Esophageal involvement in a patient with pemphigus vulgaris.

Pemphigus vulgaris (PV) is characterized by acantholysis (loss of adhesion among keratinocytes), which leads to the formation of intraepithelial blisters. We present the case of a 43-year-old female with no prior medical history, who was diagnosed with PV due to persistent gingivitis and oral erosions.

Epistaxis en el paciente cirrótico: una complicación a tener en cuenta / Epistaxis in the cirrhotic patient: A complication to be considered

Introducción: La epistaxis en los pacientes cirróticos es un hecho frecuente. No obstante, la literatura publicada hasta la fecha es muy escasa. Material y métodos: Serie de casos retrospectiva de pacientes con cirrosis que presentaron una epistaxis significativa, entre los años 2006 y 2016. Resultados: Se recogieron datos de 39 pacientes cirróticos con una edad media de 61,4 (±14) años, 75% varones. Las principales comorbilidades fueron la hipertensión arterial (33%) y la diabetes mellitus (26%). Siete (18%) pacientes tomaban antiagregantes y 3 (8%) anticoagulantes. Un tercio de los pacientes tenían antecedentes de epistaxis y 6 presentaban alguna patología ORL previa. La principal etiología de la cirrosis fue el alcohol en el 46% de los casos, siendo 15 (38%) pacientes Child A, 12 (31%) Child B y 12 (31%) Child C. La mediana de MELD al ingreso fue de 16 [12-21]. Treinta y cinco (97%) pacientes presentaban hipertensión portal. Al ingreso, la mediana de plaquetas fue de 89.000 [60.000-163.000] y la media de INR de 1,52 (±0,37). Clínicamente, en 8 (21%) pacientes la epistaxis se presentó simulando una hemorragia digestiva como hematemesis o melenas al ser la sangre deglutida. En 10 (26%) pacientes la epistaxis fue considerada como el probable desencadenante de una encefalopatía hepática. Dos pacientes requirieron ingreso en UCI por el sangrado y 8 (21%) fallecieron durante el ingreso, por causas no directamente relacionadas con la epistaxis. Conclusiones: La epistaxis es una complicación a tener en cuenta, pudiendo actuar como desencadenante de encefalopatía o simular un episodio de hemorragia digestiva

Introduction: Epistaxis in cirrhotic patients is a common issue. However, the literature published to date is very scarce. Material and methods: Retrospective case series of patients with cirrhosis who presented with a significant epistaxis, between 2006 and 2016. Results: Data were collected from 39 cirrhotic patients with a mean age of 61.4 (±14) years, 75% of which were males. The main comorbidities were hypertension (33%) and diabetes mellitus (26%). Seven (18%) patients were taking antiplatelet drugs and 3 (8%) anticoagulants. One third of patients had a previous history of epistaxis and 6 had a previous ENT pathology. The main aetiological factor of cirrhosis was alcohol in 46% of cases, with 15 (38%) patients presenting with Child A, 12 (31%) Child B and 12 (31%) Child C class. The median MELD score upon admission was 16 [12-21]. Thirty-five (97%) patients had portal hypertension. At admission, the median platelet count was 89,000 [60,000-163,000] and mean INR was 1.52 (±0.37). Clinically, epistaxis presented as haematemesis or melaena in 8 (21%) patients, simulating gastrointestinal bleeding due to swallowing of blood. In 10 (26%) patients, epistaxis was considered as the probable trigger of an episode of hepatic encephalopathy. Two patients required ICU admission due to bleeding and 8 (21%) died during hospitalisation due to causes not directly related to epistaxis. Conclusions: Epistaxis is a complication to be taken into account in cirrhotic patients, as it can act as an encephalopathy trigger or simulate an episode of gastrointestinal bleeding

Epistaxis in the cirrhotic patient: A complication to be considered. / Epistaxis en el paciente cirrótico: una complicación a tener en cuenta.

