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INTRODUCTION: Portal vein thrombosis (PVT) is the most frequent cause of portal hypertension in paediatric population. Baveno VI Consensus considers endoscopic variceal ligation as the second therapeutic option after meso-Rex bypass (surgical shunt). AIM: Analyse the diagnostic profitability of non-invasive scales in order to predict the risk of oesophageal varices (OV) in children with PVT. MATERIAL AND METHODS: Descriptive retrospective study where every upper gastrointestinal endoscopy (UGE) carried on patients <15 years old with non-cirrhotic PVT were included. There were divided according to the presence of OV and sex, cause, age, previous gastrointestinal bleeding or treatments, results of UGE and scales (Clinical Prediction Rule - CPR), Varices Prediction Rule - VPR), King's Variceal Prediction Score - K-VaPS) and Platelet count/Spleen diameter Ratio - PSR). Qualitative variables were expressed as absolute frequency and percentage, and quantitative variables as median and interquartile range. U Mann-Whitney and Hanley-McNeil tests were used for comparisons. RESULTS: Forty-five UGE were analysed. 80% (n=36) presented OV: median of 3 (2-3) and 33.3% (n=12) required endoscopic variceal ligation. Statistical differences were demonstrated between both groups: CPR (142.39 [132.22-166.53] vs. 122.75 [115.24-133.15]; p=0.003), VPR (9.91 [9.36-11.75] vs. 5.6 [3.34-8.39]; p=0.001), K-VaPS (117.86 [99.66-126.58] vs. 99.64 [94.88-10.18]; p=0.019), PSR (2384.62 [1902.22-3201.63] vs. 1252.5 [579.6-2144.42]; p=0.05), with and area under the curve AUROC>75%, without statistical differences between scales. CONCLUSIONS: In paediatric patients with non-cirrotic PVT non-invasive scales can be used as a tool to predict the presence of OV and raise the indication of UGE.
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INTRODUCTION: The aim of this study was to investigate the accuracy of liver and spleen stiffness measurement by transient elastography for the prediction of gastroesophageal varices in patients with HCV-associated cirrhosis treated with new direct-acting antiviral agents. PATIENTS AND METHODS: This cross-sectional observational study included patients with compensated HCV-related cirrhosis and sustained virological response after direct-acting antiviral therapy. Patients underwent liver and spleen stiffness measurement, abdominal ultrasound and oesophago-gastroduodenoscopy. Clinical and laboratory data and non-invasive markers such as the liver stiffness-spleen diameter to platelet ratio score, variceal risk index and platelet count to spleen diameter ratio were analyzed. RESULTS: Ninety-seven consecutive patients were included. Liver stiffness measurement (12.2 vs 16; p=0.02), spleen stiffness measurement (39.4 vs 46.05; p=0.04), liver stiffness-spleen diameter to platelet ratio score (1.21 vs 2.02; p=0.008), platelet count to spleen diameter ratio (1102.19 vs 829.7; p=0.04) and variceal risk index (-3.4 vs -1.02; p=0.01) showed significant differences between patients without/with gastroesophageal varices. The best cut-off value to discard the presence of gastroesophageal varices was 12.3kPa for liver stiffness measurement and 27kPa for spleen stiffness measurement. However, diagnostic accuracy was moderate (AUROC: 0.671 and 0.624 respectively). Combining different non-invasive parameters did not significantly improve the overall performance. DISCUSSION: Liver and spleen stiffness measurement showed suboptimal results for non-invasive assessment of gastroesophageal varices in HCV cirrhotic patients treated with direct-acting antiviral agents. Our results suggest that non-invasive methods cannot substitute standard procedures for predicting gastroesophageal varices in this population.
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Antivirais/administração & dosagem , Técnicas de Imagem por Elasticidade , Varizes Esofágicas e Gástricas/etiologia , Hepatite C Crônica/complicações , Cirrose Hepática/complicações , Hepatopatias/complicações , Hepatopatias/diagnóstico por imagem , Esplenopatias/complicações , Esplenopatias/diagnóstico por imagem , Administração Oral , Idoso , Estudos Transversais , Varizes Esofágicas e Gástricas/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos TestesRESUMO
Early TIPS is basically a new application of an old concept. This intervention used to be a useful rescue therapy when other interventions failed but has now become a primary intervention in patients with variceal bleeding and risk factors for poor prognosis. This technique has also been proven to control bleeding and has a definite survival advantage at 6 weeks and 1 year over standard therapy with vasoactive drugs and endoscopy, without increasing the rate of adverse events. In well-trained hands and with appropriate candidate selection, early TIPS is a safe, life-saving and evidenced-based procedure.
