Experiencia inicial con derivación biliar mediante coledocoduodenostomía guiada por ultrasonido endoscópico en la obstrucción biliar maligna en un hospital de referencia en Colombia / Initial experience with endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy (EUS-CDS) in malignant biliary obstruction in a reference hospital in Colombia

Resumen Introducción: en pacientes con obstrucción biliar distal maligna en quienes la derivación biliar mediante colangiopancreatografía retrógrada endoscópica (CPRE) no sea factible o sea fallida, el drenaje biliar guiado por ultrasonido endoscópico mediante coledocoduodenostomía es una opción terapéutica viable, de la que se describen altas tasas de éxito técnico y clínico con una baja morbimortalidad. Adicionalmente, este método podría ser superior en la mejora de la calidad de vida en comparación con el manejo percutáneo o quirúrgico. Objetivo: describir la experiencia inicial con el drenaje biliar guiado por ultrasonido endoscópico en pacientes con obstrucción biliar maligna en un centro de referencia. Métodos: es una serie de casos retrospectiva de 6 pacientes con obstrucción biliar maligna a quienes se les realizó inicialmente una CPRE que fue fallida, por lo cual se procedió a realizar coledocoduodenostomía guiada por ultrasonografía endoscópica. Se describieron las tasas de éxito técnico, éxito clínico, eventos adversos, tasas de disfunción y tiempo de supervivencia de los pacientes. Resultados: se analizaron 6 casos, predominó el sexo femenino, con un promedio de edad de 71,8 ± 19,8 años; las indicaciones fueron adenocarcinoma de páncreas, tumor periampular y colangiocarcinoma distal. Se observó un éxito técnico en el 100 % de los casos y éxito clínico en 83,3 % de los casos. No se registraron eventos adversos graves. En el seguimiento de los casos se observó una supervivencia del 66,7 % a los 30 días. Conclusión: la coledocoduodenostomía es una alternativa terapéutica viable, segura y efectiva en pacientes con obstrucción biliar maligna en quienes la CPRE fue fallida, con una alta tasa de éxito técnico y clínico.

Abstract Introduction: Patients with malignant biliary distal obstruction who cannot be treated with endoscopic retrograde cholangiopancreatography (ERCP) or who had a failed ERCP, can find alternative treatment in endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy. EUS-CDS performs with high rates of technical and clinical success and with low rates of morbimortality. Moreover, this method could have the potential to improve the patient's quality of life, compared with percutaneous or surgical means. Objective: This study aims to describe the initial experience with endoscopic ultrasound-guided biliary drainage in patients with malignant biliary distal obstruction in a reference center. Methods: Retrospective case review of six patients with malignant biliary obstruction and prior ERCP-placed and failed. Endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy was performed as an alternative method. Technical and clinical success rates, adverse event rates, dysfunction rates, and patient survival time were described. Results: 6 cases were analyzed with a higher proportion of female patients, with a mean age of 71,8 ± 19,8 years. The symptoms were related to pancreas adenocarcinoma, periampullary tumor, and distal cholangiocarcinoma. The procedure was technically successful in 100% of cases and clinically successful in 83% of cases. Serious adverse events were nor reported. After 30 days, a survival rate of 66,7 % was observed. Conclusion: Choledochoduodenostomy is a viable, safe, and effective method in patients with malignant biliary obstruction who had a failed ERCP, and it has high rates of technical and clinical success.

