they are treated with pancreatic enzymes. AIM: To asses the frequency of SIBO in patients with CP. PATIENTS AND METHODS: We studied 14 patients with CP using an hydrogen breath test with lactulose to detect SIBO, a nonabsorbable carbohydrate, whose results are not influenced by the presence of exocrine insufficiency. Main symptoms and signs were bloating in 9 (64%), recurrent abdominal pain in 8 (57%), intermittent diarrhea in 5 (36%) and steatorrhea in 5 (36%). At the same time we studied a healthy control group paired by age and sex. RESULTS: SIBO was present in 13 of 14 patients with CP (92%) and in 1 of 14 controls (p<0.001). The only patient with CP and without SIBO was recently diagnosed and had minimal morphologic alterations in computed tomography and endoscopic pancreatography. CONCLUSIONS: SIBO is common in CP and may be responsible for persistent symptoms. Proper diagnosis and treatment could alleviate symptoms and improve quality of Ufe.

Sobrecrecimiento bacteriano intestinal en pacientes con pancreatitis crónica / Small intestine bacterial overgrowth in patients with chronic pancreatitis

Background: Previous reports describe 30-40 percent of small intestine bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP), SIBO is a cause of persistent symptoms in this group of patients even when they are treated with pancreatic enzymes. Aim: To asses the frequency of SIBO in patients with CP. Patients and methods: We studied 14 patients with CP using an hydrogen breath test with lactulose to detect SIBO, a nonabsorbable carbohydrate, whose results are not influenced by the presence of exocrine insufficiency. Main symptoms and signs were bloating in 9 (64 percent), recurrent abdominal pain in 8 (57 percent), intermittent diarrhea in 5 (36 percent) and steatorrhea in 5 (36 percent). At the same time we studied a healthy control group paired by age and sex. Results: SIBO was present in 13 of 14 patients with CP (92 percent) and in 1 of 14 controls (p<0.001). The only patient with CP and without SIBO was recently diagnosed and had minimal morphologic alterations in computed tomography and endoscopic pancreatography Conclusions: SIBO is common in CP and may be responsible for persistent symptoms. Proper diagnosis and treatment could alleviate symptoms and improve quality of life.

Hepatitis aguda alcohólica asociada a pancreatitis aguda grave / Acute alcoholic hepatitis and severe acute pancreatitis

Alcohol is a common cause of hepatic and pancreatic damage. Despite the widespread alcohol consumption simultaneous presentation of acute alcoholic hepatitis and pancreatitis is uncomnon. We describe a case of a patient with alcoholic hepatitis in association acute pancreatitis, who developed multiorgan failure and died. The association of liver and pancreatic disease in clinical practice is discussed.

El alcohol es un factor etiológico común de daño hepático y pancreático. A pesar de su extenso consumo la presentación simultánea de hepatitis y pancreatitis aguda alcohólica es excepcional. Se presenta un caso de esta situación, que evolucionó hacia la falla orgánica múltiple con desenlace fatal. Se discute la asociación de daño hepático y pancreático agudo en la práctica Clínica.

[Pancreatic exocrine function in diabetes mellitus. Determination of fecal elastase]. / Función pancreática exocrina en diabetes mellitus. Determinación de elastasa fecal.

BACKGROUND: One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. AIM: To study pancreatic exocrine function in diabetics patients. MATERIAL AND METHODS: Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. RESULTS: Mean age was 60+/-12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 microg/g) in 47 (67%) patients, mildly decreased (100-200 microg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic complications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy or with insulin requirement. CONCLUSIONS: One third of this group of diabetic patients had decreased levels of fecal elastase, that was associated with the time of evolution of diabetes. Patients with lower levels of elastase have significantly more steatorrhea. Among diabetics it is possible to find a group of patients with non diagnosed chronic pancreatitis.

Función pancreática exocrina en diabetes mellitus: Determinación de elastasa fecal / Pancreatic exocrine function in diabetes mellitus: Determination of fecal elastase

Background: One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. Aim: To study pancreatic exocrine function in diabetics patients. Material and methods: Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. Results: Mean age was 60±12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 µg/g) in 47 (67%) patients, mildly decreased (100-200 µg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic complications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy or with insulin requirement. Conclusions: One third of this group of diabetic patients had decreased levels of fecal elastase, that was associated with the time of evolution of diabetes. Patients with lower levels of elastase have significantly more steatorrhea. Among diabetics it is possible to find a group of patients with non diagnosed chronic pancreatitis.

