Multiple malignant primary neoplasms in patients with gatric neoplasms in the health district of León.

OBJECTIVES: We analyzed the characteristics of patients with gastric tumors diagnosed with multiple malignant primary neoplasm (MMPN) in the Health District of León. MATERIAL AND METHODS: Using the information in the Tumor Registry at León Hospital patients selected were those with gastric neoplasms diagnosed between 1993 and 2002. A follow-up was performed until December 31, 2004, and the characteristics of patients diagnosed with a second neoplasm were analyzed. RESULTS: MMPN prevalence was 1,96%; 56% of patients had a history of cancer in first-degree relatives. The most frequent second neoplasms were digestive (26%) and urologic (21%); 87% of patients were diagnosed with a second neoplasm within the first two years. No significative differences in survival were observed among patients with synchronous or metachronous MMPN. CONCLUSIONS: MMPN in patients with gastric neoplasms is a relevant problem. While external carcinogenic agents could act as promoters in the development of second neoplasms, these patients seem to have a genetic background favoring the development of MMPN. Secondary prevention is the best measure to avoid MMPN development.

[Enteral prostheses for palliative treatment of gastroduodenal obstruction: endoscopic procedure]. / Prótesis enterales en el tratamiento paliativo de la obstrucción gastroduodenal: técnica endoscópica.

Malignant gastroduodenal obstruction may cause significant morbidity. Insertion of enteral prostheses as a palliative treatment is an acceptable option to achieve an appropriate gastric voiding without the morbidity associated to palliative surgery, with a lesser procedure-related mortality and a lower cost, while providing a better quality of life. Its is important to unify and consolidate the endoscopic procedure for the placement of enteral prostheses, avoiding variations that may preclude an adequate analysis of this procedure outcome.

[Needle-knife sphincterotomy for biliary access: a prospective study]. / Esfinterotomía de aguja como técnica de acceso a la vía biliar: estudio prospectivo.

OBJECTIVE: Needle-knife sphincterotomy (NKS) is used to achieve biliary access when routine cannulation methods have been unsuccessful. The aim of this study was to analyze the results of NNS in patients with an inaccessible common bile duct (difficult cannulation) using standard techniques in endoscopic retrograde cholangiopancreatography and the factors associated with the success of this procedure and complications. MATERIAL AND METHODS: We performed a prospective study of 72 patients who underwent NKS performed by the same endoscopist (J.E.) because of difficult cannulation of the common bile duct between January 1998 and December 2004. The results were analyzed in terms of successful biliary access, whether this was achieved in one or more sessions, its possible association with the underlying disease, and the incidence and severity of complications. RESULTS: Seventy-two NKS were performed from a total of 1062 sphincterotomies (6.7%). A total of 77.7% of the patients underwent prior implantation of a pancreatic prosthesis (NKS-PP). The final diagnosis was: choledocholithiasis (31.9%), cancer of the pancreas (16.6%), cholangiocarcinoma (13.8%), benign stenosis (8.3%), dysfunction of the sphincter of Oddi (6.9%), normal (6.9%), and miscellaneous (13.8%). Cannulation was successful in 87.5% (63/72), and was achieved in the first session in 73% (46/63). Biliary access was achieved in 72.7% of patients (16/22) with biliopancreatic neoplasms versus 94% (47/50) of those with other diagnoses (p = 0.03). Eleven patients (15.2%) presented 12 complications (16.6%) (6 pancreatitis, 4 cholangitis, 1 papillary hemorrhage, and 1 portal vein filling). The use of a pancreatic prosthesis was related to a higher success rate and significantly fewer complications (p = 0.03). CONCLUSIONS: NKS-PP can be a safe procedure in patients with difficult cannulation of the common bile duct. The presence of biliopancreatic neoplasm is a risk factor for failure to achieve biliary access compared with other diagnoses. The complication rate was similar to that found in other studies. No cases of severe pancreatitis or perforations were found.

