[Percutaneous transhepatic biliary drainage in obstructive jaundice]. / Drenaje biliar transhepático percutáneo en las ictericias obstructivas.

PTC was performed in 86 patients with obstructive jaundice, between February/80--March/81 diagnosing 20 cases of the hepatic hilium carcinoma, 14 of pancreatic carcinoma, and 2 multiplex abscess of the liver. PTC-D was successfully attempted on 16 patients, catheterizing the intrahepatic biliary tree in 15 and maintaining a good biliary flow in 10 of them. The catheter was on the correct position into the biliary tree in 6 patients, and the drainage continued for 7-20 days. General improvement was obtained in 83.33%, itching decreased in 40% and disappeared in 60%, cholestasis was reduced in 100% and sepsis in 75%. Complications of the technique were: pain during the introduction of the guide wire (18.75%) and transitory hemobilia (31.21%). PTC-D seems to be a procedure with a precisely indication in every transitory obstructive jaundice, in order to put the patient in better conditions to a definitive therapy: 1) Surgery 2) Prosthesis 3) External-internal biliary drainage.

[Intestinal metaplasia of the stomach. Frequency in a study of endoscopic biopsies]. / Metaplasia intestinal gástrica. Frecuencia en un estudio de biopsias endoscópicas.

The histologic sections of gastric endoscopic biopsies performed during a 4 years period were reexamined. Those cases in which the whole mucosa was not included in the biopsy and those of cancer or peptic ulcer in which another biopsy of normal mucosa outside of the lesion was not obtained, were ruled out. The presence of intestinal metaplasia (IM) and gastritis was investigated. Gastritis was classified according to Whitehead. No attempt was made to grade IM. The relationship of the frequency of IM with age, severity of gastritis, cancer, peptic ulcer and different areas of the stomach was studied. Cases without cancer or peptic ulcer were used as controls. IM was present in 67 (32.1%) out of 209 cases that were reviewed. A significant difference in the frequency of IM was found between those cases below 40 years and those with 41 or more. The difference was not significant when the following decades were considered (tables 1, 2 and 3). Either was there any significant difference of frequency between sexes. According to our criteria for the selection of cases only 16 carcinomas were included in this series. IM was observed in 50% of the cases. Fifteen patients had more than 50 years. There was a considerable difference in the percentage of IM between this group and that of the controls with 50 or more years, nevertheless this difference was not significant, probably because of the small number of cases, (table 6). IM was found in 48.8% of 43 cases with peptic ulcer.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fine-needle aspiration puncture of abdominal masses using echographic monitoring. Cytological diagnosis and experience with biological markers]. / Puncion aspiración con aguja fina de masas abdominales bajo control ecográfico. Diagnóstico citológico y experiencia con marcadores biológicos.

43 fine needle aspiration biopsies of abdominal masses were performed under echographic guide. Cytologic diagnosis was done with routine techniques. Tumor, lineage and origin biologic markers were detected by immunocytochemical methods. Sensibility, specificity and accuracy of this procedure were evaluated. Advantages of the method are discussed.

[Endoscopic cholangiography in biliary tract diseases in HIV+ patients]. / La colangiografía endoscópica en afecciones de la vía biliar en pacientes HIV+.

UNLABELLED: Biliary tract involvement in the course of the infection by HIV was first described in 1983. Since then, various opportunistic infections have been responsible of different biliary lesions, coming to a new entity called "cholangiopathy associated to HIV". Our aim was to determined the use of ERCP in the management of HIV patients with cholestasis. From August 1994 to October 1997, 11 HIV patients (8 men, 3 women, mean age 35 y.) were submitted to ERCP because of jaundice (n = 8), upper right abdominal pain (n = 8), fever (n = 6), pruritus (n = 5) and elevated alkaline phosphatase (n-10). In 7 the diagnosis of AIDS had already be made. All had hepatobiliary ultrasound and endoscopic periampullar duodenal mucosa biopsy was taken in 7. According to Cello, 4 types of radiologic lesions were considered: 1) Papillary stenosis with dilated extrahepatic biliary tract. 2) Sclerosing cholangitis (focal intra or extrahepatic stenosis and dilatations). 3) Association of types 1 and 2.4) Choledocal long stenosis in the absence of previous biliary surgery or chronic pancreatitis. Five patients (45%) had biliary abnormalities; in 3 related to HIV infection: sclerosing cholangitis (n = 2) and papillary stenosis (n = 1). Two had choledocal stones. Four had upper right abdominal pain and dilated bile ducts at ultrasound. Cryptosporidium was found in duodenal mucosa in one patient with sclerosing cholangitis and in the patient with papillary stenosis. Biliary stents were placed without sphincterotomy in 2, with relief of pain and improving of cholestasis in only one. The choledocal stones were removed endoscopically in one patient and by surgery in the other. CONCLUSION: The ERCP is a useful method in the diagnosis and treatment of the biliary tract abnormalities associated to HIV.

