Manipulation of microbiota with probiotics as an alternative for treatment of hepatic encephalopathy.

Hepatic encephalopathy is a cerebral alteration mainly caused by hepatic insufficiency or portosystemic shunt. It ranges from minimal neurologic manifestations to coma in its overt stage. The multifactorial pathophysiology of hepatic encephalopathy has rendered numerous treatment alternatives, among which the modification of dysbiosis and hyperammonemia are currently considered to be effective, not only clinically, but also regarding cost. Recent work has developed knowledge of probiotics in different clinical settings including the relationship of the gut microenvironment to liver cirrhosis. The aim of this review was to analyze the results of clinical trials on the effect of different probiotics on hepatic encephalopathy.

Metabolic and genetic markers' associations with elevated levels of alanine aminotransferase in adolescents.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD), the most common chronic liver disease in adolescents, is a feature of metabolic syndrome (MetS). Obesity and insulin resistance (IR) are risk factors for NAFLD, as well as inflammation-related genetic markers. The relationship between metabolic or inflammation-related genetic markers and alanine aminotransferase (ALT) is not fully understood. We examined the relationship of MetS, metabolic and inflammation-related genetic markers with elevated ALT in adolescents. METHODS: A total of 674 adolescents participated in a cross-sectional study in Guadalajara, Mexico. Elevated ALT (>40 IU/L), a surrogate marker of NAFLD, and MetS (International Diabetes Federation definition) were evaluated. Obesity, IR, lipids, C-reactive protein (CRP) and genetic markers (TNFA-308G>A, CRP+1444C>T, IL1RN and IL6-597/-572/-174 haplotype) were evaluated. Multivariate logistic regression was performed. RESULTS: Elevated ALT was observed in 3% and 14.1% (total and obese, respectively) of the adolescents. Obesity (odds ratio [OR], 5.86; 95% confidence interval [95% CI], 1.16-25.89), insulin (OR, 8.51; 95% CI, 2.61-27.71), IR (OR, 9.10; 95% CI, 2.82-29.38), total cholesterol (TC) (OR, 3.67; 95% CI, 1.25-10.72), low-density lipoprotein-cholesterol (LDL-C) (OR, 3.06; 95% CI, 1.06-8.33), non-high-density lipoprotein-cholesterol (HDL-C) (OR, 3.88; 95% CI, 1.27-11.90) and IL1RN (OR, 4.64; 95% CI, 1.10-19.53) were associated with elevated ALT. Among males, ≥2 MetS criteria were associated with elevated ALT (OR, 4.22; 95% CI, 1.14-15.71). CONCLUSIONS: Obesity, insulin, IR, high TC, high LDL-C, high non-HDL-C and IL1RN polymorphism were associated with elevated ALT. Among males, ≥2 MetS criteria were associated with elevated ALT. There is an urgent need to reduce obesity and IR in adolescents to prevent NAFLD.

Ursodeoxycholic Acid Therapy in Patients with Primary Biliary Cholangitis with Limited Liver Transplantation Availability

ABSTRACT Introduction. There is little information on survival rates of patients with primary biliary cholangtis (PBC) in developing countries. This is particularly true in Latin America, where the number of liver transplants performed remains extremely low for patients with advanced liver disease who fulfill criteria for liver transplantation. The goal of this study was to compare survival rate of patients with PBC in developing countries who were treated with ursodeoxycholic acid (UDCA) versus survival of patients who received other treatments (OT) without UDCA, prescribed before the UDCA era. Material and methods. A retrospective study was performed, including records of 78 patients with PBC in the liver unit in a third level referral hospital in Mexico City. Patients were followed for five years from initial diagnosis until death related to liver disease or to the end of the study. Patients received UDCA (15 mg/kg/per day) (n = 41) or OT (n = 37) before introduction of UDCA in Mexico. Results. Response to treatment was higher in the group that received UDCA. In the five years of follow-up, survival rates were significantly higher in the UDCA group than in the OT group. The hazard ratio of death was higher in the OT group vs. UDCA group, HR 8.78 (95% Cl, 2.52-30.61); Mayo Risk Score and gender were independently associated with the risk of death. Conclusions. The study confirms that the use of UDCA in countries with a limited liver transplant program increases survival in comparison to other treatments used before the introduction of UDCA.(AU)

Ursodeoxycholic Acid Therapy in Patients with Primary Biliary Cholangitis with Limited Liver Transplantation Availability.