INTRODUCTION: Epistaxis in cirrhotic patients is a common issue. However, the literature published to date is very scarce. MATERIAL AND METHODS: Retrospective case series of patients with cirrhosis who presented with a significant epistaxis, between 2006 and 2016. RESULTS: Data were collected from 39 cirrhotic patients with a mean age of 61.4 (±14) years, 75% of which were males. The main comorbidities were hypertension (33%) and diabetes mellitus (26%). Seven (18%) patients were taking antiplatelet drugs and 3 (8%) anticoagulants. One third of patients had a previous history of epistaxis and 6 had a previous ENT pathology. The main aetiological factor of cirrhosis was alcohol in 46% of cases, with 15 (38%) patients presenting with Child A, 12 (31%) Child B and 12 (31%) Child C class. The median MELD score upon admission was 16 [12-21]. Thirty-five (97%) patients had portal hypertension. At admission, the median platelet count was 89,000 [60,000-163,000] and mean INR was 1.52 (±0.37). Clinically, epistaxis presented as haematemesis or melaena in 8 (21%) patients, simulating gastrointestinal bleeding due to swallowing of blood. In 10 (26%) patients, epistaxis was considered as the probable trigger of an episode of hepatic encephalopathy. Two patients required ICU admission due to bleeding and 8 (21%) died during hospitalisation due to causes not directly related to epistaxis. CONCLUSIONS: Epistaxis is a complication to be taken into account in cirrhotic patients, as it can act as an encephalopathy trigger or simulate an episode of gastrointestinal bleeding.

Enteropatía pierde-proteínas resuelta tras la reparación de una eventración abdominal / Protein-losing enteropathy resolved after ventral abdominal hernia repair

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Pancreatitis aguda necrótica y aparición súbita de una masa abdominal: una complicación infrecuente / Acute necrotizing pancreatitis and sudden abdominal mass: An unusual complication

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Pancreatitis aguda como primera manifestación de un carcinoma microcítico de pulmón / Metastasis-induced aAcute pancreatitis as the initial presentation of a small cell lung carcinoma

Las metástasis de cualquier origen son una causa muy infrecuente de pancreatitis aguda. Se presenta el caso de una paciente con un episodio de pancreatitis aguda como manifestación inicial de un carcinoma microcítico de pulmón metastásico. Es importante excluir la presencia de tumores malignos en aquellos casos de pancreatitis aguda sin agente etiológico claro para mejorar el pronóstico de estos pacientes. Se revisó la literatura al respecto.

Metastases of different any origin that induceare a rare cause of acute pancreatitis are not frequent. We report the case 5 of a patient with an acute pancreatitis episode as the initial manifestation of an extended small cell lung carcinoma. The exclusion of malignancy in cases of pancreatitis of unknown origin is clinically relevant to improve the prognosis of these patients. We review the A literature review on about this topic is also presented.

Ataxia y síndrome frontal en una paciente joven resuelto con dieta sin gluten / Ataxia and frontal syndrome in a young woman resolved with a gluten-free diet

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¿Es posible suspender el tratamiento con antivirales orales en los pacientes con hepatitis crónica B antígeno e negativa? Experiencia y nuevas expectativas / Is it possible to stop treatment with nucleos(t)ide analogs in patients with e-antigen negative chronic hepatitis B? Experience and new expectations

INTRODUCCIÓN: El tratamiento de la hepatitis crónica B antígeno e negativa (HCB HBeAg negativa) con antivíricos orales (AO) suele prolongarse de forma indefinida debido a que la pérdida del antígeno de superficie como objetivo para su suspensión es un hecho infrecuente. Recientemente han aparecido las primeras evidencias que sugieren finalizar la terapia con AO en casos seleccionados. OBJETIVOS: Analizar la tasa de rebote virológico en pacientes con HCB Age negativa que suspendieron el tratamiento con AO. MATERIAL Y MÉTODOS: Estudio retrospectivo observacional que incluyó 140 casos de HCB HBeAg negativa. Veintidós pacientes, que recibieron exclusivamente AO, los suspendieron por diversos motivos realizándose un seguimiento posterior. Todos presentaban transaminasas normales, ADN indetectable y ausencia de cirrosis o comorbilidades importantes al finalizar el tratamiento. RESULTADOS: Doce pacientes presentaron rebote virológico (54,54%), transcurriendo una media de 6,38 meses (± 1,9) desde la suspensión hasta el rebote (el 75% dentro de los 12 primeros meses tras la suspensión). Cinco recibieron adefovir, uno lamivudina más adefovir, uno tenofovir y 5 lamivudina. La duración media del tratamiento, desde el inicio hasta la suspensión, fue de 38,5 meses (± 4,5). El grupo con respuesta sostenida presentaba una edad media y duración del tratamiento superior a los sujetos con rebote, si bien estas diferencias no resultaron estadísticamente significativas. CONCLUSIONES: Los resultados sugieren que es posible suspender la terapia con AO en casos seleccionados de HCB Age negativa, siempre que no exista cirrosis, se cumpla un tiempo mínimo de tratamiento, las transaminasas sean normales y el ADN indetectable de forma mantenida. En estos casos, se debe realizar un seguimiento estrecho durante el primer año y posteriormente de forma indefinida