Endoscopic retrograde cholangiopancreatography: before and after laparoscopic cholecystectomy.

In 39 patients with indication of laparoscopic cholecystectomy (LC), an endoscopic cholangiopancreatography (ERCP) was performed before the procedure whenever intermittent cholestasis, acute pancreatitis or ultrasonografic biliary tract dilatation were detected. No abnormality was found in 24 of them. In 14, bile duct stones were removed by endoscopic sphincterotomy (EST). Later they were submitted to LC, and no complication was observed. Only 1 patient with cholangiografic diagnosis of Mirizzi's syndrome underwent open cholecystectomy. Twenty-four patients were referred to ERCP between 2 and 210 days following LC, after development of complications. The etiology of these complications could be established in all the cases. Sixteen patients had bile duct stones, 14 of them were treated successfully by EST and 2, with multiple stones, required open surgery extraction. Four patients had cystic bile leaks, of which 1 healed spontaneously, 1 closed his fistula after EST and removal of stones, 1 cured after a nasobiliary tube was inserted endoscopically and 1 required surgical treatment. Four patients with complete obstruction of common bile duct by misplaced clips received surgical treatment. We conclude that ERCP is indicated before LC in patients with clinical, humoral or ultrasound findings of extrahepatic cholestasis. The application of EST plus LC systematically in cases of biliary duct stones remains still controversial. We agree that ERCP is an excellent method in the diagnosis and treatment of LC complications.

[Critical evaluation of echography in the diagnosis of cholestatic jaundice]. / Valoración crítica de la ecografía en el diagnóstico de la ictericia colestática.

Seventy one patients affected by cholestasis and jaundice were studied by means of ultrasound between september 1980 and february 1983 in order to evaluate the accuracy of this procedure in the investigation of the site of obstruction and its ethiology. The ultrasound findings were correlated with those obtained by opacification of the bile ducts, either endoscopic or percutaneous, and by surgery. The sonographic diagnosis of cholestatic jaundice was based on the size of the biliary tract taking in account that the intrahepatic branches are not evident in normal conditions and considering 4-5 mm and 7-8 mm as the upper limits for the proximal and distal segments of the common bile duct respectively. The accuracy of ultrasound in establishing the common bile duct size was 98%. Forty eight patients had extrahepatic obstruction, 45 of whom had a dilated common bile duct (94%), while 3 were normal (6%). Twenty two patients had an intrahepatic cholestasis, 20 of whom had a normal size of the common bile duct (91%) while 2 showed a dilatation (9%). Thus, the sensitivity was 95.7% and the specificity 86.9%. The ethiologic diagnosis was available in 31 patients with extrahepatic obstruction (65%) and in 7 with intrahepatic cholestasis (32%). Dilated common bile duct with stones and pancreas and gallbladder carcinoma were the most common causes of obstructions we have found in this group of patients. In patients with cholestasis and jaundice the ultrasonic diagnosis should establish the site of obstruction and, if it is possible, the ethiology.

[Evaluation of the usefulness of the physico-chemical study of ascitic fluid in patients with chronic hepatopathies, neoplasms and spontaneous peritonitis]. / Valoración de la utilidad del estudio fisicoquímico del líquido, ascítico en pacientes con hepatopatías crónicas, neoplasias y peritonitis espontánea.

In order to separate malignancy from chronic liver disease, the ascitic fluid (AF) of 45 in-patients was studied prospectively. Protein, cholesterol, triglycerides, LDH and glucose concentrations were determined in AF. Ascites/Serum (A/S) protein and LDH ratios were also established. Spontaneous bacterial peritonitis (SBP) incidence was studied in the cirrhotic group performing the pH, PMN count and culture of the AF. The 45 patients were classified in three groups: 29 with chronic liver disease, 10 with malignancy and 6 with miscellaneous pathology. Af protein concentration, its A/S ratio and AF cholesterol concentration were statistically significant (p less than 0.001) to differentiate malignancy from chronic liver disease. However, the AF glucose, triglycerides and LDH concentrations and the A/S LSH ratio were not useful in the differential diagnosis. The SBP incidence was 13%, its mortality rate 75% and the cultures were positive only in 25%.