Chronic copper poisoning in beef cattle in the state of Mato Grosso, Brazil / Intoxicação crônica por cobre em bovinos de corte no Estado de Mato Grosso, Brasil

Copper is an essential micromineral in animal feed; however, when consumed in excess, it can cause liver necrosis, hemolytic crisis, hemoglobinuric nephrosis and death in cattle. Although uncommon in this species, copper poisoning occurs as a result of exacerbated supplementation, deficiency of antagonist microminerals, or previous liver lesions. An outbreak of chronic copper poisoning is reported in semi-confined cattle after supplementation with 50 mg/Kg of dry matter copper. The cattle showed clinical signs characterized by anorexia, motor incoordination, loss of balance, jaundice, brownish or black urine, diarrhea and death, or were found dead, 10 to 302 days after consumption. Of the 35 cattle that died, 20 underwent necropsy, whose frequent findings were jaundice, enlarged liver with evident lobular pattern, black kidneys, and urinary bladder with brownish to blackish content. Microscopically, the liver showed vacuolar degeneration and/or zonal hepatocellular centrilobular or paracentral coagulative necrosis, in addition to cholestasis, mild periacinal fibrosis, apoptotic bodies, and mild to moderate mononuclear inflammation. Degeneration and necrosis of the tubular epithelium and intratubular hemoglobin cylinders were observed in the kidneys. Copper levels in the liver and kidneys ranged from 5,901.24 to 28,373.14 µmol/kg and from 303.72 to 14,021 µmol/kg, respectively. In conclusion, copper poisoning due to excessive nutritional supplementation is an important cause of jaundice, hemoglobinuria, and death in semi-confined cattle.(AU)

Cobre é um micromineral essencial, que quando em excesso induz necrose hepática, crise hemolítica, nefrose hemoglobínurica e morte em bovinos. As intoxicações, apesar de incomuns nessa espécie, ocorrem devido a suplementação exacerbada de cobre, pela deficiência de microminerais antagonistas ou secundária a lesão hepática prévia. Relata-se um surto de intoxicação crônica por cobre em bovinos semiconfinados após suplementação com 50mg/kg de cobre em matéria seca. Os bovinos manifestaram sinais clínicos caracterizados por anorexia, incoordenação motora, perda de equilíbrio, icterícia, urina acastanhada ou negra, diarreia e morte ou foram encontrados mortos, após 10 a 302 dias do início de consumo. De 35 bovinos que morreram 20 foram submetidos à necropsia sendo achada frequente icterícia, fígado aumentado e com padrão lobular evidente, rins pretos e bexiga urinária repleta de conteúdo acastanhado a enegrecida. Microscopicamente, no fígado havia degeneração vacuolar e ou necrose coagulativa hepatocelular zonal, centrolobular ou paracentral, além de degeneração vacuolar com corpúsculos de Councilman, colestase, fibrose periascinar leve, e inflamação de discreta a moderada. Nos rins havia degeneração e necrose do epitélio tubular assim como cilindros de hemoglobina intratubulares. Os níveis de cobre no fígado e rim foram de 5.901,24 a 28.373,14µmol/kg e 303,72 a 14.021µmol/kg respectivamente. A suplementação nutricional excessiva com cobre pode causar doença hemolítica com icterícia, hemoglobinúria e morte de bovinos mantidos em sistema de semiconfinamento.(AU)

Hiperbilirrubinemias hereditarias: un diagnóstico diferencial a considerar en ictericia / Hereditary hiperbilirrubinemias: a differential diagnosis to considerer in icterus

Las hiperbilirrubinemias hereditarias (HBH) son patologías originadas por defectos en las enzimas y proteínas que participan del metabolismo de la bilirrubina. El clearence de bilirrubina incluye captación y almacenamiento en hepatocitos, conjugación, excreción hacia la bilis y recaptura de su forma conjugada por hepatocitos. Las HBH varían de acuerdo a su patogenia, presentación clínica, niveles de bilirrubinemia y tratamientos disponibles. En general son poco frecuentes, a excepción del Síndrome de Gilbert. Están las que son de predominio indirecto, como el Síndrome de Gilbert y el de Crigler-Najjar, y las de predominio directo, como el Síndrome de Dubin-Johnson y el de Rotor. En general no requieren tratamiento específico y tienen curso benigno, a excepción del Síndrome de Crigler-Najjar para el cual existen medidas terapéuticas específicas a considerar, teniendo un pronóstico reservado para algunas de sus formas de presentación. Es importante el conocimiento de estos síndromes dado el alto índice de sospecha requerido para su diagnóstico y para su diferenciación de otras patologías hepatobiliares de mayor riesgo y severidad.