INTRODUCTION: There is little information on survival rates of patients with primary biliary cholangtis (PBC) in developing countries. This is particularly true in Latin America, where the number of liver transplants performed remains extremely low for patients with advanced liver disease who fulfill criteria for liver transplantation. The goal of this study was to compare survival rate of patients with PBC in developing countries who were treated with ursodeoxycholic acid (UDCA) versus survival of patients who received other treatments (OT) without UDCA, prescribed before the UDCA era. MATERIAL AND METHODS: A retrospective study was performed, including records of 78 patients with PBC in the liver unit in a third level referral hospital in Mexico City. Patients were followed for five years from initial diagnosis until death related to liver disease or to the end of the study. Patients received UDCA (15 mg/kg/per day) (n = 41) or OT (n = 37) before introduction of UDCA in Mexico. RESULTS: Response to treatment was higher in the group that received UDCA. In the five years of follow-up, survival rates were significantly higher in the UDCA group than in the OT group. The hazard ratio of death was higher in the OT group vs. UDCA group, HR 8.78 (95% CI, 2.52-30.61); Mayo Risk Score and gender were independently associated with the risk of death. CONCLUSIONS: The study confirms that the use of UDCA in countries with a limited liver transplant program increases survival in comparison to other treatments used before the introduction of UDCA.

Helicobacter pylori in esplenectomized patients with immune primary trombocytopenia / Helicobacter pylori en pacientes esplenectomizados con trombocitopenia inmune primaria

Background: Primary Immune Thrombocytopenia (TIP) is an autoimmune disease that accelerates the peripheral destruction of platelets and alters megakaryocytopoiesis. Helicobacter pylori infection and eradication has been associated with an increase in the platelet count in patients with IPT. The aim of this article is to evaluate the platelet response after H. pylori eradication in patients with chronic splenectomized IPT Methods: Between 2008 and 2009, adult patients with a diagnosis of chronic IPT, splenectomized; They were given breath test with carbon 13-labeled urea (PAU13C). Patients who tested positive received eradication treatment with amoxicillin, omeprazole and clarithromycin for 14 days. After 6 weeks of treatment, a second PAU13C was performed. Baseline platelet counts were performed and every six months until the completion of two years. Results: 40 patients, 34 women and 6 men were included, PAU13C was positive in 17 patients (42.5%). H. pylori eradication was obtained in 16 patients (94%) confirmed by post-treatment PAU13C. In the follow-up of the patients it was observed that there was increase of platelets in 7 of the patients with eradication of H. pylori, while of the patients not infected in 9 also an increase of platelets was observed. Conclusions: There were no differences in the increase in platelet count among patients positive or negative to the H. pylori breath test at followup at 24 months.

Introducción: La trombocitopenia inmune primaria (TIP) es una enfermedad autoinmune que acelera la destrucción periférica de las plaquetas y altera la megacariocitopoyesis. La erradicación de la infección por Helicobacter pylori se ha asociado al incremento en la cuenta de plaquetas en los pacientes con TIP. El objetivo de este trabajo fue evaluar la respuesta de plaquetas después de la erradicación del H. pylori en pacientes con TIP crónica esplenectomizados. Métodos: Entre 2008-2009 fueron incluidos pacientes adultos con diagnóstico de TIP crónica, esplenectomizados; se les realizó prueba de aliento con urea marcada con carbono 13 (PAU13C). Los pacientes que resultaron positivos a la prueba recibieron tratamiento de erradicación con amoxicilina, omeprazol y claritromicina por 14 días. Después de 6 semanas de tratamiento, se realizó una segunda PAU13C. Se realizaron cuenta de Plaquetas basal y cada seis meses hasta completar dos años. Resultados: Se incluyeron 40 pacientes, 34 mujeres y 6 hombres, la PAU13C resultó positiva en 17 pacientes (42.5%). La erradicación del H. pylori se obtuvo en 16 pacientes (94%) confirmado por PAU13C postratamiento. En el seguimiento de los pacientes se observó que hubo incremento de las plaquetas en 7 de los pacientes con erradicación del H. pylori, mientras que de los pacientes no infectados en 9 también se observó aumento de plaquetas. Conclusiones: No hubo diferencias en el incremento en la cuenta de plaquetas entre los pacientes positivos o negativos a la prueba de aliento para H. pylori en el seguimiento a 24 meses.