[Multiple malignant neoplasms in patients with prostate tumours in the health district of Leon]. / Neoplasias malignas múltiples en pacientes con cáncer de próstata en el área sanitaria de León.

OBJECTIVE: We analyze the characteristics of the patients with prostate tumours who developed a multiple malignant primary neoplasms (MMPN) in the health district of León, the impact on survival and the prognostic variables. MATERIAL AND METHODS: We have used the data from the Tumour Registry of the Hospital of León and we have selected all those patients who were diagnosed of a prostate tumor between 1993 and 2002. Later we made two groups: the first with 67 patients with MMPN and a second group with 145 patients with single prostate tumours diagnosed during 1996 and 1997. RESULTS: Prevalence of MMPM was of 5.57 percent. Patients with MMPN were 3 years younger than those with single tumours, with a high frequency (41 percent) of familial oncologic antecedents on first degree parents. The more frequent association was the synchronous urologic neoplasm. During the next two years from diagnosed of prostate tumour, 86 percent of patients with MMPN were diagnosed of their second neoplasm. Survival of metachronous MMPN patients was lower than synchronous MMPN patients, being the variables with prognosis significance the age, metachronous MMPN, stage of second neoplasms and if the second neoplasms was or not urologic. CONCLUSIONS: MMPN in patients with prostatic tumours are frequent in our medium. A genetic base may be associated in these patients. Prognosis of metachronous MMPN patients is worse. No differences were observed about prognosis with single tumour patients.

[Nutrition and colorectal cancer]. / Alimentación y cáncer colorrectal.

Colorectal cancer is the most common tumor behind lung cancer in men and breast cancer in women. Its prevalence shows a wide geographic variability, which, along with epidemiological and experimental evidence, suggests a considerable participation of environmental factors, mainly dietary in its cause. It is not known which dietary components have an undisputed influence on the risk of colorectal cancer, nor how they condition the different genetic susceptibilities of the individuals. However, we do know of the protective action that consuming vegetables has, and the increased risk associated with saturated fats and red meats, especially when associated with other factors like a hypocaloric diet, obesity, sedentary life, or the use of alcohol. Fiber, however, has not proven the risk reducing properties that were attributed to it by epidemiological studies, possibly because this term encompassed several very different substances. Moreover, it is very difficult to know the effect of an isolated nutrient as these are intimately entwined in the foods. It should be kept in mind that many substances, like plants, as well as the usual nutrients, contain a large number of components with unknown effects and that the manner in which the foods are prepared or eaten, no doubt are of influence. A healthy lifestyle with regard to the risk of colorectal cancer, should no doubt include the consumption of large amounts of vegetables and whole cereals, a limit of the caloric intake with fats not exceeding 30%, to eat fish and chicken rather than red meat, to avoid alcohol, and to regularly partake of physical exercise.

[Inflammatory bowel disease: importance of nutrition today]. / Enfermedad inflamatoria intestinal: importancia de la nutrición hoy.

Malnutrition is a very common situation in patients inflammatory with intestinal disease (IID), which can be caused by a multitude of factors. It has been shown that nutritional support not only improves the nutritional condition of the patients, but in Crohn's disease it also has an effect on the activity of the disease, although this effect is smaller than that of steroids. Elemental diets are no more efficient than polymeric diets except under very special circumstances, but they are more expensive and patients tolerate them worse. A digestive pause is not recommended unless there is an absolute contraindication for the use of the digestive tract. Therefore, parenteral nutrition, which is more expensive and can cause serious complications, will be reserved for very specific indications. The use of fish oil supplements, either because it competes with arachidonic acid and prevents the initiation of the inflammatory cascade, or because it decreases the production of cytokines, has shown to be potentially useful in inflammatory intestinal disease, and this must be confirmed by further studies. Short chain fatty acids enemas have shown promising results in distal ulcerative colitis but the lack of homogeneity in the studies makes it necessary for these results to be consolidated in new studies. Nutritional support is especially interesting in children with inflammatory intestinal disease given that the growth retardation which is often seen in severe cases, can be controlled by adequate enteral or parenteral diets.