Hereditary hiperbilirrubinemias (HBH) are pathologies originated from the defect of the enzymes and proteins involved in the metabolism of bilirubin. The bilirubin clearance includes uptake and storage in hepatocytes, conjugation, excretion into bile and recapture of its conjugated form by hepatocytes. HBH vary according to their pathogenesis, clinical presentation, levels of bilirubin and available treatments. Generally they are infrequent, except for Gilbert Syndrome. There are those with indirect bilirubin predominance, such as Gilbert and Crigler-Najjar syndromes, and those with direct bilirubin predominance, including Dubin-Johnson and Rotor syndromes. In general, they do not require specific treatment and have a benign course, with the exception of the Crigler-Najjar Syndrome, for which there are specific therapeutic measures to consider, as well as a reserved prognosis for some of their forms of presentation. The knowledge of these syndromes is important 2 given the high index of suspicion required for its diagnosis and for its differentiation from other hepatobiliary pathologies of greater risk and severity.

Prevalence of non A to E hepatitis in Mumbai, India / Prevalencia de la hepatitis no A /E en Mumbai, India

Introduction: Acute viral hepatitis is a common problem in India. World wide data shows that 5 to 20 percent of this is caused by non A-E hepatitis. There is no data in India regarding non A-E hepatitis. We carried out this study to evaluate the epidemiology, clinical features, risk factors and outcome of non A-E hepatitis. Material and methods: In this single centre study, we evaluated all patients admitted with features of acute viral hepatitis at our hospital between the period of February to July 2015. A detailed history about the epidemiology, risk factors and clinical features was done. Patients were evaluated with bilirubin, transaminases and prothrombin time. Each patient was investigated for IgM HAV, IgM HEV, HBsAg and Antibody against hepatitis C. Patients turning out negative were investigated for presence of autoimmune hepatitis or Wilson's disease. All viral markers were repeated a week later to confirm non A-E status. Results: A total 265 patients were included of which 41 (15.4%) patients were non A-E hepatitis. They had higher age (28.55 vs 34.99, p<0.05) but similar gender and sub urban location. Median SEC classification was A2 in hepatitis A/E group as compared to A3 in non A-E group. The duration of symptoms and clinical features between the two groups were similar with Anorexia, Malasie, Nausea/vomiting being most common. The risk factors between the two groups were similar. The bilirubin and transaminases were non significantly lower than hepatitis A/E patients while albumin levels were significantly lower. The outcomes of both groups were similar with no mortality or fulminant hepatitis. Conclusion: Non A-E hepatitis patients tends to be older, lower SEC class and had lower albumin levels as compared to hepatitis A/E

Introdución: La hepatitis viral aguda es un problema común en la India. Los datos mundiales indican que el 5 al 20% es causada por hepatitis no A-E. No hay datos en la India sobre hepatitis no A-E. Objetivo: Se realiza este estudio para evaluar la epidemiología, clínica, factores de riesgo y pronóstico de la hepatitis no A-E. Material y métodos: En este estudio de un solo centro evaluamos a todos los pacientes que se admitieron con clínica de hepatitis viral aguda en nuestro hospital en el periodo de febrero a julio del 2015. Se realizó una historia detallada para evaluar la epidemiología, características clínicas. Se les tomó bilirrubinas, transaminasas y tiempo de protrombina. A cada paciente se le realizó HAV IgM, HEV IgM, HbsAg y anticuerpo anti hepatitis C. Los que fueron negativos se les estudió para hepatitis autoinmune y enfermedad de Wilson. Todos los marcadores virales se repitieron a la semana para confirmar hepatitis no A-E. Resultados: Se incluyeron 256 pacientes, 41 de ellos (15,4%) fueron hepatitis no A-E. Tuvieron más edad (28,55 vs 34,99, p<0,05), pero el mismo género y ubicación urbana. La clasificación media SEC fue A2 en el grupo hepatitis A/E, comparada con 3 en el grupo de no A-E. La duración de los síntomas y el desarrollo clínico fue similar en ambos grupos, siendo la anorexia el malestar general, las náuseas y los vómitos los más frecuentes. El factor de riesgo fue similar, al igual que las transaminasas, mientras que la albúmina fue significativamente menor. El resultado fue similar sin caso alguno de hepatitis fulminante. Conclusión: Los pacientes con hepatitis no A-E tienden a ser mayores, de clase SEC más baja y con valores de albumina más bajos que los pacientes con hepatitis A-E