[Parenteral nutrition in pediatric patients: indications and complications in third level]. / Nutrición parenteral en pacientes pediátricos: indicación y complicaciones en tercer nivel.

BACKGROUND: Parenteral nutrition (PN) is a mixture that covers the nutritional needs when enteral nutrition is not an option; however, PN is not free of complications. The aim of our study was to determine the indication and frequency of NP complications in pediatric patients treated at a tertiary center. METHODS: Children receiving PN at the Hospital de Pediatría del Centro Médico Nacional Siglo XXI were included. Demographic and anthropometric characteristics were recorded, as well as the reason of indicating PN, the time of administration, and the complications associated to this type of nutrition. RESULTS: Sixty-nine pediatric patients with PN were included: 33 neonates, 18 infants (between one and 11 months of age), nine preschoolers (from 1 to 5 years of age), and nine children over five years of age. Instructions for initiating the PN were given for the treatment of 71 % of the patients with diseases of the digestive tract who were treated surgically. Complications of PN occurred in 87 % of the children and 76.7 % had more than one complication. Metabolic complications occurred in 98 % of the children while mechanical and infectious complications only in 1 %, respectively. CONCLUSIONS: Parenteral nutrition was indicated more frequently in pediatric patients with digestive diseases treated surgically. Metabolic complications were the main concern in pediatric patients with PN.

Introducción: la nutrición parenteral (NP) es una mezcla que cubre las necesidades nutricionales cuando no es posible lograr esta tarea por la vía enteral en el paciente; sin embargo, no está exenta de complicaciones. El objetivo del estudio fue conocer la indicación y la frecuencia de complicaciones de la NP en pacientes pediátricos atendidos en un centro de tercer nivel. Métodos: se incluyeron niños que recibieron NP en el Hospital de Pediatría del Centro Médico Nacional Siglo XXI del Instituto Mexicano del Seguro Social. Se registraron las características demográficas, antropométricas, la causa de la indicación de la NP, su tiempo de administración y las complicaciones asociadas a este tipo de nutrición. Resultados: se incluyeron 69 pacientes pediátricos: 33 recién nacidos (RN) y 18 lactantes entre uno y 11 meses de edad; nueve preescolares entre uno y cinco años, y nueve niños mayores de cinco años. Las enfermedades del tracto digestivo tratadas quirúrgicamente constituyeron el 71 % de las indicaciones para el inicio de NP. Se presentaron complicaciones en el 87 % de los pacientes y 76.7% tuvieron más de una complicación. Las complicaciones metabólicas representaron 98 %, las mecánicas 1 % y las infecciosas 1 %. Conclusión: la NP en este centro de tercer nivel se indicó principalmente a pacientes sometidos a cirugía del tracto digestivo.

Guidelines for the diagnosis and treatment of extrahepatic portal vein obstruction (EHPVO) in children.

INTRODUCTION: Extrahepatic portal vein obstruction is an important cause of portal hypertension among children. The etiology is heterogeneous and there are few evidences related to the optimal treatment. AIM AND METHODS: To establish guidelines for the diagnosis and treatment of EHPVO in children, a group of gastroenterologists and pediatric surgery experts reviewed and analyzed data reported in the literature and issued evidence-based recommendations. RESULTS: Pediatric EHPVO is idiopathic in most of the cases. Digestive hemorrhage and/or hypersplenism are the main symptoms. Doppler ultrasound is a non-invasive technique with a high degree of accuracy for the diagnosis. Morbidity is related to variceal bleeding, recurrent thrombosis, portal biliopathy and hypersplenism. Endoscopic therapy is effective in controlling acute variceal hemorrhage and it seems that vasoactive drug therapy can be helpful. For primary prophylaxis of variceal bleeding, there are insufficient data for the use of beta blockers or endoscopic therapy. For secondary prophylaxis, sclerotherapy or variceal band ligation is effective; there is scare evidence to recommend beta-blockers. Surgery shunt is indicated in children with variceal bleeding who fail endoscopic therapy and for symptomatic hypersplenism; spleno-renal or meso-ilio-cava shunting is the alternative when Mesorex bypass is not feasible due to anatomic problems or in centers with no experience. CONCLUSIONS: Prospective control studies are required for a better knowledge of the natural history of EHPVO, etiology identification including prothrombotic states, efficacy of beta-blockers and comparison with endoscopic therapy on primary and secondary prophylaxis.