[Nutrition in the surgical patient: immunonutrition]. / Nutrición en el paciente quirúrgico: inmunonutrición.

Malnutrition plays an important role in the rate of postoperative complications that interfere with our surgical activity, impairing immune response mechanisms; synthesis and regeneration processes are damaged and the fight against infection is altered. Preoperative and postoperative administration of diets enriched with diverse substances included under the name of "immunonutrients" reduces the rate of complications. Our knowledge about the mechanisms of action of each immunonutrient is increasing as well as the fact that the combined action of these substances improves the immune system and protects the organism against the negative effect of the systemic inflammatory response syndrome.

[The effect of changes in nutritional status induced by age on oxidative liver metabolism]. / Influencia de los cambios en el estado nutritivo inducidos por la edad sobre el metabolismo oxidativo hepático.

INTRODUCTION: The hepatic oxidative metabolism is essential for the biotransformation of a large number substances, among which are found many drugs which are commonly used in clinical practice. The nutritional status of individuals has been shown to be of influence on this function. Aging produces a deterioration of the hepatic oxidative metabolism, without the cause for this situation having been clarified. Also, aging modifies the body composition of the individuals. The objective of this study is to evaluate whether the modifications which arise in the nutritive status due to age, can alter the hepatic oxidative capacity. MATERIAL AND METHODS: 165 elderly people of both sexes were studied, with an average age of 82 years, and 24 young people, with an average age of 29 years. All participants were subjected to a clinical questionnaire, along with an evaluation of anthropometric, biochemical, and immunological nutritive parameters. The study of the oxidative metabolism was conducted by evaluating the kinetics of antipyrine. RESULTS: The elderly people showed a decrease in the antipyrine clearance rate (Ap Cl) (P < 0.001), and a lengthening of their life-span (P < 0.05) with respect to the younger people. There was a significant correlation in the elderly people, between the Ap Cl and age, weight, size, the distribution volume, and the muscular area of the arm. A multiple regression analysis showed a predictive value which was independent for age, the AST, the lymphocytes, and size. CONCLUSION: Elderly people have a marked depression of the hepatic oxidative metabolism. The factors which participate in their nutritional situation, are of influence on this function. It is necessary to keep all the above in mind when it comes to prescribing drugs which require this type of biotransformation, in order to avoid adverse effects or drug interactions.

[Hepatic metabolism of cholesterol]. / Metabolismo hepático del colesterol.

Cholesterol is an essential component of all tissues, as it is a part of the structure of cell membranes, and it is an immediate precursor of a series of essential substances such as vitamins, steroid hormones, and bile acids. Under physiologic conditions, the intake and output of cholesterol in the organism is coordinated and balanced with the aim of guaranteeing the availability of adequate amounts of cholesterol to satisfy the needs of the different tissues (fig. 1). Under pathological conditions there is an imbalance between these mechanism, which leads to an increase in the circulating levels of cholesterol, leading to pathological processes such as hyperlipemias, atherosclerosis and bile stones. The liver plays a central role in the regulation of the homeostasis of cholesterol. The molecule enters the liver in the form of chylomicrons and low density lipoproteins (LDL), through lipoprotein receptors, and this is also the most important organ for the de novo biosynthesis of cholesterol from acetyl coenzyme A, by means of a cascade enzyme reaction in which the enzyme 3-hydroxy-3 methyl glutaryl CoA reductase (HMG-CoA) is the key of the entire process. Cholesterol is found in the liver in the form of cholesterol esters or as free cholesterol. The two most effective ways of eliminating body cholesterol are found in the liver, with the degradation of the compound to bile acids and the biliary secretion of cholesterol. The conversion to bile acids takes place through a series of enzymatic steps in which the formation of 7-alpha-hydroxycholesterol by the enzyme cholesterol 7-alpha-hydroxylase is the key of the process. The biliary secretion of cholesterol is 600 mg/day. Both the abundance and the universality of cholesterol in living things as its clinical implications emphasize the importance and interest of this compound.