Colangitis biliar primaria. Parte 2. Actualización: diagnóstico, enfermedades asociadas, tratamiento y pronóstico / Primary Biliary Cholangitis. Part 2. State of the Art, Diagnosis, Associated Diseases, Treatment and Prognosis

La colangitis biliar primaria (CBP), es una colangiopatía crónica caracterizada por la destrucción selectiva de las células epiteliales biliares de conductos hepáticos de pequeño y mediano calibre, que afecta principalmente a mujeres. Los principales síntomas son la fatiga y el prurito, sin embargo, gran porcentaje de los pacientes pueden ser asintomáticos. El diagnóstico se basa en anticuerpos antimitocondriales (AMA) con títulos >1:40, fosfatasa alcalina >1,5 veces del límite superior normal por más de 24 semanas e histología hepática compatible con la patología. Se asocia con múltiples enfermedades principalmente de carácter autoinmune extra hepáticas, enfermedades tiroideas, óseas, entre otras. El tratamiento de primera línea es el ácido ursodesoxicólico (AUDC) que a pesar que no cura la enfermedad, mejora las pruebas del perfil hepático, así como el retraso en la progresión a cirrosis. Actualmente se encuentran en estudio nuevos tratamientos y terapias adyuvantes. El propósito de esta revisión es ofrecer una actualización de este tema que se presenta en los servicios de medicina interna y gastroenterología; para su realización se conformó un equipo interdisciplinar que desarrolló una búsqueda en la base Medline a través de PubMed con los tesauros correspondientes y se procedió a una lectura crítica y analítica de títulos, resúmenes y textos completos para el filtro, extracción y síntesis de la información encontrada

Primary biliary cholangitis (PBC) is a chronic autoimmune cholangiopathy characterized by a selective destruction of biliary epithelial cells of small and medium caliber hepatic ducts, which mainly affects women. The main symptoms are fatigue and pruritus, however, a large proportion of patients may be asymptomatic. The diagnosis is based on AMA titers >1:40, alkaline phosphatase >1.5 times the upper limit for more than 24 weeks and compatible liver histology. It is associated with multiple autoimmune diseases mainly extrahepatic, thyroid diseases, bone diseases, among others. The first line treatment is ursodeoxycholic acid (UDCA), that improves liver function tests and delay the progression to cirrhosis. Currently, there are new treatments and adjuvant therapies on study. The purpose of this review is to offer an update in this topic, which is very important in gastroenterology and internal medicine. We formed an interdisciplinary team to search in the data base Medline thorough PubMed with the keywords describe below, we made a critical lecture of the titles and abstracts of each article to write this paper

Colangitis biliar primaria. Parte 1. Actualización: generalidades, epidemiología, factores involucrados, fisiopatología y manifestaciones clínicas / Primary biliary cholangitis. Part 1. State of the art, epidemiology, physiopathology and clinical manifestations