Non-invasive markers of liver fibrosis in chronic liver disease in a group of Mexican children. A multicenter study.

INTRODUCTION: Identifying liver fibrosis is important to evaluate the severity of liver damage and to establish a prognosis. Utility of non-invasive markers of liver fibrosis has been proved in adults but there are few reports in children. The aim of this study was to evaluate Fibrotest® score and APRI suitability to identify children with liver fibrosis. MATERIAL AND METHODS: 68 children with chronic liver disease requiring liver biopsy were prospectively included from three 3rd-level pediatric hospitals. The same pathologist evaluated all liver biopsies; fibrosis degree was determined by METAVIR score. Serum samples were obtained to determine Fibrotest® and APRI. AUROC were used to determine cut-off and differentiate between advanced fibrosis (METAVIR F3, F4) and no fibrosis (F0). RESULTS: 68 biopsies were evaluated; METAVIR > F3 was identified in 26 (38%). Non invasive liver fibrosis markers to differentiate between advanced and no fibrosis were: Fibrotest® AUROC = 0.90 (95% CI 0.77-1.00) (cut-off value 0.35) sensitivity 88.00% (95% CI 68-96) and specificity 80% (95% CI 29-98); and for APRI AUROC = 0.97 (95% CI 0.92-1.00) (cut-off value 0.82), sensitivity 88% (95% CI 68-96) and specificity = 100% (95% CI 46-100). CONCLUSION: These results suggest the utility of Fibrotest® and APRI to identify advanced fibrosis; they can be recommended to select patients for liver biopsy and during patient follow-up.

Anatomical cardiac alterations in liver cirrhosis: an autopsy study.

BACKGROUND: It has been suggested that liver cirrhosis (LC), regardless of etiology, may be associated with anatomical cardiac alterations. OBJECTIVE: To describe the frequency and type of macroscopical anatomic cardiac abnormalities present in alcoholic and non-alcoholic cirrhotic patients in an autopsy series. MATERIAL AND METHODS: The autopsy records performed at our institution during a 12-year period (1990-2002) were reviewed. All cases with final diagnosis of LC were included, their demographic characteristics as well as cirrhosis etiology and macroscopic anatomical cardiac abnormalities (MACA) analyzed. Patients with any known history of heart disease prior to diagnosis of cirrhosis were excluded. RESULTS: A total of 1,176 autopsies were performed, of which 135 cases (11.5%) were patients with LC. Two patients with cardiac cirrhosis were excluded. Chronic alcohol abuse (29%) and chronic hepatitis due to hepatitis C virus (HCV) infection (20%) were the most common causes of cirrhosis. The etiology was not identified in 35% of the cases, even after exhaustive clinical, serological and/or radiological assessment. In the postmortem analysis, 43% of the cases were informed to have MACA (47% in the group of patients with alcoholic cirrhosis and 41% in other types of cirrhosis); this rate increased to 62% in patients with ascites. The most frequent alterations were cardiomegaly and left ventricular hypertrophy (LVH). CONCLUSION: The results confirm the high frequency of cardiac abnormalities in patients with cirrhosis, regardless of cirrhosis etiology.

Mucosectomía rectal con engrapadora sola y combinada con otros procedimientos quirúrgicos anorrectales: análisis multivariado de los factores que afectan el resultado clínico / Stapled rectal mucosectomy alone and in combination with other surgical anorectal procedures: multivariate analysis of factors affecting clinical outcome

