Epidemiology and associated factors of irritable bowel syndrome in an Andean community from Peru.

INTRODUCTION: Irritable bowel syndrome (IBS) is a chronic functional bowel condition with an average world prevalence of 11.2%. Is associated with multiple factors as female sex, young age, stress, anxiety and depression which can have a negative impact on quality of life. IBS in Peru is not investigated at all specially in the Andean region. The objective of this study is to determine the prevalence and associated factors of IBS in an Andean community from Peru using the Rome IV criteria. MATERIALS AND METHODS: Cross-sectional study in a rural community dedicated to livestock and agriculture in Peru at 3,235 meters above sea level. Questionnaires provided by the Rome Foundation as the Rome IV - Diagnostic questionnaire for adults, Irritable Bowel Syndrome - Symptom Severity Scale and Bristol stool scale were used. RESULTS: 130 residents met the inclusion criteria. 46.9% were males with an average age of 54 years old. 11.54% presented red flags and were not included in the analysis. 13.1% were diagnosed with IBS and 52.9% presented constipation as predominant bowel pattern. 52.9% presented a mild course of the disease. In the chi-square analysis, factors as depression, anxiety, female sex, younger age, liquefied petroleum gas exposure for cooking and education achievement were statistically significant associated to IBS. In the logistic regression analysis, anxiety was the unique independent predictor factor with an OR of 9.6 (95% IC: 1.78-51.82). CONCLUSION: IBS is a prevalent condition in the Andean region and should be managed as a public health issue to improve quality of life.

Clinical and endoscopic findings of patients with cutaneous Kaposi sarcomaand gastrointestinal involvement. Experience in a single center of Lima-Peruin the last 3 years.

INTRODUCTION: Kaposi sarcoma is a low-grade angioproliferative neoplasm strongly associated with infection by herpes virus type 8 (HHV-8). Gastrointestinal (GI) involvement is an infrequent finding, whose clinical and endoscopic characteristics are poorly defined in the literature. OBJECTIVE: The aim of our study was to describe the clinical and endoscopic findings of patients with gastrointestinal Kaposi Sarcoma. MATERIALS AND METHODS: We reviewed all clinical histories, endoscopic and anatomopathologic reports of all patients with cutaneous Kaposi sarcoma (CKS) who came to Cayetano Heredia Gastroenterology Service during the period between August 2015 to October 2018. We included all patients with CKS that had gastrointestinal involvement confirmed with biopsy. RESULTS: We found 50 patients with cutaneous Kaposi sarcoma. Thirteen patients had gastrointestinal Kaposi sarcoma (26%). 53.8% (7/13 cases) were asymptomatic. 92.3% (12/13 cases) had HIV infection. Nine of the twelve HIV+ patients had CD4 count below 200 cells/µl. When Kaposi affects GI tract, the mayority have multiple GI organs affected. Stomach and colon are the most common sites affected. CONCLUSION: Gastrointestinal involvement was presented in 26% of our patients with cutaneos Kaposi sarcoma, a half of them had no GI symptoms. The majority of cases were young male and had HIV in AIDS stage. The mortality in our series was 15.3% at 6 months of follow-up.

[Comparison of the prevalence of Helicobacter pylori infection in dyspeptic patients between two institutional centers of different socio-economic strata during 2017-2018]. / Comparación de prevalencia de infección por Helicobacter pylori en pacientes con dispepsia entre dos instituciones de diferentes estratos socioeconómicos en el periodo 2017-2018.

Helicobacter pylori (Hp) infection is associated with multiple digestive problems from gastroduodenal ulcers to gastric adenocarcinoma and/or MALT lymphoma. Peru is considered a place of high prevalence of Hp. In the world, significant differences have been described in the prevalence of Hp infection associated with the socioeconomic characteristics of the population. OBJECTIVE: To compare the prevalence of Hp infection in dyspeptic patients between 2 institutional centers of different socio-economic strata during 2017-2018. MATERIALS AND METHODS: A sample of 633 patients with dyspepsia was collected retrospectively and randomly, without previous endoscopic study, or a history of Hp eradication therapy that came to the gastroenterology services of the Hospital Cayetano Heredia (HCH) in San Martin de Porres, and of the Anglo American Clinic (CAA) in San Isidro, during the period of June 2017 - July 2018 (CAA: 300 and HCH: 333). Proceeding then to review the clinical history, endoscopy report and pathological anatomy of each of them, for further statistical analysis using the SPSS program. RESULTS: A prevalence of Hp was found in the HCH of 54.1%, while in the CAA it was only 29.3% (p < 0.05), this relationship being maintained in the different age groups. Likewise, the prevalence of intestinal metaplasia (MI) in the total of patients with dyspepsia in the HCH was 33.9% (MI + in Hp + was 34.4%) and in the CAA the presence of MI without considering the Hp status was only 6.7% (MI + in HP + was 6.8%) (p < 0.05). Finally, the presence of gastric atrophy in the HCH was 26.7% and in the CAA it was 1.3% (p < 0.05). CONCLUSION: There is a clear relationship between the low socioeconomic stratum and the presence of Hp, gastric atrophy and intestinal metaplasia (the latter relationship remaining independent of Hp status).