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Varizes Esofágicas e Gástricas/cirurgia , Seleção de Pacientes , Derivação Portossistêmica Transjugular Intra-Hepática , Ensaios Clínicos como Assunto , Estudos de Coortes , Contraindicações de Procedimentos , Gerenciamento Clínico , Varizes Esofágicas e Gástricas/complicações , Hemorragia Gastrointestinal/etiologia , Humanos , Hipertensão Portal/complicações , Estudos Multicêntricos como Assunto , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Terapia de Salvação , Resultado do TratamentoRESUMO
BACKGROUND: Gastroesophageal varices are present in approximately 50% of patients with liver cirrhosis. The aim of this study was to evaluate liver stiffness measurement (LSM), Fib-4, Forns Index and Lok Score as noninvasive predictors of esophageal varices (EV). METHODS: This prospective study included 65 patients with HCV-related liver cirrhosis. All patients underwent routine laboratory tests, transient elastograhy (TE) and esophagogastroduodenoscopy. FIB-4, Forns Index and Lok Score were calculated. The diagnostic performances of these methods were assessed using sensitivity, specificity, positive predictive value, negative predictive value, accuracy and receiver operating characteristic curves. RESULTS: All predictors (LSM, FIB-4, Forns Index and Lok Score) demonstrated statistically significant correlation with the presence and the grade of EV. TE could diagnose EV at a cutoff value of 18.2kPa. Fib-4, Forns Index, and Lok Score could diagnose EV at cutoff values of 2.8, 6.61 and 0.63, respectively. For prediction of large varices (grade 2, 3), LSM showed the highest accuracy (80%) with a cutoff of 22.4kPa and AUROC of 0.801. Its sensitivity was 84%, specificity 72%, PPV 84% and NPV 72%. The diagnostic accuracies of FIB-4, Forns Index and Lok Score were 70%, 70% and76%, respectively, at cutoffs of 3.3, 6.9 and 0.7, respectively. For diagnosis of large esophageal varices, adding TE to each of the other diagnostic indices (serum fibrosis scores) increased their sensitivities with little decrease in their specificities. Moreover, this combination decreased the LR- in all tests. CONCLUSION: Noninvasive predictors can restrict endoscopic screening. This is very important as non invasiveness is now a major goal in hepatology.
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Técnicas de Imagem por Elasticidade , Hepatite C Crônica/complicações , Cirrose Hepática/complicações , Índice de Gravidade de Doença , Fatores Etários , Colesterol/sangue , Estudos Transversais , Elasticidade , Endoscopia do Sistema Digestório , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/etiologia , Feminino , Humanos , Hipertensão Portal/etiologia , Hipertensão Portal/fisiopatologia , Fígado/fisiopatologia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Contagem de Plaquetas , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Sensibilidade e EspecificidadeRESUMO
The term portosinusoidal vascular disorder (PSVD) refers to a clinical-pathological entity that encompasses those patients with intrahepatic vascular damage without cirrhosis at risk of developing severe complications of portal hypertension. Numerous systemic diseases, genetic disorders, and toxic agents have been associated with this pathology, making its diagnosis an important clinical challenge. The recent description of uniform diagnostic criteria and a better understanding of its pathophysiology will allow for better identification of patients, even in early stages of the disease. Although there is currently no effective etiological treatment available, early diagnosis allows for the development of preventive strategies for some severe complications of portal hypertension.
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Hipertensão Portal , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Hipertensão Portal/complicações , Hipertensão Portal/terapia , Veia Porta , Doenças Vasculares/diagnóstico , Doenças Vasculares/etiologiaRESUMO
INTRODUCTION AND AIM: Esophageal varices are one of the complications of portal hypertension in cirrhotic patients that lead to high morbidity and mortality. Our aim was to assess the fecal calprotectin (FC) level in Egyptian cirrhotic patients as a non-invasive marker for the presence of esophageal varices. MATERIALS AND METHODS: The current study included 250 participants in the period from June 2019 to November 2020, divided into three groups: group 1: 100 HCV cirrhotic patients with esophageal varices that would then be subdivided, according to the Paquet classification; group 2: 100 HCV cirrhotic patients without esophageal varices; group 3: 50 normal age and sex-matched healthy subjects as the control group. Patients with other causes of abnormal calprotectin results were excluded. RESULTS: The comparison of FC in the three study groups revealed a statistically significant difference, with FC levels higher in groups 1 and 2 (mean 66.4±10.41 and 48.4±10.92, respectively). There was a significant difference in FC levels between the subgroups, subdivided according to the Paquet classification (P=.001). FC levels were higher in the grade III and IV subgroups. FC in the diagnosis of HCV cirrhotic patients with esophageal varices showed the best performance when the cut-off value was >55; AUC was 0.918, with 92% sensitivity, 95% specificity, and 93% accuracy. CONCLUSION: FC levels serve as a screening tool for esophageal varices. FC was higher in cirrhotic patients with esophageal varices, especially in the grade III and IV subgroups, according to the Paquet classification.
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La enfermedad vascular porto-sinusoidal es una causa infrecuente de hipertensión portal no cirrótica, fue descrita recientemente y es poco diagnosticada por el desconocimiento entre los médicos. Se considera en casos de hipertensión portal clínicamente significativa, en ausencia de cirrosis. El diagnóstico se basa en los hallazgos de la biopsia. El pronóstico de la enfermedad es mejor que el de los pacientes cirróticos, y el tratamiento es similar al de la hipertensión portal y al de las complicaciones que presentan los pacientes con cirrosis. Se presenta el caso de una paciente con várices esofágicas con estudios de imágenes no compatibles con cirrosis y hallazgos específicos en la biopsia de enfermedad vascular porto-sinusoidal. Este caso muestra el ejercicio diagnóstico en un caso de enfermedad vascular porto-sinusoidal de una paciente de Colombia, así como el resultado de las intervenciones terapéuticas y la evolución en el tiempo.