[Diarrhea and AIDS: more complex diagnostic techniques; better therapeutic results]. / Diarrea y SIDA: técnicas diagnósticas más complejas; mejores resultados terapéuticos.

During 17 months, 73 HIV-positive patients with diarrhea lasting at least for 14 days, were studied prospectively. The patients had stool specimen examinations negative for enteric pathogens, or positive for one of them, but with no response to specific treatment. All patients were subcomitted to digestive endoscopy and biopsies were taken for microbiological and histological studies. The etiology of the diarrhea could be established in 48 patients (66%). In 45, the cause was an enteric infection. There was association of 2 pathogens in 11 patients, and of 3 in 1 patient. The agents found were: Cryptosporidium (24%), MAI (16%), Giardia lambila (12%), isospora belli (5%), Shigella (5%), Salmonella (5%); Entamoeba histolytica (3%), HSV (3%), tuberculosis (2%), adherent bacteria (2%) and spirochetes (2%). In 3 patients the etiology was not infection, their diagnoses were coeliac disease, lymphoma and idiophatic colonic ulcers, respectively. In 51% of the cases only the examination of endoscopic biopsy specimens could identify the cause of the diarrhea. These results justify the use of these methods to improve diagnosis and therapeutic attempts in these patients.

[Treatment with extracorporeal shockwave (ESWL) in lithiasis of the common bile duct]. / Tratamiento con ondas de choque extracorporeas (ESWL) en la litiasis de la viá biliar principal.

During 2 years (1988-1990) 373 patients were studied by ERCP in order to establish the etiology of cholestasis. Biliary duct stones were found in 190. Thirty-nine were treated surgically and 151 by endoscopic sphincterotomy and different extraction techniques. In 12 patients of the last group (9 women, 3 men, mean age 71 years, 9 had undergone cholecystectomy and 3 has their gallbladders in situ), ESWL was used as additional treatment to fragment the stones that could not be removed with the Dormia basket or with mechanical lithotripsy. Four patients had only one stone in their biliary ducts, 5 had two, and 3 had more than two stones. The size of the stones was greater than 2.5 cm. in 11 patients, only 1 patient had a 1 cm. diameter stone. In each session between 1200 and 5000 shock waves were administered (mean 1400). In 8 patients (66%), the fragmentation was successful to achieve their spontaneous passage or their extraction with a basket. In 4 who received only one session of ESWL, the procedure failed to break the stones. Side effects were observed in 3 cases: mild haemobilia in 1, skin petechiae and pain in 2 patients. No complications were observed in the long term follow-up. We conclude that ESWL is useful in the treatment of biliary duct stones which cannot be extracted through sphincterotomy with a basket or mechanical lithotripsy.

Drenaje biliar transhepático percutáneo en las ictericias obstructivas / [Percutaneous transhepatic biliary drainage in obstructive jaundice]

PTC was performed in 86 patients with obstructive jaundice, between February/80--March/81 diagnosing 20 cases of the hepatic hilium carcinoma, 14 of pancreatic carcinoma, and 2 multiplex abscess of the liver. PTC-D was successfully attempted on 16 patients, catheterizing the intrahepatic biliary tree in 15 and maintaining a good biliary flow in 10 of them. The catheter was on the correct position into the biliary tree in 6 patients, and the drainage continued for 7-20 days. General improvement was obtained in 83.33

, itching decreased in 40

and disappeared in 60

, cholestasis was reduced in 100

and sepsis in 75

. Complications of the technique were: pain during the introduction of the guide wire (18.75

) and transitory hemobilia (31.21

). PTC-D seems to be a procedure with a precisely indication in every transitory obstructive jaundice, in order to put the patient in better conditions to a definitive therapy: 1) Surgery 2) Prosthesis 3) External-internal biliary drainage.