[Colonic balantidiasis: report of a fatal case and review of the literature]. / Balantidiasis colónica: reporte de un caso fatal y revisión de la literatura.

Balantidiasis is a zoonosis produced by Balantidium coli, which inhabits the large intestine of the pig and man. Infection is uncommon in humans and mainly affects the colon. It occurs more frequently in developing countries, tropical and subtropical regions. Colonic balantidiasis can occur in most cases asymptomatically and reach in the most severe cases such as dysenteric diarrhea that can be complicated by low digestive bleeding and even perforation. We present the case of a 72-year-old man, from the Peruvian highlands, who was a farmer and breeder of swine and sheep, who came for 3 months of illness, initially characterized by liquid stools with bloodless mucus, abdominal pain, nausea, vomiting and in the last month of illness he presents dysenteric diarrhea. Colonoscopy was performed due to suspicion of infectious colitis, Balantidium coli trophozoites were found in the fresh sample and colonic tissue biopsy. Patient receives treatment with amebicide and antibacterial without clinical improvement, presenting as a complication multiple perforation in the sigmoid colon, treated with resection and terminal colostomy. Finally, the patient died despite receiving medical and surgical treatment.

[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.

[Use of cyanoacrylate as a treatment of gastric varices in a public hospital in Lima - Peru]. / Uso de cianoacrilato como tratamiento de várices gástricas en un hospitalp úblico nivel III en Lima - Per ú.

OBJECTIVE: To evaluate the therapeutic success of endoscopic therapy with N-butyl-2-cyanoacrylate and to determine the re- bleeding and mortality rates. MATERIALS AND METHODS: Prospective analytical observational study of 47 cases of patients with gastric varices who were treated with N-butyl-2-cyanoacrylate, using a 1: 1 mixture with lipiodol between 2013 and 2017 in a level III public hospital in Lima - Peru. The therapeutic indication was active hemorrhage, primary or secondary prophylaxis. RESULTS: Of the 47 patients, 5 (10.6%) had active hemorrhage, control was obtained in all cases, 24 (51.1%) had stigmas of recent bleeding during endoscopy. Secondary prophylaxis was performed in 16 (34%) patients and primary prophylaxis in 2 (4.7%). 59.6% required a single session with a total volume of cyanoacrylate (ml / patient) of 1.28 ± 0.44. The endoscopic finding was GOV-2 in 78.7% of the cases, IGV-1 in 12.8% and GOV-1 in 8.5%. Seven patients (14.8%) presented late re- bleeding, with successful new therapy in 6 of them, one dying due to therapy failure. Of the six (12.76%) patients who died in total, 5 (83.3%) were due to other causes. No adverse events related to the therapy were reported. No adverse events were reported. Variceal obturation was observed in 28 (59.5%) patients. CONCLUSIONS: Endoscopic management of gastric varices with cyanoacrylate is a safe and effective treatment, with low recurrence and mortality rates.

[Medical malpractice in public hospitals]. / La culpa médica en la responsabilidad de los hospitales públicos.

Under Chilean public law, liability of a public hospital appears when the institution fails to accomplish its mandatory duties or incurs in negligence. As in private law liability, this system requires to determine the duties of hospitals and, in case of a medical accident, professional standards or duties. This paper explores the two main categories of medical malpractice, namely erroneous diagnosis and treatment failures based on public law theory and judiciary methods.

[Fulminating ischemic hepatitis induced by severe cardiac dysfunction: case report]. / Hepatitis isquémica fulminante inducida por disfunción cardiaca severa: reporte de caso.

Ischemic Hepatitis is an uncommon entity in daily clinical practice with a prevalence of 0.16 to 0.5% among patients admitted to a critical care unit, associated with an approximate 60% mortality rate. This liver disease is characterized by a rapid and marked increase (more than 20 times the normal value) of the level of transaminases secondary to a severe and persistent hepatic hypoperfusion caused by multiple etiologies, which may be transient when the triggering cause is timely identified and appropiately treated. The case of an elderly adult patient with a clinical, epidemiological and biochemical profile compatible with ischemic hepatitis secondary to severe cardiac dysfunction is presented below.