Porto-sinusoidal vascular disease is an uncommon cause of non-cirrhotic portal hypertension. It was recently described and is rarely diagnosed due to lack of knowledge among doctors. It is considered in cases of clinically significant portal hypertension in the absence of cirrhosis, and the diagnosis is based on biopsy findings. The prognosis of the disease is better than that of cirrhotic patients, and the treatment is similar to that of portal hypertension, including the management of complications associated with cirrhosis. We present the case of a patient with esophageal varices, whose imaging studies were not compatible with cirrhosis, alongside specific biopsy findings of porto-sinusoidal vascular disease. This case illustrates the diagnostic process in a patient from Colombia with portosinusoidal vascular disease, as well as the outcomes of therapeutic interventions and the patient´s evolution over time.
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Introducción. La hipertensión portal (HTP) se define como una elevación anormal de la presión venosa en el sistema portal que lleva al desarrollo de vías colaterales para desviar el flujo sanguíneo de la zona. Dentro de su etiología están las relacionadas con la cirrosis hepática y otras causas denominadas no cirróticas. El objetivo de este estudio fue evaluar los principales hallazgos demográficos, clínicos y paraclínicos en un grupo de pacientes con HTP, y determinar el uso de ayudas invasivas y no invasivas, y su disponibilidad para el diagnóstico y seguimiento de los pacientes en los centros que no cuentan con laboratorio de hemodinamia hepática, reflejando la dinámica de múltiples escenarios en Colombia. Metodología. Se realizó un estudio descriptivo de corte transversal, retrospectivo, en pacientes atendidos en una institución de tercer nivel del sur de Colombia, entre enero del año 2015 y diciembre del año 2020. Resultados. Se obtuvo una muestra de 61 pacientes en donde la mayoría de casos correspondían a hombres en la séptima década de la vida, procedentes del área urbana. La principal causa de consulta fue el sangrado digestivo (39,3 %), asociado a la presencia de telangiectasias (arañas vasculares) en el 37,2 %, seguido de circulación colateral (31,3 %) e ictericia (19,7 %). En la ecografía abdominal (realizada en el 57,4 % de los pacientes) predominaron la cirrosis (68 %) y la presencia de esplenomegalia (14,2 %), y en lospacientes con Doppler portal (realizado en el 16,4 %) se encontró hígado cirrótico (80 %) y dilatación portal (40 %). Con respecto a los hallazgos en la esofagogastroduodenoscopia predominó la presencia de várices esofágicas y gastritis crónica. Conclusión. El principal motivo de consulta fue el sangrado digestivo, en tanto que la cirrosis fue el antecedente y el hallazgo imagenológico más frecuente, seguido de las várices esofágicas. Se encontró que el uso de paraclínicos, ecografía abdominal, ecografía con Doppler portal y esofagogastroduodenoscopia fueron los más utilizados en el contexto clínico de los pacientes con el diagnóstico de HTP.
Introduction. Portal hypertension (PHT) is defined as an abnormal elevation of venous pressure in the portal system that leads to the development of collateral pathways to divert blood flow from the area. Within its etiology are those related to liver cirrhosis and other so-called non cirrhotic causes. The aim of this study was to evaluate the main demographic, clinical and paraclinical findings in a group of patients with PHT, and to determine the use of invasive and non-invasive aids, and their availability for the diagnosis and follow-up of patients in centers that do not have a hepatic hemodynamics laboratory, reflecting the dynamics of multiple scenarios in Colombia. Methodology. A descriptive, retrospective, cross-sectional, retrospective study was conducted in patients attended in a third level institution in Southern Colombia, between January 2015 and December 2020. Results. A sample of 61 patients was obtained where the majority of cases corresponded to men in the seventh decade of life, from the urban area. The main cause of consultation was digestive bleeding (39.3%), associated with the presence of telangiectasias (spider veins) in 37.2%, followed by collateral circulation (31.3%) and jaundice (19.7%). In abdominal ultrasound (performed in 57.4% of the patients), cirrhosis (68%) and the presence of splenomegaly (14.2%) predominated, and in patients with portal Doppler (performed in 16.4%), cirrhotic liver (80%) and portal dilatation (40%) were found. With respect to the findings in the esophagogastroduodenoscopy, esophageal varices and chronic gastritis were predominant. Conclusion. The main reason for consultation was gastrointestinal bleeding, while cirrhosis was the most frequent history and imaging finding, followed by esophageal varices. It was found that the use of paraclinics, abdominal ultrasound, ultrasound with portal Doppler and esophagogastroduodenoscopy were the most used in the clinical context of patients diagnosed with PHT.