La colangitis biliar primaria (CBP), es una colangiopatía crónica caracterizada por la destrucción selectiva de las células epiteliales biliares de conductos hepáticos de pequeño y mediano calibre, que afecta principalmente a mujeres. Los principales síntomas son la fatiga y el prurito, sin embargo, gran porcentaje de los pacientes pueden ser asintomáticos. El diagnóstico se basa en anticuerpos antimitocondriales (AMA) con títulos >1:40, fosfatasa alcalina >1,5 veces del límite superior normal por más de 24 semanas e histología hepática compatible con la patología. Se asocia con múltiples enfermedades principalmente de carácter autoinmune extra hepáticas, enfermedades tiroideas, óseas, entre otras. El tratamiento de primera línea es el ácido ursodesoxicólico (AUDC) que a pesar que no cura la enfermedad, mejora las pruebas del perfil hepático, así como el retraso en la progresión a cirrosis. Actualmente se encuentran en estudio nuevos tratamientos y terapias adyuvantes. El propósito de esta revisión es ofrecer una actualización de este tema que se presenta en los servicios de medicina interna y gastroenterología; para su realización se conformó un equipo interdisciplinario que desarrolló una búsqueda en la base Medline a través de PubMed con las palabras claves correspondientes y se procedió a una lectura crítica y analítica de títulos, resúmenes y textos completos para el filtro, extracción y síntesis de la información encontrada

Primary biliary cholangitis (PBC) is a chronic autoimmune cholangiopathy characterized by a selective destruction of biliary epithelial cells of small and medium caliber hepatic ducts, which mainly affects women. The main symptoms are fatigue and pruritus, however, a large proportion of patients may be asymptomatic. The diagnosis is based on AMA titers >1:40, alkaline phosphatase >1.5 times the upper limit for more than 24 weeks and compatible liver histology. It is associated with multiple autoimmune diseases mainly extrahepatic, thyroid diseases, bone diseases, among others. The first line treatment is ursodeoxycholic acid (UDCA), that improves liver function tests and delay the progression to cirrhosis. Currently, there are new treatments and adjuvant therapies on study. The purpose of this review is to offer an update in this topic, which is very important in gastroenterology and internal medicine. We formed an interdisciplinary team to search in the database Medline thorough PubMed with the key words describe below, we made a critical lecture of the titles and abstracts of each article to write this paper

Morbilidad y mortalidad de las derivaciones biliodigestivas / Morbidity and mortality in biliary bypasses

Objetivo: Determinar la morbilidad y la mortalidad en las derivaciones biliodigestivas en el servicio de Cirugía general en el Hospital Enrique Cabrera, de enero de 2007 a diciembre de 2011. Material y Métodos: Se realizó una investigación observacional, descriptiva y prospectiva. La muestra fue constituida por 51 pacientes a los que se les realizó una o más derivaciones biliodigestivas. Las variables estudiadas fueron edad, sexo, causa de intervención, tecnica quirúrgica, complicaciones, estado al egreso y causa de muerte. Se calculó la frecuencia de complicaciones y la mortalidad para cada técnica. Resultados: Fueron intervenidos quirúrgicamente 51 pacientes, con un promedio de edad de 57,5 años El tumor de cabeza de páncreas correspondió a 56,9% de los casos y la lesión de vía biliar, a 17,6%. La infección del sitio quirúrgico ocurrió en 33,3%. Fallecieron 50% de los operados por ténica de Whipple. La técnica quirúrgica más utilizada fue la coledocoduodenostomía. La mortalidad fue 11,8% y la principal causa de muerte, la falla multiorgánica. Conclusiones: El tumor de cabeza de páncreas fue la causa de intervención más frecuente La pancreatoduodenectomía de Whipple reportó la mayor morbimortalidad. Las tasas de incidencia de complicaciones y de mortalidad para la cirugía biliodigestiva fueron altas.