Objetivo: Comparar el resultado clínico de la mucosectomía rectal con engrapadora (MRE) sola y de la MRE combinada con esfinterotomía y con plastia anal de colgajos cutáneos, y examinar qué factores influyen sobre las complicaciones y la satisfacción del paciente. Material y métodos: Se incluyeron pacientes con enfermedad hemorroidal grados II a IV sometidos a MRE sola o en combinación con otros procedimientos. Se analizaron las complicaciones posoperatorias, resolución de síntomas y grado de satisfacción. Resultados: 241 pacientes consecutivos con seguimiento mínimo de un año se dividieron en tres grupos: MRE sola (n = 187), MRE combinada con esfinterotomía (n = 31) y MRE combinada con plastia de colgajos (n = 23). Los pacientes con MRE con esfinterotomía presentaron un porcentaje de complicaciones mayor que el resto (32 versus 12.8 % y 13 %, respectivamente, p = 0.02). La MRE con esfinterotomía se asoció con mayor riesgo de complicaciones que la MRE sola (RM = 3.5, IC 95 % = 1.4-8.7); la inclusión exclusiva de epitelio columnar en la zona resecada se asoció con menor riesgo de complicaciones que cuando se incluyó además epitelio transicional (RM = 0.4, IC 95 % = 0.2-0.8). La resolución de síntomas preoperatorios en la mayor parte de los pacientes fue > 80 % en los tres grupos. No hubo asociación de complicaciones o del tipo de procedimiento con el grado de satisfacción. Cuando el porcentaje de síntomas resueltos fue < 80 % se asoció con grado bajo o intermedio de satisfacción (p < 0.001). Conclusiones: La resolución de los síntomas preoperatorios con los tres procedimientos es similar. La MRE con esfinterotomía tiene mayor riesgo de complicaciones. El grado de satisfacción se asocia con la resolución de los síntomas preoperatorios.

BACKGROUND: We undertook this study to compare the clinical outcome of stapled rectal mucosectomy (SRM) alone and in combination with sphincterotomy and cutaneous flap anoplasty and to determine the influence of factors related to complications and patient satisfaction. METHODS: Patients with second- to fourth-degree hemorrhoids who underwent SRM alone or in combination with other anorectal procedures were included. Postoperative complications, symptom resolution and patient satisfaction were analyzed. RESULTS: Two hundred forty one patients with a minimum follow-up of 1 year were divided into three groups: SRM alone (n = 187), SRM combined with sphincterotomy (n = 31) and SRM combined with cutaneous flap anoplasty (n = 23). Patients with SRM with sphincterotomy showed a higher complication rate than the other groups (32 vs. 12.8% and 13%, respectively, p = 0.02). SRM combined with sphincterotomy was associated with a higher rate of complications (OR = 3.5; 95% CI = 1.4-8.7). SRM alone with low mucosal resection was associated with a lower complications rate (OR = 0.4, 95% CI = 0.2-0.8). Resolution of preoperative symptoms was >80% among the three groups. There was no association between complications and type of procedure with satisfaction level. Resolution of symptoms <80% was associated with low/intermediate level of satisfaction (p <0.001). CONCLUSIONS: Resolution of preoperative symptoms is similar among the three groups. SRM combined with sphincterotomy has a higher risk of complications. The satisfaction level is associated with resolution of preoperative symptoms.

Acute pancreatitis in children with acute lymphoblastic leukemia treated with L-asparaginase.

BACKGROUND: L-asparaginase (L-asp) is used as part of the initial treatment in children with acute lymphoblastic leukemia (ALL), inducing remission in 83% to 95% of the treated patients. Major toxicity effects reported are hypersensitivity reactions and dysfunctions of the liver and pancreas. Acute pancreatitis (AP) induced by L-asp has been noted in 2.5% to 16% of the treated patients. The purpose of this study was to determine the frequency and outcome of AP in children with ALL treated with L-asp in a tertiary care pediatric hospital. METHODS: From January 1999 to June 2005, the charts of children with ALL admitted for L-asp treatment were reviewed. Data from children who developed AP were analyzed retrospectively. AP was defined as the presence of clinical data (nausea, vomiting, and abdominal pain), elevated pancreatic enzymes, and changes in the abdominal ultrasound and/or computed tomography (CT) scan. Clinical and biochemical data, abdominal ultrasound, and CT scan findings, complications, treatment, and outcome were analyzed retrospectively. RESULTS: During the last 6 years, 266 ALL new cases were started on chemotherapy including L-asp, of which 18 of 266 (6.7%) developed AP. Pancreatic necrosis by CT scan was found in 10 patients, peripancreatic collections and pseudocyst formation were detected in 5 and 3 cases, respectively, and resolved by cystogastrostomy or drainage. Two patients developed chronic pancreatitis and 3 diabetes. There was no relationship between number of doses and pancreatic toxicity. None of the patient died due to pancreatic toxicity. CONCLUSIONS: L-asp is an effective drug to treat ALL, the administration of L-asp requires the monitoring of pancreatic toxicity to detect AP and have treatment initiated as early as possible. Chronic complications after AP occur in almost one third of cases.