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Masculino, 49 años de edad, con antecedente patológico de Hipertensión Arterial no controlada y alcoholismo crónico, quien presentó dolor en epigastrio y vómitos con sangre (hematemesis), fue llevado a clínica privada de donde es referido a un hospital público, falleciendo al llegar, por lo que fue remitido a autopsia medicolegal...(AU)
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Humanos , Masculino , Autopsia , Varizes Esofágicas e Gástricas , Medicina LegalRESUMO
Introducción: La hemorragia digestiva alta tiene una elevada morbimortalidad. La endoscopía digestiva alta es el estudio de elección para su diagnóstico y tratamiento. Objetivo: Describir la conducta ante la hemorragia digestiva alta. Métodos: Para la revisión bibliográfica se consultaron artículos científicos indexados en idioma español e inglés, relacionados con la hemorragia digestiva, publicados en las bases de datos PubMed, SciELO, Medline y Cochrane, pertenecientes a autores dedicados al estudio de este tema. Desarrollo: La hemorragia digestiva alta se clasifica, según la etiología de origen, en variceal y no variceal. La mayoría de los pacientes con hemorragia digestiva alta el sangrado se autolimita. La causa más habitual es la úlcera péptica, pero en caso de sangrado masivo la etiología más frecuente es la variceal. El empleo precoz de la terlipresina en los pacientes con hemorragia digestiva alta variceal mejora el control del sangrado y disminuye la mortalidad. Se debe hacer uso de escalas validadas de estratificación del riesgo: escala de riesgo de Rockall (tiene como propósito principal predecir la mortalidad y riesgo de resangrado del paciente) y la escala de Glasgow-Blatchford). Conclusiones: Sospechar la presencia de hemorragia digestiva alta, estratificar su riesgo e instaurar el manejo inicial y apropiado constituye una prioridad para el médico de urgencia(AU)
Introduction: Upper gastrointestinal bleeding presents high morbidity and mortality. Upper gastrointestinal endoscopy is the study of choice for its diagnosis and treatment. Objective: To describe the management of upper gastrointestinal bleeding. Methods: For the bibliographic review, the consultation was carried out of scientific articles indexed in Spanish and English, related to gastrointestinal bleeding, published in the databases PubMed, SciELO, Medline and Cochrane, belonging to authors dedicated to the study of this subject. Development: Upper gastrointestinal bleeding is classified, according to the etiology of origin, into variceal and nonvariceal. In most patients with upper gastrointestinal bleeding the bleeding as such is self-limiting. The most common cause is peptic ulcer; however, in the case of massive bleeding, the most frequent etiology is variceal. Early use of terlipressin in patients with variceal upper gastrointestinal bleeding improves bleeding control and decreases mortality. Validated risk stratification scales should be used: Rockall risk scale (its main purpose is to predict patient mortality and risk of bleeding recurrence) and the Glasgow-Blatchford scale. Conclusions: Suspecting the presence of upper gastrointestinal bleeding, stratifying its risk, as well as instituting initial and appropriate management, are a priority for the emergency physician(AU)
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Humanos , Endoscopia Gastrointestinal/métodos , Terlipressina/uso terapêutico , Hemorragia/etiologia , Literatura de Revisão como Assunto , Bases de Dados BibliográficasRESUMO
Nuestro objetivo fue desarrollar un test diagnóstico para predecir la etiología de la Hemorragia Digestiva Alta Variceal (HDAV). Realizamos un estudio de cohorte retrospectivo. Se revisaron historias clínicas de pacientes mayores de 18 años con Hemorragia Digestiva Alta (HDA) que acudieron al servicio de emergencia del Hospital Cayetano Heredia (HCH) de Lima-Perú entre el 2019 a 2022, se recolectaron datos demográficos, de laboratorio y clínicos; posteriormente, se identificaron variables predictivas de HDAV mediante una regresión logística múltiple. A cada variable con capacidad predictiva se les asignó un puntaje con un punto de corte y sirvió para construir una escala predictiva de HDAV. Se incluyeron 197 historias clínicas de pacientes con HDA, de los cuales 127 (64%) tuvieron sangrado de causa no variceal, y, 70 (36%), variceal. Se identificaron 4 factores predictivos independientes: hematemesis (vómito rojo) (OR: 4,192, IC 95%: 1,586-11,082), recuento de plaquetas (OR: 3,786, IC 95%: 1,324-10,826), antecedente de HDA (OR: 2,634, IC 95%: 1,017-6,820), signos de enfermedad hepática crónica (OR: 11,244, IC 95%: 3,067-35,047), con los que se construyó una escala predictiva, con un punto de corte >7 y ≤7; que mostró una sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo, cociente de probabilidad positivo, y, negativo de 58,6%, 90,6%, 77,4%, 79,9%, 6,20, y 0,46 respectivamente. En conclusión, la escala predictiva con un punto de corte >7 es útil para predecir la presencia de la HDAV en pacientes que acuden a la emergencia por HDA.
