Hígado graso no alcohólico / Non-alcoholic fatty liver disease

La esteatosis hepática no alcohólica es la acumulación excesiva de grasa en el hígado, en ausencia de causas secundarias y constituye la etiología frecuente de enfermedad hepática crónica sin terapia efectiva demostrada. La enfermedad incluye esteatosis, inflamación, fibrosis/cirrosis y hepatocarcinoma. El fenómeno inicial ocurre en la grasa corporal, con hipertrofia adipocitaria, liberación de adipoquinas y citoquinas pro-inflamatorias, que inducirán resistencia a la insulina. Este fenómeno provocará liberación de ácidos grasos a la circulación, captados por hepatocitos. En su evaluación clínica existen diferentes algoritmos con múltiples variables, limitando la biopsia hepática solo a casos excepcionales. Es esencial modificar el estilo de vida y bajar de peso. En diabéticos, metformina y pioglitazona son de primera elección. Los bloqueadores de la angiotensina son útiles en hipertensos con EHNA. Para prevenir la progresión de la enfermedad y en pacientes no diabéticos, asociar vitamina E. Las estatinas pueden utilizarse dada la asociación con patología cardiovascular.

Nonalcoholic fatty liver disease is characterized by excessive hepatic fat accumulation in the abscence of secundary causes. It is the most common cause of chronic liver disease. The spectrum ranges from benign steatosis, steatohepatitis, cirrhosis and hepatocarcinoma. The initial event is the hyperthofied adipocytes, and the release of adipokines and chemokines, that induce insulin resistance, and then free fatty acids into the circulation that accumulate in the liver. Algorithms have been proposed to target liver biopsy only to select patients. Lifestyle modifications to achieve weight loss are essential for all patients with NAFLD. For diabetics treatment should be with metformin and pioglitazone if glycaemic control is not achieved. Angiotensin receptor blockers are the antihypertensive agent of choice in patients with nonalcoholic steatohepatitis (NASH). If lifestyle changes and metabolic syndrome are unsuccessful in preventing disease progression, vitami E should be considered, also in non-diabetic patients with advance (NASH).

Fístula arterio-venosa intrahepática como causa de hipertensión portal no cirrótica, en paciente portador de hepatitis autoinmune: diagnóstico y tratamiento: caso clínico / Autoimmune hepatitis patient carrier with non cirrhotic portal hypertension caused by an intrahepatic portal arteriovenous fistula: diagnosis and treatment: clinical case

Portal hypertension (PH) is defined as pathological increase of hydrostatic pressure in the portal venous system, usually related to liver cirrhosis. Among the uncommon causes of PH is the arteriovenous intra or extrahepatic fistula (AVF) of traumatic, iatrogenic or congenital origin. Clinical history and ultrasound findings of AVF are very important for the diagnosis. From a therapeutic point of view, there are three alternatives: clinical/imaging follow-up, surgical repair and transcutaneous catheter embolization. A report of a clinical case and a review of the literature are presented. Patient with portal hypertension as a result of intra hepatic AVF, successfully treated by transcutaneous catheter embolization. A 54 year-old female patient, and cholecystectomized and with history of breast cancer, presented altered liver function tests several months after gallbladder surgery. Once biliary disease was ruled out, liver biopsy was performed, which was compatible with autoimmune hepatitis. During follow-up, intrahepatic AVF was observed by means of ultrasound. Underlying disease was successfully managed with Prednisone and Azathioprine. Nine years later, she experienced an episode of confusion and disorientation compatible with hepatic encephalopathy (HE) and esophageal varices diagnosed by upper endoscopy. Laboratory tests and imaging did not show progression baseline liver disease. Angiographic procedures confirmed an intra hepatic AVF and selective embolization was carried out. There was clinical remission of HE and esophageal varices. We concluded, that transcutaneous catheter embolization is a valid alternative for the treatment of intra hepatic AVF, which accounted for the successful result for this particular patient.

La hipertensión portal (HP) se define como el aumento patológico de la presión hidrostática en el sistema venoso portal, habitualmente relacionada con cirrosis hepática. Entre las causas infrecuentes de HP está la fístula arterio-venosa (FAV) intra o extrahepática de origen traumáticas, iatrogénicas o congénitas entre otras. En el diagnóstico son importantes los antecedentes clínicos y hallazgos ecográficos que demuestran FAV. Desde el punto de vista terapéutico, existen tres alternativas: seguimiento clínico y de imágenes, reparación quirúrgica y embolización con catéter transcutáneo. Se presenta caso clínico de paciente con (HP) a consecuencia de una FAV intrahepática, tratada satisfactoriamente mediante embolización con catéter transcutáneo y revisión de la literatura pertinente. Se trata de una paciente de 54 años con antecedentes de cáncer mamario y colecistectomía en quien se constatan alteraciones de pruebas hepáticas varios meses con posterioridad a cirugía vesicular. Una vez descartada patología biliar, se realizó biopsia hepática la que fue compatible con hepatitis autoinmune. Durante el seguimiento se pesquisó FAV intrahepática como hallazgo ecográfi co. Su enfermedad de base se trató satisfactoriamente con Prednisona y Azatioprina. Nueve años más tarde, consulta por episodio de confusión y desorientación compatible con encefalopatía hepática (EH) y presencia de várices esofágicas a la endoscopia. Tanto el laboratorio como imágenes no mostraron progresión de enfermedad hepática de base. Es sometida a procedimiento angiográfico, que confirmó FAV intrahepática, procediendo a embolización selectiva. Hubo remisión del cuadro clínico de EH y regresión de las várices esofágicas. Se concluye que la embolización con catéter transcutáneo, es una alternativa válida en el tratamiento de FAV intrahepáticas, terapia que constituyó la solución definitiva del cuadro clínico reportado.

Cirrosis biliar primaria: experiencia de trece años en dos centros de referencia / Primary biliary cirrhosis: a thirteen years experience

Background: Primary biliary cirrhosis (PBC) is a chronic cholestatic disease, which can progress to hepatic failure. Aim: To study the clinical presentation, pathological features, treatment and outcome of a group of patients with PBC. Material and methods: Retrospective review of medical records of 115 patients (110 females, age range 30-76 years) with PBC. Clinical presentation, pathological stage, treatment, outcome and eventual use of liver transplantation, were recorded. Result: Seventy eight percent of patients were symptomatic at presentation (itching in 69% and malaise in 62%). Antimitochondrial antibodies were positive in 56%. No clinical or laboratory differences were observed between symptomatic patients or those with positive antimitochondrial antibodies and the rest of the study group. Sjögren syndrome was present in 38%, hypothyroidism in 13%, scleroderma in 7% and rheumatoid arthritis in 5%. Initially, 61% had fibrosis and/or cirrhosis, and ursodeoxycholic acid was indicated in 94% of the patients. Fifteen patients underwent liver transplantation due to upper digestive bleeding or itching. Survival has been 67% at 36 months after transplantation. In one transplanted liver, PBC recurred. Conclusions: An early diagnosis and treatment of a progressive disease such as PBC will reduce the incidence of complications and the use of costly treatments.