Objectives: To determine the morbidity and mortality in biliary bypasses in the Service of General Surgery at the Enrique Cabrera Hospital from January of 2007 to December of 2011. Material and Methods: It was carried out an observational, descriptive and prospective study. The sample constituted by 51 patients who had underwent a biliary bypass. The studied variables were: age, sex, intervention cause, surgical technique, complications, condition at discharge and cause of death. Frequency of complications and mortality were calculated for each technique. Results: Fifty one patients underwent a biliary bypass, age average of 57,5 year-old. The head's pancreas tumor was 56,9% and biliary's ducts lesions 17,6%. Surgical wound infection occurred in 33,3% of cases, and 50% of those who underwent a Whipple's technique died. The more used surgical technique was the choledocoduodenostomy. The mortality was of 11,8% and the main cause of death was multiorganic failure. Conclusions: The head's pancreas tumor was the cause that underwent surgery. The Whipple's pancreatoduodenectomy reported the highest morbidity and mortality. The frequency of complications and mortality for a biliary bypass were high.

Anemia de células falciformes: Guía de manejo pediátrico / Sickle cell disease: pediatric management guide

La anemia de células falciformes o drepanocítica es una enfermedad común en la edad pediátrica, con alta mortalidad en menores de 5 años de edad. Cuando un niño hereda esta condición de sus padres quienes son portadores, los glóbulos rojos sufren un cambio de forma o “falciformación”, alterando el flujo de sangre y provocando enfermedad, dolor y daño de órganos. Es necesario el despistaje universal a todos los recién nacidos, para identificar los afectados e iniciar tempranamente su cuidado y educación a los padres para prevenir ytratar las complicaciones, permitiéndoles tener una mejor calidad de vida. Se presentan unas guías y opciones terapéuticas para laprevención y el manejo de las complicaciones

Sickle cell disease (SCD) is a common condition in childhood with a high mortality rate, especially under 5 years of age. When children inherit SCD from their carrier parents, the red blood cells form an abnormal sickled shape. As a result, blood does not flow well, causingdisease, pain and organ damage. Universal newborn screening is necessary to identify and treat early those affected babies, thus preventing complications and allowing them to have a healthier life. Here is a set of guidelines and treatment options to prevent and manage sickle cell related complications

Ictericia obstructiva secundaria a migración de fragmentos de hepatocarcinoma a la vía biliar / Obstructive jaundice secondary to hepatocellular carcinoma fragments migrated to common bile duct

Obstructive j aundice is a rare presentation of hepatocellular carcinoma (HC), and when it occurs, usually is due to progressive damage from cirrhosis, or extensive tumor infiltration. Tumor growth through the bile duct is being described with increasing frequency as a cause of obstructive j aundice. Rarely, it may be hepatocarcinoma fragments that migrate to the bile duct, obstructing it. We present a case of obstructive jaundice due to migration of fragments of hepatocellular carcinoma to the bile duct in a patient treated 7 years before, for an HC with a curative resection.

La ictericia obstructiva es una presentación poco común en un hepatocarcinoma (HC). Cuando en estos casos existe ictericia, habitualmente se debe a daño progresivo por cirrosis, o a infiltración tumoral extensa. El crecimiento o vaciamiento tumoral hacia la vía biliar se ha descrito ocasionalmente como causa de ictericia obstructiva. En raras ocasiones, puede tratarse de fragmentos de hepatocarcinoma que migran hacia la vía biliar, obstruyéndola. Presentamos un caso de ictericia obstructiva por migración de fragmentos de hepatocarcinoma a la vía biliar, en un paciente tratado 7 años antes por un HC, con resección curativa.