Our objective was to develop a diagnostic test to predict the etiology of Variceal Upper Gastrointestinal Bleeding (VUGIB). We conducted a retrospective cohort study. Medical records of patients over 18 years of age with Upper Gastrointestinal Bleeding (UGIB) who attended the emergency service of Hospital Cayetano Heredia (HCH) in Lima-Peru between 2019 and 2022 were reviewed; demographic, laboratory and clinical data were collected. Subsequently, predictive variables of variceal upper gastrointestinal bleeding (VUGIB) were identified using multiple logistic regression. Each variable with predictive capacity was assigned a score with a cut-off point and served to build a predictive scale for VUGIB. 197 medical records of patients with UGIB were included, of which 127 (64%) had non-variceal bleeding, and 70 (36%), variceal. Four independent predictors were identified: hematemesis (red vomit) (OR: 4,192, 95% CI: 1.586-11.082), platelet count (OR: 3.786, 95% CI: 1.324-10.826), history of UGIB (OR: 2.634, 95% CI: 1.017-6.820), signs of chronic liver disease (OR: 11.244, 95% CI: 3.067-35.047), with which a predictive scale was constructed, with a cut-off point >7 and ≤7; which showed a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative of 58.6%, 90.6%, 77.4%, 79.9%, 6.20, and 0.46 respectively. In conclusion, the predictive scale with a cut-off point >7 is useful for predicting the presence of VUGIB in patients who attend the emergency room for UGIB.
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La hipertensión portal es un síndrome complejo producido por un aumento de la resistencia al flujo venoso esplácnico a nivel de la vena porta o sus ramas, con una circulación sistémica hiperdinámica caracterizada por vasodilatación periférica y aumento del gasto cardíaco. El sitio de obstrucción al flujo portal puede ser prehepático (hígado normal), intrahepático (como en la cirrosis) o posthepático (síndrome de BuddChiari). En los pacientes pediátricos, las causas prehepáticas e intrahepáticas se reparten en proporciones casi iguales (aproximadamente el 50 % cada una). La expresión clínica y el impacto individual son muy variados, pero en todos los casos expresan un deterioro en la salud de los pacientes y la necesidad de corregir el problema, tanto en sus consecuencias como, idealmente, en sus causas.
Portal hypertension is a complex syndrome caused by increased resistance to the splachnic venous flow at the portal vein level, with a hyperdynamic systemic circulation characterized by peripheral vasodilation and high cardiac output. Portal flow can be obstructed at prehepatic (¨normal liver¨), intrahepatic (as in cirrhosis), or post-hepatic level (as in Budd-Chiari syndrome). In pediatric patients, prehepatic and intrahepatic causes are almost equally distributed (nearly 50% each). Clinical presentation and individual impact are heterogeneous, but in each case, it is the expression of a worsening condition and the need to solve the problem, either by treating its consequences or (ideally) its causes.
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Humanos , Criança , Adolescente , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Hipertensão Portal/tratamento farmacológico , Veia Porta , Vasodilatação , Seguimentos , Cirrose Hepática/complicaçõesRESUMO
Abstract Introduction: The platelet count/spleen diameter (PC/SD) ratio is a noninvasive method for the diagnosis of esophageal varices (EV) used as an alternative to endoscopy in patients with cirrhosis. Objective: To evaluate the diagnostic performance of the PC/SD ratio (cut-off point <909) to detect EV in patients with cirrhosis treated at a tertiary referral hospital in Bogotá D.C., Colombia. Materials and methods: A prospective diagnostic test accuracy study was conducted in 66 patients with cirrhosis treated at the Hospital Universitario de La Samaritana between July and December 2018. A descriptive analysis of the data was performed. In addition, the diagnostic performance of the PC/SD ratio (cut-off point <909) for the detection of EV was compared with the findings reported in the esophagogastroduodenoscopy (gold standard), calculating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-). A significance level of p<0.05 was considered. Results: The mean age of the participants was 65.5 years, 53.03% were female, and the most common causes of cirrhosis were alcohol consumption (40.90%) and autoimmune hepatitis (22.72%). EV was diagnosed in 48 patients (72.72%). The PC/SC ratio showed sensitivity of 60%, specificity of 78%, PPV of 0.88, NPV of 0.42, LR+ of 2.73, and LR- of 0.51. Conclusion: The low sensitivity, specificity, and NPV found in the present study suggest that the PC/SD ratio (cut-off point <909) may not be a useful diagnostic test for detecting EV in patients with cirrhosis.
Resumen Introducción. El índice de recuento de plaquetas/diámetro del bazo (RP/DB) es un método no invasivo para el diagnóstico de varices esofágicas (VE) que se usa como alternativa a la endoscopia en pacientes con cirrosis. Objetivo. Evaluar el rendimiento diagnóstico del índice RP/DM (punto de corte <909) para detectar VE en pacientes cirróticos atendidos en un hospital de tercer nivel de Bogotá D.C., Colombia. Materiales y métodos. Estudio prospectivo de validez de prueba diagnóstica realizado en 66 pacientes cirróticos atendidos en el Hospital Universitario de La Samaritana entre julio y diciembre de 2018. Se realizó un análisis descriptivo de los datos. Además, el rendimiento diagnóstico del índice RP/DM (punto de corte <909) para la detección de VE se comparó con los hallazgos de la esofagogastroduodenoscopia (prueba de oro), calculándose su sensibilidad, especificidad, valor predictivo positivo (VPP), valor predictivo negativo (VPN), razón de probabilidad positiva (LR+) y razón de probabilidad negativa (LR-). Se consideró un nivel de significancia de p<0.05. Resultados. La edad promedio de los participantes fue 65.5 años, 53.03% eran mujeres y las causas más comunes de cirrosis fueron consumo de alcohol (40.90%) y hepatitis autoinmune (22.72%). Las VE fueron diagnosticadas en 48 pacientes (72.72%). El índice RP/DM tuvo una sensibilidad de 60%, una especificidad de 78%, un VPP de 0.88, un VPN de 0.42, una LR+ de 2.73 y una LR- de 0.51. Conclusión. La baja sensibilidad, especificidad y VPN encontrados en el presente estudio sugieren que el índice RP/DM (punto de corte <909) podría no ser una prueba diagnóstica útil para detectar VE en pacientes cirróticos.
