[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.

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.

Mejora del curso clínico de la cirrosis hepática por virus de hepatitis C posterior al tratamiento efectivo con antivirales de acción directa / Improvement of clinical course of liver cirrhosis due to chronic hepatitis C after sucessful treatment with direct acting antivirals

RESUMEN Los antivirales de acción directa son drogas nuevas altamente efectivas y seguras para el tratamiento de la hepatitis C crónica. Sin embargo, a pesar de la erradicación del virus de hepatitis C en pacientes con cirrosis hepática descompensada, aun es controversial su efecto en la mejora del cuadro clínico, disminución de complicaciones asociadas, riesgo de desarrollo de hipertensión portal y hepatocarcinoma. Presentamos dos pacientes con cirrosis hepática descompensada Child B por hepatitis C quienes recibieron tratamiento con drogas antivirales de acción directa. Luego del tratamiento, y confirmada la carga viral indetectable - respuesta viral sostenida - ambos pacientes mostraron una mejora significativa del curso clínico de la cirrosis hepática - Child A - y disminución de los niveles de fibrosis hepática determinados por métodos no invasivos.

ABSTRACT Direct-acting antivirals are new drugs, highly effective and safe against chronic hepatitis C. However, despite of hepatitis C erradication in patients with decompensated liver cirrhosis, their effect in improving the clinical course, reducing liver-related complications and the risk of developing portal hypertension and hepatocellular carcinoma is still controversial. We present two patients with decompensated liver cirrhosis Child B due to hepatitis C who received treatment with direct-acting antiviral drugs. After treatment, and with the confirmation of undetectable viral load - sustained viral response - both patients showed significant improvement in the clinical course of liver cirrhosis - Child A - and a decrease in the amount of liver fibrosis measured with non invasive methods.

[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.

[Peruvian experience in the treatment of chronic hepatites C with the new direct acting antiviral drugs]. / Experiencia peruana en el tratamiento de hepatitis crónica C con las nuevas drogas antivirales de acción directa.

OBJECTIVE: The ideal therapy for chronic hepatitis C is the use of direct acting antivirals (DAA). In Peru there is no data in this aspect, in that sense it is necessary to report real life experience with these drugs. MATERIAL AND METHODS: A digital survey was sent through e-mail to hepatologists, and the data of four is considered in this study. Statistical analysis was descriptive. RESULTS: We included 63 patients, mean age was 59 years, 49.21% were male, cirrhosis was present in 49.21%, and 34.92% was non-responder to PEGIFN and Ribavirin. Genotype 1 was present in 93.65%, and subtype 1a was 58.73%, there were only 2 cases with Gt 2 and one with Gt 3. There were 10 different DAA combinations used, and the most effective were Sofosbuvir/Ledipasvir, Sofosbuvir/Ledipasvir/Ribavirina and Sofosbuvir/Simeprevir, in all these cases the Sustained Viral Response (SVR) was 100%. The other combinations had SVR < 90% or only 1-2 patients included. All patients tolerated treatments and no serious adverse events occurred. CONCLUSIONS: In real life antiviral treatment for hepatitis C with AAD is effective and well tolerated. The best SVR was obtained with Sofosbuvir/Ledipasvir, Sofosbuvir/Ledipasvir/Ribavirina and Sofosbuvir/Simeprevir. This report may be useful to consider treatment strategies with focus in public health.

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.

Experiencia peruana en el tratamiento de hepatitis crónica C con las nuevas drogas antivirales de acción directa / Peruvian experience in the treatment of chronic hepatites C with the new direct acting antiviral drugs