Stapled rectal mucosectomy alone and in combination with other surgical anorectal procedures: multivariate analysis of factors affecting clinical outcome.

BACKGROUND: We undertook this study to compare the clinical outcome of stapled rectal mucosectomy (SRM) alone and in combination with sphincterotomy and cutaneous flap anoplasty and to determine the influence of factors related to complications and patient satisfaction. METHODS: Patients with second- to fourth-degree hemorrhoids who underwent SRM alone or in combination with other anorectal procedures were included. Postoperative complications, symptom resolution and patient satisfaction were analyzed. RESULTS: Two hundred forty one patients with a minimum follow-up of 1 year were divided into three groups: SRM alone (n = 187), SRM combined with sphincterotomy (n = 31) and SRM combined with cutaneous flap anoplasty (n = 23). Patients with SRM with sphincterotomy showed a higher complication rate than the other groups (32 vs. 12.8% and 13%, respectively, p = 0.02). SRM combined with sphincterotomy was associated with a higher rate of complications (OR = 3.5; 95% CI = 1.4-8.7). SRM alone with low mucosal resection was associated with a lower complications rate (OR = 0.4, 95% CI = 0.2-0.8). Resolution of preoperative symptoms was >80% among the three groups. There was no association between complications and type of procedure with satisfaction level. Resolution of symptoms <80% was associated with low/intermediate level of satisfaction (p <0.001). CONCLUSIONS: Resolution of preoperative symptoms is similar among the three groups. SRM combined with sphincterotomy has a higher risk of complications. The satisfaction level is associated with resolution of preoperative symptoms.

[Causes of non-cardiac chest pain: multidisciplinary perspective]. / Causas de dolor torácico no cardiaco.

BACKGROUND: Non-cardiac chest pain (NCCP) is defined by recurrent episodes of substernal chest pain non related to ischemic heart disease, it's origin being in many cases the gastrointestinal tract; however, it may be associated to psychosomatic disorder. OBJECTIVES: To investigate the main causes of NCCP and to evaluate associated psychiatric comorbidity. METHODS: Patients with NCCP referred by a cardiologist were assessed underwent an upper endoscopy, ambulatory pH monitoring and stationary esophageal manometry. NCCP was considered gastro esophageal reflux disease (GERD) positive when the endoscopy and/or ambulatory pH monitoring were abnormal. When all results were normal, the symptom was considered as a functional chest pain (FCP). Patients were assessed by the Psychiatry service and diagnosed in accordance to the Diagnostic and Statistics Manual of Mental Diseases, fourth edition (DSM-IV). Several other test were applied for the assessment of anxiety and depression. RESULTS: Thirty-four patients were included (25 women and nine men; average age: 46.2 +/- 11.56 years). Three patients were eliminated because of refusal of the psychiatric evaluation. In 21 (68%) patients, NCCP was GERD-positive and in 10 (32%) to FCP. The most common symptoms associated to chest pain were: heartburn in 23 (74%), regurgitation in 21 (68%) and dysphagia in 15 (48%) patients. Upper endoscopy was abnormal in four cases; ambulatory pH monitoring was abnormal in 21 (67.7%) patients. The frequency of psychiatric disorders related to NCCP was 52%, in 10 patients with GERD-positive (48%) and six patients with FCP (60%). Mayor depression was the most common diagnoses identified among both groups. CONCLUSION: The high frequency of GERD and psychiatric disorders found in NCCP supports the multidisciplinary approach to NCCP.

Splenic hydatidosis: a rare differential diagnosis in a cystic lesion of the spleen.