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RESUMEN La transformación cavernomatosa de vena porta es una condición caracterizada por la formación de una red de venas colaterales dilatadas a lo largo de una vena porta previamente trombosada. Es considerada una entidad de baja frecuencia y se presenta más comúnmente en población pediátrica. Presentamos el caso de una mujer adulta con diagnóstico de transformación cavernomatosa de vena porta, originado como consecuencia de una trombocitemia esencial oculta. Como medida terapéutica a la hipertensión portal se realizó una ligadura endoscópica de várices gastroesofágicas en múltiples oportunidades sin resultados positivos. No se practicó derivación portosistémica por la presencia de abundantes colaterales. Finalmente, se realizó una esplenectomía, posterior a lo cual se logró evidenciar una trombocitemia esencial. La paciente evolucionó con múltiples complicaciones médico-quirúrgicas, que la llevaron a una falla multisistémica y posterior fallecimiento. No existen datos de prevalencia regional ni se han reportado casos de transformación cavernomatosa de vena porta asociado a trombocitemia esencial por lo que consideramos de gran importancia dar a conocer este caso, de modo a poder ayudar a establecer con mayor precisión y rapidez el diagnóstico y tratamiento de esta rara entidad.
ABSTRACT Cavernous transformation of the portal vein is a condition characterized by the formation of a network of dilated collateral veins along a previously thrombosed portal vein. It is considered a low-frequency entity and occurs more commonly in the pediatric population. We present the case of an adult woman with a diagnosis of cavernous transformation of the portal vein, originated as a consequence of occult essential thrombocythemia. As a therapeutic measure for portal hypertension, endoscopic ligation of gastroesophageal varices was performed on multiple occasions without positive results. Portosystemic bypass was not performed due to the presence of abundant collaterals. Finally, a splenectomy was performed, after which essential thrombocythemia was evidenced. The patient evolved with multiple medical-surgical complications, which led to multisystem failure and subsequent death. There are no regional prevalence data, nor have there been reports of cavernous transformation of the portal vein associated with essential thrombocythemia, for which reason we consider of great importance to make this case known, in order to help establish the diagnosis and treatment of this rare entity with greater precision and speed.
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Resumen La hipertensión portal se define como la alteración patológica en el gradiente de presión a nivel del sistema portal, es decir, la diferencia entre la presión de la vena porta y la vena cava inferior. El valor normal es entre 1-5 mm Hg y se considera hipertensión cuando es mayor de 10 mm Hg. En este artículo, se describe el caso de una paciente de 5 años con un cuadro de hipertensión portal secundario a várices esofágicas y trombosis de la vena porta, confirmado por endoscopia de vías digestivas alta y angioresonancia magnética. La paciente fue atendida en la Fundación Clínica Infantil Club Noel de la ciudad de Cali, Colombia, entre los meses de diciembre del 2018 y febrero del 2019.
Abstract Portal hypertension is defined as the pathological increase in the portal pressure gradient, which is the difference between the pressure of the portal vein and the inferior vena cava. Normally portal vein pressure ranges between 1-5 mmHg and is considered hypertension when it is higher than 10 mmHg. In this study the case of a 5-year-old patient that suffers from secondary portal hypertension to portal venous thrombosis and esophageal varices is presented. The diagnostic is confirmed by an endoscopy of the upper gastrointestinal tract and by a magnetic angioresonance. The patient was treated at the Fundacion Clinica Infantil Club Noel located in Cali, Colombia, between the months of December 2018 and February 2019.