BACKGROUND: Treatment of HBeAg-negative chronic hepatitis B (CHB) with nucleos(t)ide analogues (NA) is usually indefinite, since the loss of HBsAg, as a criterion for its discontinuation, is a rare event. Recent evidence suggests that discontinuing NA therapy may be feasible in selected patients. OBJECTIVES: To analyze the rate of virological relapse in patients with HBeAg-negative CHB who discontinued treatment with NAs. METHODS: We performed a single-center observational study that included 140 patients with HBsAg-negative CHB. Twenty-two patients, who received only NAs, discontinued treatment for different reasons and were subsequently monitored. All had normal ALT and AST, undetectable DNA and absence of cirrhosis or significant comorbidities before stopping treatment. RESULTS: Twelve patients showed virologic relapse (54.54%). The mean interval between discontinuation and relapse was 6.38 months (± 1.9) (75% relapsed during the first 12 months after discontinuation). Five received adefovir, 1 lamivudine and adefovir, 1 tenofovir and 5 lamivudine alone. The mean treatment duration in this group was 38.5 months (± 4.5). The sustained response group had a higher mean age and longer treatment duration than patients with virologic relapse but these differences were not statistically significant. CONCLUSIONS: The results suggest that NA treatment can be stopped in selected patients with CHB as long as they are not cirrhotic, have completed a minimum period of treatment, have normal ALT and sustained undetectable DNA. These patients should be closely monitored during the first year and then indefinitely

Orbital metastasis from hepatocellular carcinoma

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[Is it possible to stop treatment with nucleos(t)ide analogs in patients with e-antigen negative chronic hepatitis B? Experience and new expectations]. / ¿Es posible suspender el tratamiento con antivirales orales en los pacientes con hepatitis crónica B antígeno e negativa? Experiencia y nuevas expectativas.

BACKGROUND: Treatment of HBeAg-negative chronic hepatitis B (CHB) with nucleos(t)ide analogues (NA) is usually indefinite, since the loss of HBsAg, as a criterion for its discontinuation, is a rare event. Recent evidence suggests that discontinuing NA therapy may be feasible in selected patients. OBJECTIVES: To analyze the rate of virological relapse in patients with HBeAg-negative CHB who discontinued treatment with NAs. METHODS: We performed a single-center observational study that included 140 patients with HBsAg-negative CHB. Twenty-two patients, who received only NAs, discontinued treatment for different reasons and were subsequently monitored. All had normal ALT and AST, undetectable DNA and absence of cirrhosis or significant comorbidities before stopping treatment. RESULTS: Twelve patients showed virologic relapse (54.54%). The mean interval between discontinuation and relapse was 6.38 months (± 1.9) (75% relapsed during the first 12 months after discontinuation). Five received adefovir, 1 lamivudine and adefovir, 1 tenofovir and 5 lamivudine alone. The mean treatment duration in this group was 38.5 months (± 4.5). The sustained response group had a higher mean age and longer treatment duration than patients with virologic relapse but these differences were not statistically significant. CONCLUSIONS: The results suggest that NA treatment can be stopped in selected patients with CHB as long as they are not cirrhotic, have completed a minimum period of treatment, have normal ALT and sustained undetectable DNA. These patients should be closely monitored during the first year and then indefinitely.

Cápsula endoscópica y hemorragia digestiva de origen oscuro: ¿importa la forma de presentación? / Capsule endoscopy and obscure gastrointestinal bleeding: does the form of presentation matter?