Cystic tumours of the spleen are generally rare, and a parasitic origin is relatively unlikely. The present case report shows, however that when a splenic cyst is found, the differential diagnosis must always consider the possibility of echinococcosis. We report the case of a patient suffering from a cystic lesion of the spleen where surgery and histopathology yielded the diagnosis of splenic echinococcosis. Abdominal pain in the left upper quadrant and splenomegaly detected by simple abdominal radiology are the most commonly found indicators for this disease. The treatment should be surgical, attempting to preserve as much splenic tissue as possible, although conservative treatment is frequently unfeasable due to massive involvement of the spleen. Although rare, splenic hydatidosis should be included in the differential diagnosis when a cystic splenic lesion is identified with sonography or CT scan.

[Evaluation of lipid digestion using the 13C-mixed triglyceride breath test in patients with chronic pancreatitis]. / Evaluación de la digestión de lípidos por medio de la prueba en aliento con triglicérido mixto marcado con 13C en pacientes con pancreatitis crónica.

BACKGROUND: Steatorrhea represents the indirect sign of lipid maldigestion in chronic pancreatitis and even when the measurement of fecal fat is considered as a gold standard for the diagnosis of steatorrhea, this test is not commonly used within clinical practice because of the inconvenience related to sample collection. Although the use of breath test using mixted tryglicerides was initally validated as an indirect alternative for the assessment of exocrine pancreas reserve, only recently has used this method as a surrogate for the measurement of fat in feces. AIM: To evaluate fat digestion by means of the breath test with 13C labelled mixed triglycerides in patients with chronic pancreatitis. MATERIAL AND METHODS: Patients with chronic pancreatitis underwent clinical and biochemical evaluation. The latter included serum amylase, lipase, betacarotenes; fecal fat analysis and breath test using 13C-mixed tryglicerides. Breath test results are expressed as the percentage of 13C recovered in the breath sample. RESULTS: Seventeen patients (age: 45 +/- 5 years) were included, of which 7 had steatorrhea (fecal fat greater than 7 g/day). In patients with steatorrhea, the percentage of recovered 13C from breath was significantly lower (6 +/- 4%) than in patients without it (25 +/- 5%). CONCLUSION: Results suggest the uselfuness of breath test with 13C-mixed tryglicerides as an alternative for the assessment of lipid digestion in patients with chronic pancreatitis.

Frequency of increased aminotransferases levels and associated metabolic abnormalities in obese and overweight children of an elementary school in Mexico City.

BACKGROUND: Elevated ALT is an indirect marker of NAFLD in patients with non-alcohol abuse and without other known causes of chronic hepatitis. Obesity, type 2 diabetes and some dyslipidemias are associated to this condition. The purpose of this study was to determine the frequency of increased aminotransferases and associated metabolic anomalies among overweight and obese children. METHODS: Children from an elementary school with obesity or overweight were included. Medical history and anthropometrics measurements were recorded and serum liver function tests, lipid profile, glucose and insulin levels, and HOMA index were determined. NAFLD diagnosis was considered in those children with ALT>40 U/L and AST/ALT ratio<1 after exclusion of other causes of chronic hepatitis. RESULTS: Increase ALT levels (>40 U/L) were found in 34/ 80 (42%) obese and overweight children; mean age was 9.5+/-1.1 years and mean BMI of 25.8+/-3. The metabolic abnormalities in the study group were similar, there were no differences in insulin concentration, insulin resistance determined by HOMA-IR Index, serum lipid profile and serum glucose between children with or without increased ALT. CONCLUSIONS: The frequency (42%) of elevated ALT levels in children with excess body weight in this study was greater to those reported in other pediatric populations. There were no differences among the metabolic alterations with or without increased ALT; these findings support that the principal pathogenic factor involved in the development of the hepatic injury may be located in the liver.

Lack of agreement between the revised criteria of impaired fasting glucose and impaired glucose tolerance in children with excess body weight.