Nephritic syndrome associated to skin infection, hepatitis A, and pneumonia: a case report / Síndrome nefrítico asociado con infección cutánea, hepatitis A y neumonía: informe de un caso

Introduction: Glomerulonephritis is the most common cause of acute and chronic renal disease. The prototype of acute glomerulonephritis is acute post-infectious glomerulonephritis. Recently, increased cases of glomerulopathy have been associated with bacterial, viral, and other infections. Acute nephritic syndrome is part of glomerulonephritis with an acute beginning, characterized by hematuria, hypertension, edema, and oliguria due to the reduction of glomerular filtration reflected in an increase of nitrogen compounds.Development: This paper shows a male infant at 2 years and 7 months of age with nephritic syndrome associated to a skin infection, pneumonia, and hepatitis A virus infection. Conclusion: Acute glomerulonephritis may be associated to streptococcus or another coincidental infection. Children with skin infection, hepatitis A, or pneumonia who reveal abnormal urinalysis, hypertension, azotemia, or oliguria should be evaluated for concomitant glomerulonephritis.

Introducción: La glomerulonefritis es la causa más frecuente de enfermedad renal aguda y crónica. El prototipo de la glomerulonefritis aguda es la glomerulonefritis aguda post-infecciosa. Recientemente, se ha asociado un aumento en la cantidad de glomerulopatías con infecciones bacterianas, virales y otras. El síndrome nefrítico agudo hace parte de las glomerulonefritis de comienzo agudo, caracterizado por hematuria, hipertensión arterial, edema, oliguria y disminución de la filtración glomerular con la retención de productos azoados.Desarrollo: Se presenta un niño de 2 años y 7 meses de edad con síndrome nefrítico asociado con infección cutánea, neumonía e infección por virus de la hepatitis A. Conclusión: La glomerulonefritis aguda puede estar asociada con estreptococo solamente o con otra infección coincidental. Los niños con infección cutánea, hepatitis viral o neumonía, que hayan presentando anormalidades en el uro análisis, hipertensión, azohemia u oliguria, se deben evaluar para glomerulonefritis asociada.

Clinical and regulatory protocol for the treatment of jaundice in adults and elderly subjects: a support for the health care network and regulatory system / Protocolo clínico e de regulação para o tratamento de icterícia no adulto e idoso: subsídio para as redes assistenciais e o complexo regulador

PURPOSE: Clinical interventions and controlled access to the health care system can be improved by a Regulatory System (RS) and Clinical and Regulatory Protocols (CRPs). The objective of the present paper is to present the methodology used for elaborating the CRPs. METHODS: The process used to elaborate the CPRs involved a scientific co-operation between university and health care system. Workshops were held and attended by primary care practitioners, RS team, and matrix team (university specialists supporting primary care practitioners). RESULTS: The treatment of jaundice in adults and elderly subjects is amongst the themes selected for elaborating the CRPs since jaundice is a medical sign frequently seen in four clinical scenarios involving distinctive diagnostic and therapeutic interventions which can be performed in different health care settings. Evaluation guidelines as well as the clinical and regulatory procedures were established for different health care settings. The most relevant clinical and regulatory interventions were expressed as algorithms in order to facilitate the use of CRPs by health care practitioners. CONCLUSION: It is expected that the implementation of this protocol will minimise the imbalance between the icteric patients' needs and the treatment modalities being offered, thus contributing to a more co-operative health care network.

OBJETIVO: As ações clínicas e de ordenação do acesso à rede de saúde podem ser aperfeiçoadas pelo Complexo Regulador (CR) e pelos Protocolos Clínicos e de Regulação (PCR). Nesse trabalho apresenta-se a metodologia de elaboração dos PCR mediante cooperação entre universidade e sistema de saúde. MÉTODOS: O processo utilizado para a elaboração dos PCR envolve oficinas com a participação de profissionais da atenção básica, do CR e das equipes matriciais (especialistas da universidade que dão suporte às equipes de atenção básica). RESULTADOS: Dentre os temas selecionados para elaboração dos PCR, incluiu-se a icterícia no adulto e no idoso. Trata-se de um sinal clínico que comporta quatro cenários de apresentação com distintos percursos diagnósticos e terapêuticos passíveis de serem executados em diferentes pontos da rede assistencial. As diretrizes de avaliação, bem como as decisões e ações clínicas e reguladoras cabíveis para os diferentes cenários foram estabelecidas desde a atenção básica até o hospital terciário. As ações clínicas e reguladoras mais relevantes foram colocadas em algoritmo para facilitar o emprego do protocolo pelos profissionais de saúde. CONCLUSÃO: Há a expectativa que a implementação desse protocolo possa minimizar o descompasso entre as necessidades dos pacientes ictéricos e a modalidade de serviço oferecida e, assim, contribuir para a configuração de uma rede assistencial mais cooperativa.