[Accuracy of ASGE predictors in diagnosis of coledocolithiasis in a public hospital of Lima, Peru]. / Precisión de los predictores de la ASGE en el diagnóstico de coledocolitiasis en un hospital público de Lima, Perú.

BACKGROUND: The predictors proposed by the American Society of Gastrointestinal Endoscopy (ASGE) are commonly used topredict the presence and management of choledocholithiasis. OBJECTIVE: To evaluate the performance and precision of thepredictors of choledocholithiasis proposed by ASGE. MATERIALS AND METHODS: Prospective and longitudinal study performed ata third level hospital during January 2015 to June 2017. All patients with high and intermediate probability of choledocholithiasiswho underwent endoscopic retrograde cholangiopancreatography (ERCP) were included according to the criteria proposedby the ASGE. RESULTS: A total of 246 patients with suspected choledocholithiasis were analyzed. Of the 228 patients withhigh probability criteria 144 (63.2% = performance) had choledocholithiasis in ERCP with an accuracy of 62% (sensitivity:94.1% and specificity: 9.7%). Among the 18 patients with intermediate probability criteria, 9 (50% = performance) hadcholedocholithiasis with an accuracy of 38% (sensitivity: 5.9% and specificity: 90.3%). In the multivariate analysis, the presenceof stone in the bile duct by ultrasonography (OR: 1.937, 95% CI 1.048-3.580, p=0.035) and age 55 and over (OR: 2.121, 95%CI, 1.101-4.088, p=0.025) were the strongest predictors for choledocholithiasis. CONCLUSIONS: The application of the criteriaof the ASGE to predict the probability of choledocholithiasis, in our population has a performance greater than 50%, however,it is necessary to improve these parameters to avoid an unnecessary performance of ERCP.

[Duodenal melanoma: a case report and review of the literature]. / Melanoma duodenal: reporte de caso y revisión de la literatura.

We report the case of a male patient of 75 years old who presents with abdominal pain, hyporexia, early satiety, general malaise and watery stools, admitted in emergency for an episode of syncope. On physical examination, hepatomegaly of 6cm below the right costal margin was detected. CT scan showed multiple liver metastases. An upper endoscopy found multiple hyperpigmented lesions on the second portion of the duodenum. Histology and immunohistochemistry studies concluded it was duodenal melanoma. Skin and ocular examination did not reveal associated neoplastic lesions.

[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.

[Validation of the rapid urease test for the detection of Helicobacter pylori in a Peruvian hospital]. / Validación del test rápido de la ureasa para la detección del Helicobacter pylori en el Hospital Nacional Cayetano Heredia, Lima, Perú.

OBJECTIVE: To validate a rapid urease test (RUT) in Cayetano Heredia Hospital (HCH) in Lima, Peru. MATERIALS AND METHODS: This is a prospective observational study that included 181 patients over 18 years old with dyspeptic symptoms. All of them underwent upper gastrointestinal endoscopy at the Department of Gastroenterology at HCH. They had not received, during the last four weeks, proton pump inhibitors (PPIs), bismuth or antibiotics. Two biopsies of antrum were taken, one to perform the TRU (Sensibacter pylori test®) and the other one for pathology, in order to determine by both methods the presence of H. pylori infection. TRU's results were compared with pathology ́s (gold standard). RESULTS: 181 patients, average age 52.8±13.5 years, were evaluated. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) at 20 minutes were 86.8%, 98.5%, 81.5% and 99% and at 24 hours 97.3%, 99.5%, 95.7% y 99.1% respectively. CONCLUSION: The rapid urease test is a reliable, accessible and easy to apply test for the diagnosis of H. pylori infection.

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.

[Prevalence and severity of the hepatopulmonar syndrome in patients with liver cirrhosis attended at Cayetano Heredia Hospital, between January and December 2015]. / Prevalencia y severidad del síndrome hepatopulmonar en pacientes concirrosis hepática del Hospital Nacional Cayetano Heredia, entre enero y diciembre del 2015.

INTRODUCTION: The hepatopulmonary syndrome (HPS) is a rare complication of liver cirrhosis (LC) which significantly diminishes the quality of life for people who suffer. OBJECTIVES: To determine the prevalence and severity of HPS in patients with CH treated at the Cayetano Heredia (HCH) Hospital in the period from January to December 2015. MATERIALS AND METHODS: Cross-sectional study with sample size needed to determine the point prevalence calculated in 297 patients. RESULTS: The prevalence of HPS in 0.7% and the identified cases were classified as mild and severe SHP. CONCLUSION: The prevalence of HPS is very low in the population of patients with liver cirrhosis treated at the Cayetano Heredia Hospital.