OBJECTIVE: The aim of this study was to describe the agreement between impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) in children with excess body weight using the original and the revised definitions of IFG. RESEARCH DESIGN AND METHODS: Obese and overweight children aged 4-17 years were included (n = 533). Anthropometric parameters and biochemical tests (fasting and 2-h glucose tests after an oral glucose load [1.75 g/kg]) were performed. Case subjects with a fasting plasma glucose >/=126 mg/dl were excluded. The diagnostic parameters of the original and the revised definitions of IFG for detecting IGT were estimated. The analysis of agreement between these categories was made using the kappa test. RESULTS: The prevalence of IFG increased from 6.2 to 13.3% using the new criteria. The prevalence of IFG became closer to the prevalence of IGT (14.8%). The revised criteria increased the sensitivity from 26.6 to 36.7%. However, the new IFG definition was not useful for identifying IGT cases. Of the 71 case subjects with IFG, only 29 (40.8%) had IGT. In addition, 50 case subjects with IGT (9.4%) and 13 with diabetes (2.4%) had a fasting glycemia <100 mg/dl. A poor agreement was found between the 2003 IFG definition and abnormal 2-h postchallenge plasma glucose (kappa = 0.359). The proportion of false-positive cases increased (36.3-59.1%) under the new definition. CONCLUSIONS: The new definition modestly increases the sensitivity of IFG for detecting IGT in children with excess body weight. Despite this, more than one-half of these cases are not detected. In addition, the false-positive rate was increased by 61%.

[Microscopic colitis]. / Colitis microscópica.

BACKGROUND: Microscopic colitis is responsible for a proportion of difficult diagnosis cases with chronic diarrhea. Diagnosis is clinically suspected when chemical and macroscopic examination result negative and is made only by histopathologic findings. OBJECTIVE: To describe clinical, biochemical, colonoscopic, and histologic features and the treatment response of four cases with microscopic colitis. METHODS: We inform on the findings in four females patients presenting with chronic watery diarrhea with normal biochemical and colonoscopic tests. RESULTS: In these cases, diagnoses mode were lymphocytic colitis two and collagenous colitis two. The long term duration of watery diarrhea was 5 months. The average number of depositions were 10 in 24 h. Diagnosis was made after microscopic examination of the colonic mucosa in the absence of endoscopic abnormalities and normal chemistries. All patients had a satisfactory response to treatment. CONCLUSIONS: The diagnosis of microscopic colitis is made by histopathology findings. The therapeutic response is generally satisfactory.

Case report of multiple myeloma and hypothyroidism in primary biliary cirrhosis

Se informa el caso de una mujer con cirrosis biliar primaria asociada a mieloma múltiple e hipotiroidismo. La biopsia hepática mostró daño histológico estadio II-III de la clasificación de Scheuer. El mieloma múltiple era estadio II-A y correspondió al tipo IgG-lambda. Se han informado otros tres casos adicionales en la literatura que presentaron cirrosis biliar primaria asociada a mieloma múltiple. Como grupo, los cuatro casos han cursado con daño hepatico leve moderado, con lesiones óseas extensas; en tres el mieloma múltiple ha sido del tipo IgG-lambda. Aunque esta asociación puede ser sólo incidental, existen evidencias que hacen sospechar una relación patológica entre estas enfermedades: este reporte resume esta información

El drenaje biliar endoscópico en colangitis supurativa aguda / Endoscopic bile drainage in acute suppurative cholangitis

La colangitis supurativa aguda es una entidad que amenaza la vida siendo la descomprensión biliar temprana, esencial para la supervivencia. Se analizó retrolectivamente la evolución de 31 pacientes (21 mujeres y 10 hombres con una edad promedio de 64 años) con colangitis supurativa aguda (CSA) a quienes se les realizó drenaje biliar (DB) endoscópico y/o esfinterotomía. Doce pacientes habían presentado cuadros previos sugestivos de colangitis en el año previo al procedimiento. La estancia hospitalaria fue de 18ñ12 días, ocurriendo cinco muertes durante la hospitalización, ninguna relacionada con la descompresión biliar, 16 pacientes tenían colecistectomía previa, 12 habían presentado colangitis en el año previo, 23 pacientes tuvieron coledocolitiasis y tres pacientes más tuvieron neoplasias pancreatobiliares y litiasis en colédoco. Sólo el 67.7 por ciento presentó la clásica triada de Charcot (fiebre, dolor abdominal e ictericia). Después del DB se observó disminución significativa en la concentración de bilirrubina total, aspartato aminotransferasa, alanino aminotransferasa y en el número total de leucocitos (p<0.05). La única complicación relacionada con el procedimiento endoscópico, fue la perforación retroperitoneal en un paciente. Estos resultados sugieren que la canulación endoscópica es un procedimiento seguro y efectivo para la descompresión biliar de emergencia para el tratamiento de la colangitis supurativa aguda