[Systemic amyloidosis presenting as cholestatic jaundice]. / Ictericia colestásica como forma de presentación de una amiloidosis sistémica.

We present a case of a 68 year old man with general deterioration and recent onset of jaundice that was admitted for clinical evaluation. Previous records were: treated bone tuberculosis, hypertrophic myocardiopathy and ischemic cardiopathy. Physical examination showed liver enlargement without evidence of chronic liver disease. Laboratory studies and other explorations such as abdominal ultrasound, CAT and ERCP did not leed to an objective diagnosis. Therefore, a liver biopsy was performed, showing liver amyloidosis AA type with amyloid deposits in portal spaces. The patient died three months later. The rarity of this clinical presentation is discussed and its poor prognosis outlined. Some peculiarities of liver deposits are reviewed.

[Incidence of digestive tumors in the health district of Leon, Spain in 1993-1997: high incidence of colorectal carcinoma]. / Incidencia de los tumores digestivos en el Area de Salud de León en el quinquenio 1993-1997: alta incidencia del carcinoma colorrectal.

AIM: To determine the incidence of various digestive tumors in the health district of Leon. PATIENTS AND METHODS: All digestive tumors registered in the Hospital Tumor Registry in Leon from 1993-1997 were included. Unadjusted and adjusted incidence rates of each kind of tumor, using the ICD-9 classification, were calculated. RESULTS: A total of 9,913 cancer cases were included. Diagnosis was confirmed by the Department of Pathology in 93.4%. Of these, 25.38% originated primarily in the digestive system, which represents an unadjusted incidence of 151.73 new cases per 100,000 inhabitants/year. A total of 58.07% were male and 41.93% female. Colon cancer was the most frequent (31.5%), followed by gastric cancer (25.7%) and rectal cancer (20.3%). The highest incidence, both unadjusted and adjusted, was in colon cancer (52.8 and 25.9) followed by gastric cancer (47.4 and 24.3) and rectal cancer (36.1 and 18.3, all they 10(5)/year. CONCLUSIONS: Incidence of digestive cancer in Leon is very high and that of colorectal cancer is higher than in any other region in Spain. This is only partly due to the marked aging of our population.

[Degree of association between serum levels and genotype in alpha-1-antitrypsin deficiency. Clinical usefulness]. / Grado de asociación entre valores séricos y genotipo en el déficit de alfa-1-antitripsina. Utilidad clínica.

AIM: To determine the degree of association between serum alpha-1-antitrypsin levels and its phenotypes as well as its clinical expression. PATIENTS AND METHODS: The alpha-1-antitrypsin genotype was identified using polymerase chain reaction followed by restriction enzyme digest in 212 patients in whom serum alpha-1-antitrypsin determination had been requested. The reasons for the request, the existence of pulmonary or liver disease, clinical diagnoses and functional repercussions were analyzed. RESULTS: Two hundred and twelve patients were evaluated (68% males; mean age: 34 20 years). In 23 patients (10.8%) a deficiency variant was found (one or two M alleles were lacking) and in 8 patients (3.8%) the genotype was ZZ. All patients with MM genotype had alpha-1-antitrypsin levels of 75 mg/dl or higher while none of the patients with ZZ genotype had levels higher than 40 ml/dl. All the patients with ZZ genotype showed alterations: 3 had pulmonary emphysema, 1 had chronic obstructive pulmonary disease and 4 had hypertransaminasemia. One patient with pulmonary emphysema had severe respiratory insufficiency while in the remaining patients with respiratory problems, respiratory insufficiency was slight or moderate. None of the patients with hypertransaminasemia showed echographic signs of portal hypertension or clinical or laboratory signs of reduced liver function. CONCLUSIONS: There is a close association between alpha-1-antitrypsin levels and the different genotypes. Consequently, in basal conditions with serum alpha-1-antitrypsin levels higher than 75 mg/dl genotyping is not required. The functional repercussions of deficiency variants in young adults is slight.