[Porphyria cutanea tarda as extrahepatic manifestation of chronic hepatitis C: a case report]. / Porfiria cutánea tarda como manifestación extrahepática de hepatitis Ccrónica: reporte de un caso.

The present case is a 56 year old male who present hyperpigmented and hypopigmented scars in both hands, associated with the presence of milia cysts. It was studied the metabolism of porphyrins and skin biopsy of the lesions which were compatible with porphyria cutanea tarda. In the initial laboratory, elevated transaminases values were found and subsequently identified chronic infection of hepatitis C virus. In order to treat viral infection and resolve the dermal commitment; considered extrahepatic manifestation of hepatitis C virus, treatment was started with pegylated interferon and ribavirin, with favorably development and rapid viral response, with undetectable viral load until now (24 weeks of treatment), decreased level of serum transaminases and improvement of skin lesions.

[Comparison between Glascow-Blatchford, Rockall and AIMS65 scores in patients with upper gastrointestinal bleeding in a hospital in Lima, Peru]. / Comparación de los scores Glasgow-Blatchford, Rockall y AIMS65 en pacientes con hemorragia digestiva alta en un hospital de Lima, Perú.

OBJECTIVE: Identify the best score that predicts each variable outcome (mortality, rebleeding and need for transfusion for more than 2 red blood cells pack) in patients with upper gastrointestinal bleeding until 30 days of the event. Material y methods: Patients included were those over 18 years, who had upper gastrointestinal bleeding between January 2014 to June 2015 in a general hospital of third level. The data was analyzed by the area under the curve ROC (Receiver Operating Characteristic). RESULTS: In total, there were 231 cases of upper gastrointestinal bleeding, 154 (66.7%) cases were male, the average age was 57.8 ± 20.02 years, the most common cause of bleeding was peptic ulcer: 111 (48.1%) cases, the mortality rate and rebleeding was 7.8% and 3.9% respectively. 5 patients were excluded from the analysis because they do not count with endoscopy study, the analysis was performed in 226 rest. In the evaluation of mortality, it was found an area under the curve ROC for Glasgow-Blatchford: 0.73, Rockall score: 0.86 and AIMS65 score: 0.90 (p<0.05) to predict rebleeding the Glasgow-Blatchford score: 0.73 Rockall score: 0.66 and AIMS65 score: 0.64 (p=0.41) and transfusion requirements of more than 2 globular packages the Glasgow-Blatchford score: 0.72, Rockall score: 0.67 and AIMS65 score: 0.77 (p=0.09). CONCLUSIONS: AIMS65 score is a good predictor of mortality and is useful in predicting the need for more than 2 transfusions of red blood cells pack compared to score Glasgow-Blatchford and Rockall score.

[Sarcopenia and functional disability in aged]. / Sarcopenia y dependencia funcional (DF) en el anciano.

BACKGROUND: The significance of sarcopenia in recent years is due to its relationship with functional disability (FD). OBJECTIVE: To determine whether a difference exists in the proportion of sarcopenia in older adults (OA) with different status of FD. METHODS: Subjects over 65 years of age without sarcopenia associated diseases were included. Overview of the study: 68 OA (24 with and 44 without FD). FD was assessed by Barthel index and clinical battery (stand-up test, grip dynamometry). Sarcopenia was assessed by Lovett-Kendall scale. STATISTICAL ANALYSIS: X² and OR (95% CI). RESULTS: Sarcopenia was higher in OA with FD (n = 16 of 24 [66.7%] vs. 3 of 44 [6.8%]). The FD was associated with sarcopenia (OR: 27.3; CI: 6-156). CONCLUSION: Sarcopenia is associated with functional dependence in the elderly by testing Kendall-Lovett and with various clinical and functional tools for the detection and diagnosis of FD. The proportion of sarcopenia in OA was higher in the presence of FD.

[AIMS65 score validation for upper gastrointestinal bleeding in the National Hospital Cayetano Heredia]. / Validación del score AIMS65 para hemorragia digestiva alta en el Hospital Nacional Cayetano Heredia.

