[Embolization of spontaneous portosystemic shunts as treatment for refractory hepatic encephalopathy]. / Embolización de colaterales portosistémicas espontáneas como tratamiento de la encefalopatía hepática refractaria.

BACKGROUND: Hepatic encephalopathy (HE) is a common complication of cirrhosis associated with a reduced survival. The presence of high-flux spontaneous porto-systemic shunts can induce HE even in patients with preserved liver function. AIM: To evaluate the effect of spontaneous porto-systemic shunt embolization (SPSE) over HE and its long-term evolution. MATERIAL AND METHODS: Retrospective analysis of 11 patients (91% males) with severe HE non-responsive to medical treatment in whom a SPSE was performed. The grade of HE (employing West Haven score), survival, MELD and Child-Pugh score, ammonia levels, degree of disability (employing the modified Rankin scale (mRs)) were evaluated before and at thirty days after procedure. RESULTS: The most common etiology found was non-alcoholic steatohepatitis (63.6%). A reduction of at least two score points of HE was observed in all patients after thirty days. There was a significant reduction on median (IQR) West Haven score from 3 (2-3) at baseline to 1 (0-1) after the procedure (p < 0.01). Twelve months survival was 63.6%. There was a decrease in median ammonia level from 106.5 (79-165) (ug/dL) to 56 (43-61) after SPSE (p = 0.006). The median mRS score before and after the procedure was 3 (3-5) and 1 (1-2.5), respectively (p < 0.01). CONCLUSIONS: According to our experience, SPSE is a feasible and effective alternative to improve HE and functionality of patients with refractory EH.

[Fundal variceal bleeding treated with balloon occluded endoscopic inyection sclerotherapy. Report of two cases]. / Escleroterapia endoscópica asistida mediante balón oclusivo como tratamiento de varices gástricas cardiofúndicas de alto riesgo: Reporte de dos casos y revisión de la literatura.

Management of gastrointestinal bleeding caused by fundal varices is particularly difficult to manage. The options are: transjugular intrahepatic portosystemic shunt (TIPS), endoscopic injection of cyanoacrylate or balloon-occluded retrograde transvenous obliteration (BRTO). We report a 63 year-old male with a cirrhosis caused by hepatitis C and a 66 year-old female with a cirrhosis caused by a non-alcoholic steatohepatitis. Both patients had a gastrointestinal bleeding caused by fundal varices and were treated with sclerotherapy with cyanoacrylate assisted with BRTO. Flow was interrupted in the gastro-renal shunt by a femoral access in both patients. The male patient had a new bleeding two months later and died. In the female patient an endosonography performed nine months after the procedure showed absence of remaining varices.

Successful Selective Embolization for Recurrent Hemarthrosis after Knee Arthroplasty.

Knee replacement has demonstrated to be a cost-effective treatment for severe knee osteoarthritis. Nevertheless, perioperative complications may occur, including recurrent hemarthrosis reaching an incidence between 0.3 and 1.6%. Success rate after conservative treatment has been reported to be above 80%, but in case of recurrence, computed tomography angiography, magnetic resonance angiography, and Doppler ultrasound have been used to conduct the diagnosis. Arthroscopy or selective embolization is used for treatment depending on the etiology of the bleeding. Open surgery is performed in the rare cases of failure of the above alternatives. The patient consulted seven months after total knee arthroplasty with sudden pain in the medial side of the knee. Infection was ruled out, and arthrocentesis shows hemarthrosis. Successful selective embolization of medial superior and lateral superior genicular artery was performed. After two years, the patients report 92 points in the Forgotten joint score, 0 in Womac pain, 1 in Womac stiffness, and 3 in Womac functional score.

Embolización de colaterales portosistémicas espontáneas como tratamiento de la encefalopatía hepática refractaria / Embolization of spontaneous portosystemic shunts as treatment for refractory hepatic encephalopathy

BACKGROUND: Hepatic encephalopathy (HE) is a common complication of cirrhosis associated with a reduced survival. The presence of high-flux spontaneous porto-systemic shunts can induce HE even in patients with preserved liver function. AIM: To evaluate the effect of spontaneous porto-systemic shunt embolization (SPSE) over HE and its long-term evolution. MATERIAL AND METHODS: Retrospective analysis of 11 patients (91% males) with severe HE non-responsive to medical treatment in whom a SPSE was performed. The grade of HE (employing West Haven score), survival, MELD and Child-Pugh score, ammonia levels, degree of disability (employing the modified Rankin scale (mRs)) were evaluated before and at thirty days after procedure. RESULTS: The most common etiology found was non-alcoholic steatohepatitis (63.6%). A reduction of at least two score points of HE was observed in all patients after thirty days. There was a significant reduction on median (IQR) West Haven score from 3 (2-3) at baseline to 1 (0-1) after the procedure (p < 0.01). Twelve months survival was 63.6%. There was a decrease in median ammonia level from 106.5 (79-165) (ug/dL) to 56 (43-61) after SPSE (p = 0.006). The median mRS score before and after the procedure was 3 (3-5) and 1 (1-2.5), respectively (p < 0.01). Conclusions: According to our experience, SPSE is a feasible and effective alternative to improve HE and functionality of patients with refractory EH.

Escleroterapia endoscópica asistida mediante balón oclusivo como tratamiento de varices gástricas cardiofúndicas de alto riesgo: reporte de dos casos y revisión de la literatura / Fundal variceal bleeding treated with balloon occluded endoscopic inyection sclerotherapy: report of two cases

Management of gastrointestinal bleeding caused by fundal varices is particularly difficult to manage. The options are: transjugular intrahepatic portosystemic shunt (TIPS), endoscopic injection of cyanoacrylate or balloon-occluded retrograde transvenous obliteration (BRTO). We report a 63 year-old male with a cirrhosis caused by hepatitis C and a 66 year-old female with a cirrhosis caused by a non-alcoholic steatohepatitis. Both patients had a gastrointestinal bleeding caused by fundal varices and were treated with sclerotherapy with cyanoacrylate assisted with BRTO. Flow was interrupted in the gastro-renal shunt by a femoral access in both patients. The male patient had a new bleeding two months later and died. In the female patient an endosonography performed nine months after the procedure showed absence of remaining varices.

Comparison of the clinical efficacy of two different immunosuppressive regimens in patients with chronic vogt-koyanagi-harada disease.

PURPOSE: To prospectively compare 2 immunosupressive regimens in patients with active Vogt-Koyanagi-Harada disease in spite of systemic glucocorticoid treatment. METHODS: Forty-four patients were diagnosed between 1998 and 2005. Twenty-one developed chronic intraocular inflammation in spite of glucocorticoid treatment and were randomized to receive either prednisone and azathioprine (AZA) (n = 12) or prednisone and cyclosporine (CyA) (n = 9). RESULTS: In the AZA group Tyndall score decreased from 1.21 +/- 1.10 to 0.29 +/- 0.62 (p < .01), and visual acuity (LogMAR) improved from 0.32 +/- 0.35 to 0.09 +/- 0.16 (p < .001). In the CyA group Tyndall score decreased from 1.67 +/- 1.08 to 0.16 +/- 0.51 (p < .001), and visual acuity improved from 0.41 +/- 0.40 to 0.25 +/- 0.42 (p < .001). Patients in the AZA group needed a significantly higher average prednisone dose and total cumulative dose than those in the CyA group, p < .01 for each comparison. CONCLUSIONS: Both regimens showed a good clinical efficacy, but CyA seems to be a better glucocorticoid-sparing agent than AZA.