[Spontaneous bacterial peritonitis caused by Listeria monocytogenes]. / Peritonitis bacteriana espontánea por Listeria monocytogenes.

We present a 68 year old male with alcoholic cirrhosis that was admitted with abdominal pain and fever. Hepatocarcinoma and spontaneous bacterial peritonitis by Listeria monocytogenes was diagnosed. The patient was treated with ampicillin and tobramycin during 25 days following a favorable course although ascitic fluid remained abnormal during 21 days. It is noted the rarity of Listeria as a cause of bacterial peritonitis in cirrhotic patients although they are immunodeficient. It is also important to establish the etiological origin because standard treatment of spontaneous bacterial peritonitis is cefotaxime and Listeria is resistant to this antibiotic. The 66% of spontaneous bacterial peritonitis secondary to Listeria monocytogenes infection in cirrhotic patients has been reported in Spain and this might be due to a higher incidence of human listeriosis in this country.

[Primary hepatic leiomyosarcoma in a patient with gastric non-Hodgkin lymphoma]. / Leiomiosarcoma hepático primario en un paciente con linfoma no hodgkiniano gástrico.

Primary leiomyosarcoma of the liver is a rare entity and fewer than 100 cases have been reported in the medical literature. Even more unusual is the association with another previous tumour. We report the case of a 84-year-old man who had been treated for a gastric non-Hodgkin lymphoma two years previously. He presented with a painful mass in the right upper abdomen. An ultrasound scan showed a large mass in the right lobe of the liver and chest radiography showed pulmonary metastases. Liver biopsy was performed and immunohistochemical analysis revealed a malignant leiomyosarcoma. We discuss this case and review the available literature.

[Multiple hepatic focal nodular hyperplasia: its presentation in childhood and atypical evolution]. / Hiperplasia nodular focal múltiple hepática: presentación en la infancia y evolución atípica.

Multiple focal nodular hyperplasia is an uncommon benign liver tumor although its incidence has been increasing in the last few years. A case of focal nodular hyperplasia in a young woman is described, which was discovered in infancy and which presented two nodules in each lobe. The diagnosis was subsequently confirmed by large surgical biopsy. Conservative therapy was given for 16 years during which time there was progressive tumor growth, increase of pain and cholestatic enzymes. The unusual presentation this benign lesion may have, a strategy for its diagnosis and the generally conservative management that is currently favored are discussed.

[Current status of endoscopic retrograde cholangiopancreatography. What is the effect of the introduction of magnetic resonance cholangiography?]. / Estado actual de la CPRE. Cómo se refleja la introducción de la colangiorresonancia magnética?

AIM: To determine the current status of endoscopic retrograde cholangiopancreatography (ERCP) and the effects of the introduction of magnetic resonance cholangiography (MRC) on ERCP and to evaluate the diagnostic yield of MRC since its introduction in obstructive biliary disease. MATERIAL AND METHODS: We performed a retrospective analysis of the ERCP carried out between January 1998 and December 2000 and of the MRC performed for suspected obstructive biliary disease from May 1999 to December 2000. When both techniques were performed, the diagnostic yield of MRC was evaluated. RESULTS: We performed 927 ERCP. A total of 45.3% of the patients were men. Mean age was 69.2 14.6 years. Treatment was performed on 688 occasions (77%), mainly sphincterotomy (69.9%) and placement of polyethylene (21.8%) or self-expanding (9.9%) prostheses. The number of ERCP performed each year was 261, 330 and 336 in 1998, 1999 and 2000, respectively; of these 76.6%, 80% and 76.9% were therapeutic. MRC was performed in 63 patients with suspected biliary disease. In 27 of 59 patients (45.8%) MRC was sufficient for diagnosis, avoiding the need for ERCP. In the 35 patients in whom both techniques (MRC and ERCP) were performed, the diagnostic yield of MRC compared with that of ERCP was: sensitivity 100%, specificity 50%, positive predictive value 87.1%, negative predictive value 100% and overall value 89%. The cases responsible for the low specificity (all due to choledocholithiases) were analyzed and a significant time lapse was found between the performance of MRC and ERCP (range: 7-35 days) during which choledocholithiasis probably resolved spontaneously. CONCLUSIONS: a) Contrary to what could be expected, the number of ERCP seems to be increasing with a high percentage of endoscopic treatment; b) Because of its diagnostic sensitivity, MRC is the ideal technique for eliminating the need for diagnostic ERCP, thus allowing greater development of the therapeutic aspect of ERCP.