Enfermedad Celíaca del adulto: experiencia clínica / Adult celiac disease: clinical experience

Background: The prevalence of celiac disease (CD) is unknown in Chile. We have recently noted a rise in the number of cases diagnosed among adults. Aim: To describe the clinical characteristics of a group of adult celiac patients. Patients and methods: Clinical data of patients older than 15 years with positive antitransglutaminase or antiendomysial autoantibodies and a duodenal biopsy characteristic of CD were retrospectively reviewed. Age at diagnosis, symptoms and signs and laboratory, endoscopic and histological findings, were analyzed. Results: Thirty seven patients (28 women), were studied. Median age at diagnosis was 41 years (range 15-69). Main symptoms and signs were diarrhea (78%), weight loss (38%) and abdominal pain (38%). Anemia was found in 49%, elevation of ESR in 57%, elevation of alkaline phosphatases in 54%, elevation of aspartate aminotransferase in 38% and a rise in alanine aminotransferase in 27%. Antiendomysial antibodies were positive in 17/22 (77%) and antitransglutaminase in 19/22 (86%) patients. Endoscopic findings were suggestive of CD in 47% of cases and duodenal biopsy showed intestinal villi atrophy in 34 (92%) patients. The three patients with normal histology had positive serology and a good response to gluten free diet. Conclusions: CD should be considered in the differential diagnosis of patients with unespecific digestive symptons, even when they present late in adult life. Serologic markers are a good diagnostic tool. A normal duodenal pathology does not exclude the diagnosis, if other diagnostic features are present.

[Adult celiac disease: clinical experience]. / Enfermedad Celíaca del adulto: experiencia clínica.

BACKGROUND: The prevalence of celiac disease (CD) is unknown in Chile. We have recently noted a rise in the number of cases diagnosed among adults. AIM: To describe the clinical characteristics of a group of adult celiac patients. PATIENTS AND METHODS: Clinical data of patients older than 15 years with positive antitransglutaminase or antiendomysial autoantibodies and a duodenal biopsy characteristic of CD were retrospectively reviewed. Age at diagnosis, symptoms and signs and laboratory, endoscopic and histological findings, were analyzed. RESULTS: Thirty seven patients (28 women), were studied. Median age at diagnosis was 41 years (range 15-69). Main symptoms and signs were diarrhea (78%), weight loss (38%) and abdominal pain (38%). Anemia was found in 49%, elevation of ESR in 57%, elevation of alkaline phosphatases in 54%, elevation of aspartate aminotransferase in 38% and a rise in alanine aminotransferase in 27%. Antiendomysial antibodies were positive in 17/22 (77%) and antitransglutaminase in 19/22 (86%) patients. Endoscopic findings were suggestive of CD in 47% of cases and duodenal biopsy showed intestinal villi atrophy in 34 (92%) patients. The three patients with normal histology had positive serology and a good response to gluten free diet. CONCLUSIONS: CD should be considered in the differential diagnosis of patients with unespecific digestive symptons, even when they present late in adult life. Serologic markers are a good diagnostic tool. A normal duodenal pathology does not exclude the diagnosis, if other diagnostic features are present.

Obesidad: factor de riesgo para esteatohepatitis y fibrosis hepática / Obesity as a risk factor for steatohepatitis and hepatic fibrosis

Background: Nonalcoholic fatty liver (NAFL) has been recognized as a cause of chronic liver disease. Its main risk factor is obesity. Aim: To describe the clinical and liver pathological findings in a group of patients who underwent surgery as obesity treatment. Patients and Methods: Sixty eight patients with severe or morbid obesity were subjected to surgery as obesity treatment. Each patient was evaluated with a complete clinical and laboratory medical assessment. A wedge of liver was excised during surgery. Liver biopsies were analyzed without knowledge of clinical and laboratory findings. The presence of steatosis, inflammation (portal or lobular), fibrosis and cirrhosis were recorded in the pathological analysis. Age and body mass index (BMI) were correlated with pathological data. Significance was set at a p value of less than 0.05. Results: Ninety one percent of patients had steatosis, 45 percent inflammation and 47 percent fibrosis. One patient had cirrhosis (1,4 percent). There was a statistically significant association between BMI and moderate or severe steatosis (p <0.03). There was also an association between BMI and portal (p=0.017) and lobular inflammation (p=0.034). A BMI over 40 kg/m2 (morbid obesity) was significantly associated with the presence of fibrosis (p=0.032). Moreover, the presence of moderate or severe steatosis was a risk factor for the development of hepatic fibrosis (p=0.026). Conclusions: Obesity is a major and independent risk factor for steatohepatitis and fibrosis. The degree of steatosis in the liver biopsy, is a risk factor for the development of fibrosis