Estudo da incidência de coledocolitíase em pacientes com colecistite calculosa aguda e crônica submetidos à colecistectomia vídeolaparoscópica / Study of incidence of choledocholitiasis: in patients with acute and chronic calculous cholecystitis operated by laparoscopic cholecistectomy

OBJETIVO: Avaliar a incidência da coledocolitiase em pacientes submetidos à colecistectomia laparoscópica, portadores de colecistopatia calculosa aguda e crônica. O presente estudo, também, analisa se a era laparoscópica modificou a incidência e a história natural da litíase da via biliar quando compara os dados da literatura com os índices do Grupo estudado. MÉTODO: O estudo foi realizado em um Grupo de 946 pacientes, distribuídos em Grupo A de 214 pacientes de 1991-1995 e Grupo B de 732 pacientes de 1999-2007 colecistectomizados pelo método laparoscópico. O critério diagnóstico de coledocolitíase foi estabelecido por colangiofluoroscopia de rotina em todas as operações. RESULTADOS: A incidência total de coledocolitiase no Grupo A de 9,8 por cento e no B de 5,8 por cento não mostram diferença estatística significativa entre si e com a literatura mundial (p=0,08).Nos pacientes operados por colecistite aguda também não se observou diferença estatística entre o grupo A e B na incidência de litíase da via biliar( p=0,8). A análise dos dados nos pacientes operados por colecistite crônica revela uma taxa de coledocolitíase menor no Grupo B de 3,7 por cento com significância estatística do que no A de 8,4 por cento p=0,03. CONCLUSÃO: O presente estudo revela uma diminuição expressiva na incidência de coledocolitiase no Grupo B em relação ao A e a literatura mundial quando a indicação cirúrgica ocorre na fase não complicada da doença litiásica biliar. O estudo também demonstra um aumento significativo na indicação da colecistectomia laparoscópica eletiva mais precoce no Grupo B como já observado em diversas publicações da literatura médica.

BACKGROUND: To evaluate the incidence of choledocholitiasis in patients submitted to the laparoscopic cholecystectomy, carriers of acute and chronic calculous cholecystitis .The present study also analyses if the laparoscopic age modified the incidence and the natural history of lithiasis of the biliary duct when it compares the data of literature with yhe indices of the studied group. METHOD: The study was carried out in a group of 946 patients subdivided in group A of 1991 - 1995 and group B of 732 patients of 1999 - 2007 submitted to the cholecystectomy by the laparoscope method. The diagnostic criterion of choledocholithiasis was estabilished by cholangiofluroscopy of routine in all surgeries. RESULTS: The total incidence of choledocholithiasis in the group A - 9,8 percent, and in the group B - 5,8 percent doesn't show difference significant statistics between itself and with the world-wide literature (p=0,08). In the patients operated for acute cholecystitis difference statistics was not also observed between group A and B in the incidence of lithiasis of the biliary duct (p=0,8). The analysis of the data in operated patients for chronic cholecystitis discloses a smaller tax of choledocholitiasis in group B of 3,7 percent with significant statistics in the group A of 8,4 percent p=0,03. CONCLUSION: The present study discloses an expressive reduction in the incidence of choledocholitiasis in group B in relation to the A and worl-wide literature when the surgical indication occurs in the not complicated phase of the biliary lithiasic illness. The study demonstrates a significant increase in the indication of precocious elective laparoscopic cholecystectomy in group B already observed in diverse publications of medical literature.