[Tuberculous tenosynovitis. Apropos 2 cases]. / Tenosinovitis tuberculosa. A propósito de dos observaciones.

Two cases of tenosynovitis tuberculosa are presented. It was the only tuberculosis manifestation in one of them. The other showed a normal chest X-ray but epithelioid granulomas were found in the bone marrow examination which forced a differential diagnosis to be made of multiple myeloma. The combined therapy, surgery + drug regimen for tuberculosis produced a good evolution.

[The histological lesions of chronic hepatitis C as predicting factors of sustained response to the treatment with interferon]. / Las lesiones anátomo-patológicas de la hepatitis crónica C como factores predictivos de respuesta mantenida al tratamiento con interferón.

BACKGROUND: Although many studies have been implemented in order to determine the pre-treatment factors that can predict patients' response to interferon (IFN) therapy, it is not yet clear whether characteristic histologic abnormalities in chronic hepatitis C can predict such response. AIMS: The aim of this study were to evaluate, in patients with chronic hepatitis C, (i) the predictive value of histologic lesions for the sustained response to IFN therapy (ii) other pre-treatment (epidemiological and analytical) factors known to be predictive of response. PATIENTS AND METHODS: Sustained response was retrospectively evaluated in two hundred one patients who had been treated with IFN for at least 3 months in four different hospitals from Castilla y León. The following histological parameters were studied as predictors of response: histological diagnosis, Knodell index, grading and stage, characteristic histologic lesions of HCV infection. Epidemiological and analytical parameters were also evaluated. RESULTS: The rate of patient's sustained response to IFN treatment was 16%. None of the histological parameters was useful to predict this response. By univariate analysis, age, disease evolution time, mode of viral transmission, GGT, ferritin and viral genotype were associated with a sustained response. The most powerful, and only independent predictive factor, however, was the genotype (the response odds ratio was 8.6). CONCLUSIONS: Histological parameters do not predict the response to IFN treatment. Other factors (mainly the viral genotype) are associated with a higher response percentage, although no one is useful to decide which patients are going to respond.

[Chemical disinfection. An alternative to sterilization in the treatment of cure instruments]. / Desinfección quimíca. Una alternativa a la esterilización en el tratamiento del instrumental de curas.

UNLABELLED: Sterilization is the reference method recommended to ensure the asepsia of an instrument used to perform cures. Chemical disinfection has shown itself to be highly effective in this process for endoscope equipment without there being definitive references about its efficiency on instruments used for cures. OBJECTIVE: Evaluate the efficiency of chemical disinfection on instruments used for cures, with the reference method being sterilization. METHODS: Prospective study in which the efficiency of glutaraldehyde-phenolate is compared to sterilization on 9 sets of instruments used for cures, each one having a dissection clamp and a Kocher clamp, used in 122 cures carried out in different wards at the León Hospital. Their efficiency was evaluated by means of microbiological studies after cures were performed and after disinfection or sterilization occurred. RESULTS: There were no positive cultures after either the disinfection or the sterilization. The existence of positive cultures after cures was related to the type of wound treated, clean wounds were always negative while dirty wounds were frequently positive (p < 0.05). CONCLUSION: Chemical disinfection with glutaraldehyde-phenolate is as efficient as sterilization in assuring the asepsia of instruments, while offering some clear advantages compared to sterilization since this chemical disinfection has a low cost, its use avoids the need to have duplicate instrument sets, it provides a longer life for these instruments and does not require moving instruments from their work site, thus preventing their loss.