Metaplasia intestinal gástrica: frecuencia en un estudio de biopsias endoscópicas / Intestinal metaplasia of the stomach: frequency in a study of endoscopic biopsies

Se examinaron los cortes histológicos de las biopsias gástricas efectuadas en el Htal. J. A. Fernández entre 1980 y 1983. Se descartaron solamente los casos en que el material de la muestra fue insuficiente o correspondía a una lesión focal sin otra muestra de mucosa próxima. Se consignaron: la presencia de metaplasia intestinal (MI) y de gastritis, la que fue graduada de acuerdo a la clasificación de Whitehead (5). Se estudió la relación de la presencia de metaplasia intestinal con: edad, gravedad de la gastritis, carcinoma y úlcera péptica. Se investigó la frecuencia de MI en las distintas zonas gástricas. Observamos MI en 67 (32.1%) de los 209 casos examinados. Hallamos una diferencia estadísticamente significativa entre la frecuencia en el grupo de menos de 40 años y el de más de 40. No fue significativa la diferencia entre los grupos de menos de 50 y más de 50 años. No observamos relación entre la frecuencia de MI y el sexo. La frecuencia de MI aumentó con la gravedad de la gastritis, con la presencia de carcinoma (50%) y con la úlcera péptica (48%). Las muestras obtenidas de antro presentaron MI en 37% de los casos y las de cuerpo en 10%. En 30 casos en que se efectuaron biopsias simultáneas de ambas zonas no se halló MI en cuerpo. Se discute la dificultad para comparar la frecuencia de MI en series de distintos países en las que el estudio de la mucosa gástrica se hizo con diferentes métodos y en las que los controles se seleccionaron con distintos criterios. Independientemente de estas diferencias se observa, en nuestra serie y en las que analizamos de otros autores, una similar tendencia al aumento de frecuencia en relación con: edad, carcinoma gástrico y úlcera péptica

La colangiografia endoscopica en afecciones de la via biliar en pacientes HIV+ / Endoscopic cholangiography in biliary tract diseases in HIV+ patients

El compromiso de la vía biliar en el curso de la infección por HIV se describió por primera vez en 1983. Desde entonces diversas infecciones oportunistas han sido responsables de lesiones biliares, definiendo una nueva entidad denominada colangiopatía asociada al HIV. Nuestro objetivo fue determinar la utilidad de la CPRE en el manejo de pacientes HIV + con colestasis. Desde agosto de 1994 a octubre de 1997 se efectuó CPRE en 11 HIV + (8 hombres, 3 mujeres, con edad promedio 35 años). La indicación de CPRE fue por ictericia (n=8); dolar en HD (n=8); fiebre (n=6); prurito (n=5) y aumento de la FA (n=10). Siete pacientes tenían Sida. En todos se realizó ecografía hepatobiliar. En 7 se tomó biopsia de la mucosa duodenal periampular. Las lesiones radiológicas se clasificaron según Cello en: 1- Estenosis papilar, con dilatación de la vía biliar extrahepática. 2- Colangitis esclerosantes (estenosis y dilataciones focales, intra y/o extrahepáticas). 3- Asociación de 1 y 2. 4- Estenosis larga del colédoco, en ausencia de cirurgía biliar o pancreatitis crónica. Cinco pacientes (45 por ciento) tuvieron anormalidades en la vía biliar. En 3 de ellos estuvieron relacionadas con la infección HIV: colangitis esclerosantes (n=2) y estenosis papilar (n=1). Dos presentaban litiasis coledociana. Cuatro de los 5 tuvieron dolor en HD y vía biliar dilatada en la ecografía. Se encontró Cryptosporidium en la biopsia duodenal de 1 paciente con colangitis esclerosante y en la estenosis papilar. Se colocó prótesis biliar sin esfinteropapilotomía en 2, con alivio del dolor y mejoría de la colestasis en uno de ellos. Los cálculos coledocianos se extrajeron endoscópicamente en uno y por cirugía en otro. Conclusión: La CPRE fue un método útil en el diagnóstico y tratamiento de las patologías biliares asociadas al HIV.