Objetivos: La terapia ideal para la hepatitis crónica C consiste en el uso de drogas antivirales de acción directa (DAA). En el Perú la experiencia en vida real con DAA no se conoce, por lo que el objetivo del presente estudio es reportar la alta eficacia terapéutica con estos esquemas. Material y métodos: Mediante correo electrónico se invitó a participar a través de una encuesta a médicos hepatólogos a nivel nacional. Se incluyeron los datos de 4 médicos. Los resultados fueron analizados con estadística descriptiva. Resultados: Se incluyeron 63 pacientes, la edad promedio fue 59 años, varones fueron 49,21%, cirrosis estuvo presente en el 49,21% (31/63), 34,92% había sido no respondedor a terapia con PEGIFN/RBV. El Genotipo 1 estuvo presente en 93,65% de casos, siendo el 1a el predominante (58,73%). Solo hubo dos casos de genotipo 2 y uno de genotipo 3. Se utilizaron 10 esquemas de combinación con DAA, siendo los más eficaces, Sofosbuvir/Ledipasvir, Sofosbuvir/Ledipasvir/ Ribavirina y Sofosbuvir/Simeprevir, en todos ellos se logró Respuesta Viral Sostenida (RVS) de 100%. Con los otros 7 esquemas la RVS fue menor a 90% o solo se había incluido uno o dos pacientes. La tolerancia a la terapia fue adecuada y todos los pacientes culminaron la terapia. Conclusiones: En vida real los esquemas de terapia antiviral para hepatitis C con DAA tienen alta eficacia y seguridad. Las mejores respuestas se obtuvieron con Sofosbuvir/Ledipasvir, Sofosbuvir/Ledipasvir/Ribavirina y Sofosbuvir/Simeprevir. Esta data puede ser útil para considerar estrategias de tratamiento con el enfoque de salud pública.

Objective: The ideal therapy for chronic hepatitis C is the use of direct acting antivirals (DAA). In Peru there is no data in this aspect, in that sense it is necessary to report real life experience with these drugs. Material and methods: A digital survey was sent through e-mail to hepatologists, and the data of four is considered in this study. Statistical analysis was descriptive. Results: We included 63 patients, mean age was 59 years, 49.21% were male, cirrhosis was present in 49.21%, and 34.92% was non-responder to PEGIFN and Ribavirin. Genotype 1 was present in 93.65%, and subtype 1a was 58.73%, there were only 2 cases with Gt 2 and one with Gt 3. There were 10 different DAA combinations used, and the most effective were Sofosbuvir/ Ledipasvir, Sofosbuvir/Ledipasvir/Ribavirina and Sofosbuvir/Simeprevir, in all these cases the Sustained Viral Response (SVR) was 100%. The other combinations had SVR < 90% or only 1-2 patients included. All patients tolerated treatments and no serious adverse events occurred. Conclusions: In real life antiviral treatment for hepatitis C with AAD is effective and well tolerated. The best SVR was obtained with Sofosbuvir/Ledipasvir, Sofosbuvir/Ledipasvir/Ribavirina and Sofosbuvir/Simeprevir. This report may be useful to consider treatment strategies with focus in public health.

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.

[Safety of gastroenterologist-directed propofol administration for endoscopic procedures: 10-year experience in a private clinic in Lima, Peru]. / Seguridad en la administración de propofol dirigido por gastroenterólogo entrenado en procedimientos endocópicos: experiencia de 10 años en clínica privada en Lima, Perú.

OBJECTIVE: To evaluate safety of propofol combined with Meperidine and Midazolam in colonoscopies, upper endoscopies (EGD) and Endoscopic Ultrasound (EUS) administered by a nurse supervised by a trained gastroenterologist. To compare the required doses of propofol among older and younger than 75 years old. MATERIALS AND METHODS: Retrospective descriptive study including patients 18 years of age and older who received propofol for EGD, colonoscopy (or EGD + colonoscopy) and EUS. The patients were given a baseline dose of Meperidine (25 mg) and Midazolam (1-3 mg) intravenously (IV). After 2-3 minutes, they received an IV bolus of propofol between 10-30 mg. Repeat boluses of 10-20 mg were administered at intervals no lesser than 60 seconds during the procedure, as needed according to patient`s tolerance to the procedure. RESULTS: Between September 2006 and September 2016, 9,704 procedures were performed, of which 1,598 were EGD, 3,065 colonoscopies, 2,492 EGD + colonoscopies and 57 EUS. There were 3,912 women (59.1%), and the average age was 57.1 ± 14.6 years. Eight hundred eighty (12.5%) were older than 75 years. The average dose of propofol for all the procedures was 83.2 ± 48.1 mg, for EGD and colonoscopy was 59.7 ± 36.2 mg and 77.2 ± 41 mg respectively. The average dose used in patients >75 years for EGD was 47.5 ± 37.8 mg, for colonoscopies 58.3 ± 33.4 mg and for EGD + colonoscopies was 78.7 ± 42.7 mg compared to patients <75 years in whom the average dose for EGD was 61.1 ± 35.8 mg (p<0.05), in colonoscopies was 80.5 ± 41.3 mg (p<0.05) and in EGD + colonoscopies 105.9 ± 50.2 mg (p<0.05). There were no sedation-related complications. CONCLUSIONS: Propofol combined with meperidine and midazolam in endoscopic procedures directed by a trained gastroenterologist is safe. Elderly patients (>75 years old) required significantly less doses of propofol for EGD, colonoscopy, EGD/colonoscopy and EUS.