Assuntos
Humanos , Feminino , Pré-Escolar , Veia Porta , Varizes Esofágicas e Gástricas , Trombose Venosa , Hipertensão , Hipertensão Portal , Pressão , Veia Cava Inferior , Pressão na Veia Porta , Trato Gastrointestinal Superior , EndoscopiaRESUMO
INTRODUCCIÓN: El re-sangrado de várices esofágicas posterior a la ligadura de la misma, es una complicación frecuente, que eleva de manera significativa la morbi-mortalidad en este grupo de pacientes. El presente estudio tiene la finalidad de describir la frecuencia de re-sangrado por VE luego de la ligadura endoscópica, así como la frecuencia de ciertos factores y su asociación con el re-sangrado. MATERIALES Y MÉTODOS : Estudio observacional, descriptivo y de correlación, transversal. Participaron 179 pacientes a los que se les realizó ligadura endoscópica de varices esofágicas. Para el análisis de asociación se aplicó la prueba Chi 2, se obtuvo razón de prevalencia, con IC 95%. La información fue presentada por medio de tablas con frecuencias y porcentajes. RESULTADOS: El alcoholismo fue la principal causa de la cirrosis hepática en los pacientes con ligadura de varices esofágicas, con un porcentaje de 44.1%. La mayor parte de los casos se encontró dentro de la clase funcional Child Pugh Score B, con una frecuencia del 36.3%. La frecuencia de re-sangrado fue del 49.2% (IC 95% 41.55% 56.76%), siendo más frecuente en varones mayores ≥ 65 años con el 58%, y en el sexo masculino (64.8%). Falleció el 43 % de la muestra, a causa de re-sangrado tras la ligadura. Hubo relación estadísticamente significante de el re-sangrado con factores como: TPT mayor a 33.3 (RP: 1.91, IC 95% 1.07 -3.39, valor p =0.00); anemia moderada, severa (RP: 1.43, IC 95% 1.05 1.96, valor p = 0.02) y transfusión sanguínea (RP: 2.23, IC 95% 1.37 3.65, valor p = 0.00). CONCLUSIÓN: La frecuencia de re-sangrado fue del 49.2% (tanto temprana como tardía), la mayoría de pacientes con re-sangrado fueron de sexo masculino y de 65 o más años. Se encontró relación estadísticamente significativa entre el re-sangrado y factores como: tiempo parcial de tromboplastina por encima de valores normales, anemia moderada o severa y el haber recibido transfusiones sanguíneas. La mortalidad por re-sagrando fue del 43% para toda la población de estudio.
BACKGROUND: Re-bleeding of esophageal varices after endoscopic ligation is a frequent complication, that significantly increases morbidity and mortality in this patients. This study aims to describe the frequency of rebleeding due to esophageal varices after endoscopic ligation, as well as the frequency of certain factors and their association with rebleeding. METHODS: Cross-sectional, descriptive and correlational, observational study. A total of 179 patients who underwent endoscopic ligation of esophageal varices participated. For the association analysis Chi2 test was applied, prevalence ratio was obtained, with 95% IC. Data was presented with charts, with frequencies and percentages. RESULTS: Alcoholism was the main cause of cirrhosis in patients that underwent ligation of esophageal varices (44.1%). Most of the cases were classified as Child Pugh Sore B functional class, with a frequency of 36.3%. The prevalence of rebleeding was 49.2% (95% CI 41.55%- 56.76%), it was more frequent in patients 65 years old and older (58%), and male patients (64.8%). Death rate due to rebleeding after ligation was 43%. We found significant statistical association of rebleeding with factors such as: TPT >33.3 (PR: 1.91, 95% CI 1.07-3.39, p value =0.00); moderate and severe anemia (PR: 1.43, 95% CI 1.05-1.96, p value =0.02), and blood transfusion (PR: 2.23. 95% CI 1.37-3.65, p value=0.00). CONCLUSION: Rebleeding frequency was 49.2% (early and late rebleeding), it was more common in male patients, and patients aged 65 or more. This study found statistical association between rebleeding and: elevated values of partial thromboplastin time, moderate and severe anemia, and blood transfusion. Mortality due to rebleeding was 43%.
Assuntos
Humanos , Masculino , Feminino , Varizes Esofágicas e Gástricas , Alcoolismo , Hemorragia , Ligadura , Cirrose Hepática , Fatores de Risco , MorbidadeRESUMO
RESUMEN Introducción: la cirrosis es un proceso dinámico y actualmente se conoce que cuando se elimina el agente primario de agresión que ha producido la cirrosis, se puede llegar a remitir la fibrosis. En Cuba la enfermedad representa la décima causa de muerte, con una tendencia ascendente en los últimos 20 años y una tasa de 13,4 por 100 000 habitantes. Objetivo: caracterizar clínica y endoscópicamente a pacientes con diagnóstico de cirrosis hepática. Material y método: se realizó un estudio descriptivo transversal, en el período comprendido entre los años 2017 - 19, donde el universo y la muestra quedaron constituidos por todos los pacientes mayores de 18 años ingresados con diagnóstico de cirrosis hepática. Resultados: predominó el sexo masculino en la sexta década de la vida, siento la principal causa el alcoholismo, caracterizado por manifestaciones generales, que en muchos casos debutan por complicaciones, apareciendo várices esofágicas en el 75 % de los casos, aunque gados I y II de Paquet, dependiente a un diagnóstico precoz de la enfermedad. Conclusiones: el alcoholismo crónico es la causa más frecuente de cirrosis hepática, debuta de forma frecuente por sus complicaciones, aunque el diagnóstico se hace en etapas precoces, con varices esofágicas incipientes (AU).
Summary Introduction: liver cirrhosis is a dynamic process and currently it is known that, when the primary agent of aggression that has produced the cirrhosis is eliminated, the fibrosis could remit. In Cuba, this diseases is the tenth cause of death, with an increasing tendency in the last twenty years and a rate of 13.4 per 100 000 inhabitants. Objective: to characterize, clinically and endoscopically, patients with hepatic cirrhosis diagnosis. Material and methods: a cross-sectional descriptive study was carried out, in the period 2017 - 2019, where the universe and the sample were formed by all the patients aged more than 18 years who entered the hospital with diagnosis of liver cirrhosis. Results: in this paper, male patients in their sixties predominated, being alcoholism the main cause of disease, characterized by general manifestations; patients debuted due to complications, appearing esophageal varices in 75 % of the cases, although Paquet I and II grades, in dependence to a disease precocious diagnosis. Conclusions: the authors concluded that chronic alcoholism is the most frequent cause in hepatic cirrhosis, almost always debuting by its complications, though the diagnosis is made in precocious stages, with emerging esophageal varices (AU).