OBJECTIVE: To validate the score AIMS65 in patients with upper gastrointestinal bleeding, in terms of mortality and rebleeding a 30-day event. MATERIAL AND METHODS: Patients included were those with higher age to 18 years attending the Hospital Nacional Cayetano Heredia during the period May 2013 to December 2014, by upper gastrointestinal bleeding. Data were analyzed using ROC curve (Receiver Operating Characteristic) and the area was obtained under the curve (AUC) to properly qualify the score AIMS65. RESULTS: 209 patients were included, 66.03% were male, with an average age of 58.02 years. The mortality rate was 7.65%, the multiorgan failure the most common cause of death. Plus 3.82% of the patients had recurrent bleeding and 11% required a transfusion of more than 2 units of blood. When analyzing the ROC curve with AIMS65 and mortality score a value of 0.9122 is reported; identifying it as cutoff greater than or equal to 3 value in the score AIMS65 to discriminate patients at high risk of death, likewise the ROC curve was analyzed for recurrence of bleeding with a value of 0.6266 and the need to Transfusion of packed red blood cells over two a value of 0.7421. And it was determined the average hospital stay with a value of 4.8 days, however, no correlation was found with the score AIMS65. CONCLUSIONS: AIMS65 score is a good predictor of mortality, and is useful for predicting the need for transfusion of more than 2 globular packages. However it is not a good predictor for recurrence of bleeding, or hospital stay.

[BISAP-O y APACHE-O: utility in predicting severity in acute pancreatitis in modified Atlanta classification]. / BISAP-O y APACHE-O: utilidad en la predicción de severidad en la pancreatitis aguda según la clasificación modificada de Atlanta.

OBJECTIVE: To assess the BISAP and APACHE II scores in predicting severity according to the 2012 Atlanta classification and whether the obesity factor added to these scores improves prediction. MATERIAL AND METHODS: A prospective study between January 2013 and April 2014 including all patients with acute pancreatitis was performed according to the new Atlanta 2012 classification. ROC curves were fabricated for BISAP, BISAP-O, APACHE-II scores and Apache O and appropriate cutoffs were selected to the sensitivity, specificity, PPV, NPV, RPP and RPN. RESULTS: We studied 334 patients. 65.27% were overweighted or obese. The biliar etiology was 86.53%. Only 8.38% had severe pancreatitis and 1.5% died. Areas under the ROC curve and cut points selected were: BISAP: 0.8725, 2; BISAP-O: 0.8246, 3; APACHE-II: 0.8547, 5; APACHE-O: 0.8531, 6. Using these cutoffs the sensitivity, specificity, PPV, NPV, RPP and RPN were BISAP: 60.71%, 91.83%, 40.48%, 96.23 %, 7.43, 0.43; BISAP-O: 60.71%, 86.93%, 29.82%, 96.03%, 4.76, 0.45; APACHE-II: 85.71%, 76.14%, 24.74%, 98.31%, 3.6, 0.19; APACHE-O: 82.14%, 79.41%, 26.74%, 97.98%, 4, 0.22. CONCLUSIONS: BISAP, BISAP-O, APACHE-II and APACHE-O systems can be used to identify patients at low risk of severity because of its high NPV, however their use should be cautious considering that the RPP and RPN do not reach optimal levels indicating that their value in predicting severity is limited. On the other hand adding the obesity factor did not improve their predictive ability.

[Recurrence rate of Helicobacter pylori infection two years after successful eradication in Peruvian patients presenting with postprandial distress syndrome]. / Recurrencia de la infeccióngástrica con Helicobacter pylori en adultos peruanos con distrés postprandial dos años después de la erradicaciónexitosa.

INTRODUCTION: The general reported recurrence rate of H. pylori infection in Peru is high, implying that the long term effectiveness of anti H. pylori therapy is lower than expected. This would lead to an increase in the prevalence of gastric cancer and other associated pathologies. MATERIALS AND METHODS: This is a prospective cohort study including Peruvian patients with postprandial distress and H. pylori infection confirmed by gastric biopsy who recieved treatment and achieved bacterial eradication. Two years after the initial diagnosis, patients were contacted to determine the recurrence rate of H. pylori infection through the Urea breath test. RESULTS: 101 /129 of the patients that were infected with H. pylori had a successful eradication of the infection and 28/129 failed to eradicate the bacteria. The effectiveness rate of treatment was 77.2%. Two years after successful eradication we were able to contact 65/101 participants, 5 of them presented positive urea breath tests (recurrence rate of infection of 7.7%) (IC 1.5%-13.5%, α = 0.05). The annual recurrence rate was 3.85% per year/ patient. 94% of the patients in the cohort came from poor city areas, 95.4% had drinking water at home and 90.8% drank boiled drinking water on a daily basis. CONCLUSIONS: The recurrence rate of H. pylori in some populations of Peru is lower than expected and comparable with developed countries.