Seguridad en la administración de propofol dirigido por gastroenterólogo entrenado en procedimientos endocópicos: experiencia de 10 años en clínica privada en Lima, Perú / Safety of gastroenterologist-directed propofol administration for endoscopic procedures: 10-year experience in a private clinic in Lima, Peru

Objetivo: Evaluar la seguridad de propofol combinado con meperidina y midazolam en colonoscopías, endoscopías y ecoendoscopía administrado por una enfermera supervisada por un gastroenterólogo entrenado y comparar su requerimiento en pacientes menores y mayores de 75 años. Material y métodos: Estudio descriptivo retrospectivo, que incluyó a pacientes mayores de 18 años de edad que recibieron propofol durante la endoscopía, colonoscopía (o endoscopía+colonoscopía) y ecoendoscopía. A los pacientes se les administró una dosis inicial de Meperidina (25 mg) y Midazolam (1-3 mg) por vía intravenosa (IV). Después de 2-3 minutos recibieron un bolo IV de propofol entre 10-30 mg. Se administraron bolos repetidos de 10-20 mg a intervalos no menores a 60 segundos durante cada procedimiento, titulado según necesidad y tolerancia del paciente. Resultados: Entre septiembre del 2006 y septiembre del 2016, se realizaron 9 704 procedimientos endoscópicos: 1 598 endoscopías, 3 065 colonoscopías, 2 492 endoscopía + colonoscopía y 57 eco-endoscopías. Hubo 3 912 mujeres (59,1%), la edad promedio fue de 57,1 ± 14,6 años, 880 pacientes (12,5%) mayores de 75 años. La dosis media de propofol para todos los procedimientos fue de 83,2 ± 48,1 mg, para la endoscopía y colonoscopía fue de 59,7 ± 36,2 mg y 77,2 ± 41 mg respectivamente. La dosis media utilizada en pacientes mayores de 75 años en endoscopía fue de 47,5 ± 37,8 mg, colonoscopías de 58,3 ± 33,4 mg y endoscopía + colonoscopía de 78,7 ± 42,7 mg en comparación con pacientes < 75 años en los que la dosis promedio de endoscopía fue de 61,1±35,8 mg (p <0,05), en colonoscopías de 80,5±41,3 mg (p<0,05) y en endoscopías+colonoscopías 105,9 ± 50,2 mg (p<0,05). No hubo complicaciones relacionadas con la sedación. Conclusiones: Propofol combinado con meperidina y midazolam en procedimientos endoscópicos, administrado por enfermera y dirigidos por un gastroenterólogo entrenado, es seguro. Los pacientes mayores de 75 años, necesitaron dosis significativamente menores de propofol para endoscopía, colonoscopia, endoscopía + colonoscopia y ecoendoscopía.