INTRODUCCIÓN: La hemorragia digestiva de origen oscuro (HDOO) es aquella en la que no se consigue identificar su origen tras la evaluación mediante endoscopia digestiva alta y baja. En esos casos se sospecha un origen en intestino delgado. La HDOO puede ser oculta o manifiesta. El objetivo de este estudio es analizar las características clínico-analíticas, los hallazgos de la cápsula endoscópica e investigar qué factores se relacionan con la detección de lesiones en ambas formas de presentación. MÉTODOS: Estudio retrospectivo sobre las cápsulas endoscópicas realizadas entre noviembre de 2009 y noviembre de 2012 para el estudio de HDOO. RESULTADOS: Se analizaron 284 exploraciones de 272 pacientes. Inicialmente, 12 fueron no valorables y se repitieron, analizando finalmente las cápsulas evaluables (272). Ciento catorce (41,9%) fueron normales. Los pacientes con HDOO manifiesta tenían significativamente mayor edad (70,2 vs. 67,5 años; p = 0,04), consumían más AINE (24,2% vs. 11,9%; p = 0,01), tenían menores niveles de hemoglobina (9,3 vs. 10,4; p < 0,001) y requirieron más transfusiones (64,5% vs. 32,2%; p < 0,001) respecto a los pacientes con HDOO oculta. La detección de lesiones del tipo afta-úlcera y pólipo-masa no mostró diferencias significativas entre ambas formas de presentación. Las lesiones vasculares se detectaron con mayor frecuencia en la forma de HDOO manifiesta respecto a la forma oculta (40,3% vs. 25,7%, respectivamente), (p < 0,05). Considerando el total de diagnósticos realizados por la cápsula, no se observaron diferencias en la capacidad diagnóstica entre la forma manifiesta (57%) y la forma oculta (54%), (p = 0,6). El análisis multivariado mostró cómo el consumo de fármacos: AINE (OR 2,75; p = 0,01), antiagregantes y anticoagulantes (OR 2,64; p = 0,03), así como datos analíticos: hemoglobina (OR 3,23; p < 0,001) e INR (OR 1,8; p = 0,02) predijeron de forma estadísticamente significativa la detección de lesiones con la cápsula endoscópica en la forma de HDOO manifiesta. En la forma de presentación oculta, el análisis multivariado mostró que la edad (OR 1,9; p = 0,04) y el consumo de AINE (OR 2,1; p = 0,01) estaban estadísticamente relacionados con la detección de lesiones en la cápsula. CONCLUSIONES: La cápsula endoscópica es fundamental en la valoración de la HDOO. Aunque la capacidad diagnóstica fue similar entre ambas formas de presentación, las lesiones vasculares se detectaron con mayor frecuencia en el subtipo manifiesta. Teniendo en cuenta la forma de presentación de la HDOO (manifiesta vs. oculta) y algunas características clínico-analíticas de los pacientes (edad, consumo de fármacos, hemoglobina) se podría optimizar la capacidad diagnóstica de la cápsula

INTRODUCTION: Obscure gastrointestinal bleeding (OGIB) is defined as bleeding from the gastrointestinal tract with no obvious cause after assessment with upper and lower gastrointestinal endoscopy. In these cases, the source is suspected to be in the small bowel. Obscure bleeding can be occult or overt. The aim of this study was to analyze the clinical and analytical characteristics and findings on capsule endoscopy in patients with OGIB and to determine the factors related to the detection of lesions in both forms of presentation. METHODS: We performed a retrospective study of capsule endoscopies carried out between November 2009 and November 2012 for OGIB. RESULTS: We analyzed 284 capsule endoscopies in 272 patients. Initially, 12 procedures could not be evaluated and were repeated. A total of 272 procedures were finally included in the analysis. The results of 114 (41.9%) capsule endoscopies were normal. Compared with patients with occult OGIB, those with overt OGIB were significantly older (70.2 vs. 67.5 years; p = 0.04), consumed more NSAID (24.2% vs. 11.9%; p = 0.01), had higher hemoglobin levels (9.3 vs. 10.4; p < 0,001) and more frequently required transfusion (64.5% vs 32.2%; p < 0.001). No differences were found between the two forms of presentation in the detection of canker sores-ulcers and polyps-masses. Vascular lesions were more frequently detected in overt than in occult OGIB (40.3% vs. 25.7%, respectively), (p < 0.05). When the total number of diagnoses carried out by capsule endoscopy was analyzed, no differences were found in diagnostic yield between overt OGIB (57%) and occult OGIB (54%), (p = 0.6). In overt OGIB, multivariate analysis showed that the variables that significantly predicted the detection of lesions on capsule endoscopy were consumption of medication NSAID (OR 2.75; p = 0.01), antiplatelets and anticoagulants (OR 2.64; p = 0.03) and analytical data hemoglobin (OR 3.23; p < 0.001) and INR (OR 1.8; p = 0.02). In occult OGIB, multivariate analysis showed that the factors significantly related to the detection of lesions on endoscopy were age (OR 1.9; p = 0.04) and NSAID consumption (OR 2.1; p = 0.01). CONCLUSIONS: Capsule endoscopy is essential in the assessment of OGIB. Although the diagnostic yield was similar in both forms of presentation, vascular lesions were more frequently detected in overt OGIB. The diagnostic yield of capsule endoscopy could be optimized by taking into account the form of presentation (overt vs. occult) and certain clinical and analytic data (age, drug consumption, hemoglobin) (AU)

Atrofia vellositaria sin enfermedad celíaca: ¿un nuevo síndrome o más confusión? / Non celiac villous atrophy: More confusion or a new syndrome?

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Enteropatía por olmesartán / Enteropathy by olmesartan

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Elevación de enzimas pancreáticas y edema facial. Síndrome de DRESS / Elevation of pancreatic enzymes and facial edema. DRESS syndrome

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