Assuntos
Humanos , Adolescente , Varizes Esofágicas e Gástricas/complicações , Cirrose Hepática/diagnóstico , Ascite/complicações , Epidemiologia Descritiva , Estudos Transversais , Hepatite C/diagnóstico , Alcoolismo/complicações , Endoscopia , Hepatite B/diagnóstico , Cirrose Hepática/epidemiologiaRESUMO
Resumen Se describen 21 casos con hallazgo incidental de várices esofágicas superiores (Downhill varices) en endoscopia de las vías digestivas altas. Además, se detallan algunos datos relevantes de la historia clínica y de los hallazgos endoscópicos. La relación hombres/mujeres fue 1:1 y la edad promedio fue de 67,9 años. La comorbilidad más frecuente fue la enfermedad pulmonar obstructiva crónica (EPOC), seguida de las neumoconiosis, la obesidad y el síndrome de apnea-hipopnea, todas con hipertensión pulmonar (HTP) asociada. Las tres últimas causas no han sido descritas previamente en la literatura sobre várices esofágicas superiores. Ningún paciente tenía antecedente de hemorragia variceal.
Abstract We describe 21 cases with incidental endoscopic findings of upper esophageal varices (downhill varices) and relevant data from patients' clinical histories and endoscopic findings. The male/female ratio was 1:1 and patients' average age was 67.9 years. The most frequent comorbidity was chronic obstructive pulmonary disease, followed by pneumoconiosis, obesity and apnea-hypopnea syndrome. All comorbidities had associated pulmonary hypertension. The last three causes have not been previously described in the literature on upper esophageal varices. None of the patients had histories of variceal hemorrhaging.
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Humanos , Animais , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Varizes Esofágicas e Gástricas , Endoscopia , Pneumoconiose , Doença Pulmonar Obstrutiva Crônica , Hipertensão PulmonarRESUMO
RESUMEN Las várices del intestino delgado, usualmente, están relacionadas con hipertensión portal. Las várices ectópicas secundarias a trombosis crónica aislada de la vena mesentérica superior son muy infrecuentes. El sangrado digestivo secundario a éstas representa un reto diagnóstico, dada la baja prevalencia y sospecha clínica, y terapéutico por la escasa evidencia científica existente con respecto a las opciones de tratamiento. Presentamos el caso de un hombre de 56 años, con sangrado digestivo secundario a várices yeyunales por trombosis crónica de la vena mesentérica superior, asociada a trombofilia; diagnosticadas mediante video cápsula endoscópica (VCE) y enterografía por tomografía (entero TC), sin posibilidades de manejo endoscópico ni radiológico dado el compromiso extenso, intervenido quirúrgicamente con éxito.
ABSTRACT Small bowel varices are usually associated with portal hypertension. Ectopic varices caused by isolated chronic superior mesenteric vein thrombosis are exceedingly rare. Gastrointestinal bleeding secondary to these represents a diagnostic challenge, given the low prevalence and clinical suspicion, and therapeutic dilemma due to the limited scientific evidence available regarding treatment options. We present the case of a 56-year-old man with gastrointestinal bleeding from jejunal varices due to chronic superior mesenteric vein thrombosis, associated with thrombophilia; diagnosed by video capsule endoscopic (VCE) and computed tomography enterography (CTE), with no possibility of endoscopic or radiological management given the extensive involvement, who underwent successful surgery.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Varizes/etiologia , Isquemia Mesentérica/complicações , Hemorragia Gastrointestinal/etiologia , Jejuno/irrigação sanguíneaRESUMO
Resumen Una de las consecuencias más graves de la trombosis de la vena porta extrahepática es la hipertensión portal con sangrado variceal recurrente. Una vez falla la ligadura endoscópica de las várices y el eje esplenoportal no se encuentra permeable, la devascularización tipo Sugiura modificado puede ser la única alternativa. Se ha documentado su uso en pacientes con cirrosis, pero hay poca información en personas no cirróticas. En este artículo se describe una serie de 4 casos de pacientes no cirróticos, en los cuales se realizó dicho procedimiento. Los pacientes fueron seguidos durante 12 meses y ninguno presentó episodios de resangrado de las várices esofágicas, ni tampoco se requirió la ligadura de las várices residuales. Esta cirugía se perfila como una alternativa terapéutica para este tipo de pacientes.
Abstract One of the most serious consequences of extrahepatic portal vein thrombosis is portal hypertension with recurrent variceal bleeding. Once endoscopic variceal ligation fails and the spleno-portal axis is not permeable, modified Sugiura devascularization may be the only alternative. Its use in patients with cirrhosis has been reported, but there is little information on non-cirrhotic patients. This article presents a series of four cases of non-cirrhotic patients that underwent this procedure. Patients were followed for twelve months; none presented episodes of esophageal varices re-bleeding nor required ligation of residual varices. This surgery is outlined as a therapeutic alternative for this type of patients.