Características clínicas y factores pronósticos en la insuficiencia hepática fulminante en adultos y niños / Clinical features and prognostic factors in fulminant hepatic failure in adults and children

La Insuficiencia Hepática Fulminante (IHF) es una entidad rápidamente fatal, secundaria a múltiples causas y se clasifica en hiperaguda, aguda y subaguda. El único tratamiento que modifica su pronóstico es el trasplante hepático ortotópico (THO). Objetivo: describir las características clínicas, manejo y evolución de pacientes adultos y niños con IHF. Pacientes y métodos: 51 casos de IHF, evaluando evolución, factores pronósticos, posible etiología y tratamientos realizados en el Hospital Clínico de la Universidad de Chile y Roberto del Río entre abril de 1990 y febrero del 2002. Resultados: 34 adultos (67 por ciento), edad de 46 ñ 17,6. Las causas principales fueron isquemia 29 por ciento, criptogénica 20 por ciento, drogas 14 por ciento y viral 11 por ciento. La presentación fue hiperaguda 53 por ciento, aguda 38 por ciento y subaguda 9 por ciento. Las complicaciones más frecuentes fueron respiratorias 67 por ciento, renal 67 por ciento, hematológicas 61 por ciento e infecciosas 55 por ciento. Diecisiete niños (33 por ciento), edad de 5 ñ 4,3. Las causas principales fueron viral 41,2 por ciento, criptogénica 29 por ciento, hepatitis autoinmune 17 por ciento. Las complicaciones más frecuentes fueron infecciosas 88 por ciento, cardiovascular 71 por ciento, respiratorias 65 por ciento y hematológicas 65 por ciento. Ingresaron a una Unidad de Pacientes Críticos 33 adultos y 17 niños. Sólo se transplantaron 3 (6 por ciento) pacientes (2 niños y un adulto), todos vivos hasta la fecha. La sobrevida sin transplante fue de 15 por ciento en los adultos y 20 por ciento en los niños. Conclusión: la IHF es una enfermedad de variada etiología y alta mortalidad, que requiere un manejo multidisciplinario y en que debería plantearse el THO como la única alternativa posible, si no hay contraindicación

Biopsia hepática: indicaciones, resultados y complicaciones en 349 procedimientos / Liver biopsy: indications, results and complications in 349 procedures

La Biopsia Hepática (BH) es un procedimiento de alto valor diagnóstico con mínimas complicaciones y escasa mortalidad Método. Revisión retrospectiva de 349 BH realizadas en el Hospital de la Universidad de Chile en un período de cinco años (1990-1994). Resultados. El 55 por ciento de las biopsias se realizó en mujeres y el 45 por ciento en hombres con una edad promedio general de 50 años. Las pruebas de coagulación promedio fueron tiempo de protrombina de 74 por ciento y recuento plaquetario de 190000. Las principales indicaciones fueron por daño hepático crónico de origen necroinflamatorio (alcohólico, viral o autoinmune) en un 47 por ciento y tumor hepático en un 22 por ciento. El 93 por ciento de las muestras se obtuvo por vía percutánea y el resto por vía transyular, laparoscópica o quirúrgica. El diagnóstico histológico se obtuvo en el 97,5 por ciento de los casos siendo los más frecuentes cirrosis y hepatitis crónica (35 por ciento), esteatosis hepática (13 por ciento) y la colestasis crónica (13 por ciento). Las complicaciones observadas fueron tres casos de hemoperitoneo, dos casos de hemo-neumotórax y un caso de biliperitoneo por punción vesicular. No hubo mortalidad en esta serie. Conclusiones: En el presente trabajo se confirma el valor diagnóstico y seguridad de la BH.