Valoración de la utilidad del estudio fisicoquimico del liquido ascitico en pacientes con hepatopatias cronicas, neoplasias y peritonitis espontanea

En forma prospectiva se estudió el LA de 45 pacientes internados. Se valoraron las proteínas ascitis/plasma, la enzima LDH, el cociente de LDH ascitis/plasma, la concentración de triglicéridos, colesterol y glucosa, para el diagnóstico diferencial de la ascitis neoplásica y la producida en el curso de una hepatopatía crónica. Se estableció la incidencia de peritonitis espontanea en 29 cirróticos mediante la utilización del pH, cultivo y recuento de PMN, en el LA. Los 45 pacientes fueron clasificados en tres grupos: 29 con enfermedad hepática crónica, 10 con enfermedad maligna y 6 con diferentes patologías que agrupamos bajo el nombre de misceláneas. La concentración de proteínas en el LA, el cociente de proteinas LA/P y la concentración de colesterol en el LA mostraron diferencia estadísticamente significativa (p < 0.001) entre los grupos de pacientes con enfermedad hepática y los neoplásicos. La concentración de glucosa en el LA, la de triglicéridos tanto como la de LDH y del índice LA/P de esta enzima no fueron útiles para este diagnóstico diferencial (p > 0.05). La incidencia de peritonitis bacteriana espontánea fue del 13% y la mortalidad en este grupo ascendió al 75%. Los cultivos fueron positivos solamente en el 25% de estos casos

Tratamiento con ondas de choque extracorporeas (ESWL) en la litiasis de la via biliar principal / Treatment with extracorporeal shockwave in lithiasis of the common bile duct

En el transcurso de 2 años (1988-1990) se estudiaron 373 pacientes por ERCP para determinar la etiología de una colestasis. En 190 se encontraron cálculos en la vía biliar principal. Treinta y nueve fueron tratados quirúrgicamente y en 151 se efectuó EPE y diferentes técnicas de extracción. En 12 pacientes de este grupo de utilizó como tratamiento adicional ESWL para fragmentar cálculos que ho habían podido ser extraídos con canastilla o litotripsia mecánica. De los 12, 9 eran mujeres y 3 varones con un promedio de edad de 71 años (rango 32-90). Nueve estaban colecistectomizados y 3 tenían vesícula. La litiasis coledociana fue única en 4, y 5 tenían 2 cálculos. En los restantes se comprobaron 3 o más litos. El diámetro de los cálculos superó los 2,5 cm. en 11 pacientes. Sólo en 1 fue de 1 cm. Se efectuaron entre 1200 y 5000 disparos en cada sesión, con un promedio de 1400. En 8 pacientes (66%) la fragmentación permitió la evaluación completa, espontánea o instrumental. Se fracasó en 4 casos que recibieron una sola sesión de ESWL. Se registró hematobilia leve en 1 paciente y equimosis de piel y dolor en 2. En los 8 pacientes en los que se consiguió la eliminación total de los cálculos no hubo complicaciones alejadas. El empleo de ESWL resultó ser un recursos terapéutico útil en el tratamiento de cálculos coledocianos que no pudieron ser extraídos por EPE y maniobras instrumentales con canastilla y litotripsia mecánica

Diarrea y sida: tecnicas diagnosticas mas complejas; mejores resultados terapeuticosx / Diarrhea and aids: diagnosis techniques more completes; best results

Durante 17 meses se esdudiaron prospectivamente 73 pts HIV + con diarrea más de 14 dias de evolución, sin diagnóstico etiológico por el examen de la mf, o bien con coprocultivos positivos, pero sin respuesta al tratamiento específico. A todos se les realizó endoscopía digestiva con tomas de biopsias intestinales para estudio microbiológico (directo y cultivo) e histopatológico. El diagnóstico causal de diarrea pudo realizarse en 48 prs (66 por ciento). En 45, la cuasa fue infecciosa. Hubo asociación de 2 gérmenes en 11 pts y de 3 gérmenes en 1. Los patógenos hallados fueron: Cryptosporidium (24 por ciento), CMV (21 por ciento), MAI (16 por ciento), Giardias (12 por ciento), Isospora belli (5 por ciento), Shigella (5 por ciento), Salmonella (5 por ciento) , Entamoeba histolítica (3 por ciento), HSV (3 por ciento, TBC (2 por ciento), bacteria adherente (2 por ciento) y espiroqueta (2 por ciento). En 3 pts la causa de la diarrea no fue infecciosa, en ellos se diagnosticó respectivamente enfermedad celíaca, linfoma y úlceras inespecíficas de colon. En el 51 por ciento de los casos sólo la endoscopía con biopsia intestinal permitó identificar el agente causal, resultando que justifica el uso de este método como diagnóstico en esta patología.