Objective: To evaluate safety of propofol combined with Meperidine and Midazolam in colonoscopies, upper endoscopies (EGD) and Endoscopic Ultrasound (EUS) administered by a nurse supervised by a trained gastroenterologist. To compare the required doses of propofol among older and younger than 75 years old. Materials and methods: Retrospective descriptive study including patients 18 years of age and older who received propofol for EGD, colonoscopy (or EGD + colonoscopy) and EUS. The patients were given a baseline dose of Meperidine (25 mg) and Midazolam (1-3 mg) intravenously (IV). After 2-3 minutes, they received an IV bolus of propofol between 10-30 mg. Repeat boluses of 10-20 mg were administered at intervals no lesser than 60 seconds during the procedure, as needed according to patient`s tolerance to the procedure. Results: Between September 2006 and September 2016, 9,704 procedures were performed, of which 1,598 were EGD, 3,065 colonoscopies, 2,492 EGD + colonoscopies and 57 EUS. There were 3,912 women (59.1%), and the average age was 57.1 ± 14.6 years. Eight hundred eighty (12.5%) were older than 75 years. The average dose of propofol for all the procedures was 83.2 ± 48.1 mg, for EGD and colonoscopy was 59.7 ± 36.2 mg and 77.2 ± 41 mg respectively. The average dose used in patients >75 years for EGD was 47.5 ± 37.8 mg, for colonoscopies 58.3 ± 33.4 mg and for EGD + colonoscopies was 78.7 ± 42.7 mg compared to patients <75 years in whom the average dose for EGD was 61.1 ± 35.8 mg (p<0.05), in colonoscopies was 80.5 ± 41.3 mg (p<0.05) and in EGD + colonoscopies 105.9 ± 50.2 mg (p<0.05). There were no sedation-related complications. Conclusions: Propofol combined with meperidine and midazolam in endoscopic procedures directed by a trained gastroenterologist is safe. Elderly patients (>75 years old) required significantly less doses of propofol for EGD, colonoscopy, EGD/colonoscopy and EUS.

[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.

[Gastric hemangioma as a cause of upper gastrointestinal bleeding]. / Hemangioma gástrico como causa de hemorragia digestiva alta.

Gastric hemangioma as a cause of upper gastrointestinal bleeding (UGIB) is a rare event. We present the case of an 83 years old male with a history of abdominal pain, vomiting and melena, along with an 8 Kg weight loss. The upper gastrointestinal endoscopy showed an elevated, ulcerated lesion in the gastric antrum with a visible vessel, for which he receives endoscopic therapy. In the abdominal computed tomography, a contrast enhancing, well-circumscribed mass attached to the gastric wall is observed. Due to the persistence of the UGIB, the patient suffers hemodynamic decompensation and undergoes exploratory laparotomy, where a vascularized mass is found. The pathology report informs a gastric cavernous hemangioma.

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

Penetrating gastric ulcer as a manifestation of multisystemic tuberculosis.

We present the case of a 30-year old female with a history of abdominal pain, fever, poor oral tolerance and weight loss for 6 months. An abdominal CT scan showed marked gastric dilatation due to extrinsic compression from lymphadenopathies around the second portion of the duodenum. The upper endoscopy revealed the presence of a penetrating gastric ulcer in the greater curvature. Biopsies of the lesions showed hystiocytes with granulomatous features and Acid Fast Bacilli (AFB) positive, and the cultures grew Mycobacterium tuberculosis sensitive to Isonazid and Rifampin. Subsequently anti-TB regimen was initiated achieving great clinical and endoscopic improvement.

Penetrating gastric ulcer as a manifestation of multisystemic tuberculosis / Úlcera gástrica penetrante como manifestación de tuberculosis multisistémica

We present the case of a 30-year old female with a history of abdominal pain, fever, poor oral tolerance and weight loss for 6 months. An abdominal CT scan showed marked gastric dilatation due to extrinsic compression from lymphadenopathies around the second portion of the duodenum. The upper endoscopy revealed the presence of a penetrating gastric ulcer in the greater curvature. Biopsies of the lesions showed hystiocytes with granulomatous features and Acid Fast Bacilli (AFB) positive, and the cultures grew Mycobacterium tuberculosis sensitive to Isonazid and Rifampin. Subsequently anti-TB regimen was initiated achieving great clinical and endoscopic improvement.

Se presenta un caso de una mujer de 30 años de edad con historia de dolor abdominal, fiebre, poca tolerancia oral y pérdida de peso por 6 meses. Un CT scan abdominal muestra dilatación marcada gástrica debido a una compresión extrínseca por adenopatías alrededor de la segunda porción del duodeno. Una endoscopía alta revela la presencia de una úlcera gástrica penetrante en la curvatura mayor. Las biopsias mostraron histiocitos con granulomatosis y bacilos acid fast positivos y en los cultivos crecieron micobacterium tuberculosis sensibles a isoniacidad y rifampicina. Subsecuentemente se inició el régimen anti TBC lográndose una mejoría clínica y endoscópica evidente.