Pancreatitis aguda. Diagnóstico y enfrentamiento inicial en la práctica clínica / Acute pancreatitis. Diagnosis and initial approach in clinical practice

Acute pancreatitis is a prevalent disease, with variable clinical course: several patients recover quickly and uneventfully, while others require treatment in critical care units with long hospital stay and even with a considerable mortality. The patient's symptoms, laboratory tests and radiological images allow diagnosis without major difficulties. However, early identification of more severe cases can be difficult, and it determines the adequate selection of the hospitalization unit and the quick initiation of the appropriate therapy. In this paper we give some practical treatment guidelines for the everyday clinical practice: immediate severity stratification, fluid replacement and pain control. Early enteral nutrition, monitorization of severe cases in critical care units, adequate therapeutic but no prophylactic use of antibiotics assures the best treatment results. (AU)

La alta prevalencia de lesiones premalignas gástricas y el bajo rendimiento diagnóstico de la visión endoscópica son argumentos a favor de la toma sistemática de biopsias gástricas por Protocolo Sydney / The high prevalence of gastric premalignant lesions and the low diagnostic performance of endoscopic vision advocate towards a systematic gastric biopsy sampling using Sydney Protocol

Background: Atrophic gastritis (AG) and intestinal metaplasia (IM) are stages that appear in the process of gastric carcinogenesis. Their presence requires programmed endoscopic vigilance. Objectives: To determine the frequency of AG and IM in gastric biopsies (GB) taken according to Sydney Protocol and to correlate them with endoscopic findings. Methods: Retrospective descriptive analysis of 233 upper gastrointestinal endoscopies with GB per Sydney Protocol. OLGA (Operative Link for Gastritis Assessment) and OLGIM (Operative Link for Gastric Intestinal Metaplasia Assessment) scores were calculated based on the GB description. Endoscopic findings were analyzed for atypical findings and compared to the GB report. Statistic analysis for Kappa and ANOVA was performed via Stata 12. Results: Mean age of patients was 58 ± 12 years. 69% were women. The frequency of AG and IM was 44% and 33% in the antrum, 31% and 20% in the angular incisure and 14% and 9% in the body, respectively. AG and IM were more frequent in the antrum (p < 0.05). AG and IM were more severe in the angular incisure and body (p < 0.05). We were unable to calculate OLGA and OLGIM in 6% and 9% of cases, respectively, due to absence of severity description in GB. 53% were OLGA 0, 42% OLGA I-II and 5% OLGA III-IV. 70% were OLGIM 0, 25% OLGIM I-II and 5% OLGIM III-IV. Agreement between endoscopic and histological findings was best for IM in the antrum (75.5%, Kappa 0.4). Sensitivity and specificity of endoscopic findings were 39% and 70% for AG, and 30% and 85% for IM, respectively. Conclusion: AG and IM are frequent findings in our patients. Due to the low endoscopic sensitivity for AG and IM, we suggest a systematic GB sampling using Sydney Protocol in patients over 40 years old.

Introducción: La gastritis crónica atrófica (GCA) y la metaplasia intestinal (MI) son etapas en el proceso de carcinogénesis gástrica, su presencia requiere control endoscópico programado. Objetivos: Determinar la frecuencia de GCA y MI en biopsias gástricas (BG) por protocolo de Sydney y relacionarlas con el hallazgo endoscópico. Métodos: Estudio descriptivo mediante revisión de 233 endoscopias digestivas altas con BG por Protocolo Sydney. Se graduó puntaje OLGA (Operative Link for Gastritis Assessment) y OLGIM (Operative Link for Gastric Intestinal Metaplasia Assessment) según la descripción de la BG. Se definió el hallazgo endoscópico según su informe y se comparó con BG como patrón de referencia. Estadística: Stata 12 para Kappa y ANOVA. Resultados: Edad promedio 58 ± 12 años, 69% mujeres. La frecuencia de GCA y MI en antro fue de 44 y 33%, en ángulo 31 y 20% y en cuerpo 14 y 9%, respectivamente. Hubo mayor frecuencia de GCA y MI en antro (p < 0,05). La graduación de GCA y MI fue mayor en ángulo y cuerpo (p < 0,05). No se obtuvo OLGA en 6% y OLGIM en 9% por ausencia de graduación. La frecuencia de OLGA 0 fue de 53%, OLGA I-II 42%, OLGA III-IV 5%, OLGIM O 70%, OLGIM I-II 25% y OLGIM III-IV 5%. La mejor correlación se observó entre la MI antral endoscópica con la histológica (75,5%, Kappa 0,4). La sensibilidad y especificidad endoscópica fue de 39 y 70% para GCA y 30 y 85% para MI. Conclusión: GCA y MI son hallazgos frecuentes en nuestros pacientes. Por la baja sensibilidad endoscópica en la identificación de GCA y MI sugerimos la toma sistemática de BG por protocolo de Sydney en pacientes mayores de 40 años.

Páncreas divisum y pancreatitis: su importancia en la práctica cotidiana / Pancreas divisum and pancreatitis: its importance in everyday practice

Pancreas divisum (PD) is the most common congenital anatomical variant of the pancreas. Its etiological implication in recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) has been recurrently questioned. Normal anatomy and variants: 80-90% of the population has normal anatomy, with excretion of exocrine pancreatic secretion to the duodenum by the major papilla. Three anatomical variants of PD have been described: classic PD with visible ventral duct, but total absence of fusion; PD with absence of ventral duct; and incomplete PD, with a rudimentary connection between the ventral and dorsal ducts. Clinical implication: This anatomical variant is symptomatic in less than 5% of the carriers, being associated to higher prevalence in patients with RAP However, the relationship between PD and RAP is considered probable, only in cases of association with mutation of the CFTR gene. Obstructive CP can develop in the segment drained by the dorsal duct. Diagnosis: Magnetic resonance cholangiopancreatography (MRCP) is the most sensitive diagnostic method. Other non-invasive diagnostic methods are endosonography and computed tomography (CT), the latter with lower performance. Treatment: The current trend in acute pancreatitis (AP) where PD is assumed as an etiological factor, is endoscopic resolution, with papillotomy with or without a pancreatic stent.

El páncreas divisum (PD) es la variante anatómica congénita más frecuente del páncreas. Su implicancia etiológica en pancreatitis aguda recurrente (PAR) y pancreatitis crónica (PC) ha sido frecuentemente cuestionada. Anatomía normal y variantes: 80-90% de la población presenta anatomía normal, con salida de secreción pancreática exocrina al duodeno por la papila mayor. Se han descrito 3 variantes anatómicas: PD clásico con conducto ventral visible, pero ausencia total de fusión; PD con ausencia de conducto ventral; y PD incompleto, con conexión rudimentaria entre los conductos ventral y dorsal. Implicancia clínica: Esta variante anatómica da síntomas en menos de 5% de los portadores, asociándose a mayor prevalencia en pacientes con PAR. Sin embargo, se considera probable la relación entre PD y PAR, solo en casos de asociación con mutación del gen CFTR. Pancreatitis crónica (PC) obstructiva se puede desarrollar en el segmento drenado por el conducto dorsal. Diagnóstico: La colangiopancreatografía por resonancia magnética (CPRM) es el método diagnóstico más sensible. Otros métodos diagnósticos no invasivos son la endosonografía y tomografía computada (TC), este último de menor rendimiento. Tratamiento: La tendencia actual en PA donde se asume PD como factor etiológico, es la resolución endoscópica, con papilotomía con o sin stent.

Extracción endoscópica de cálculos pancreáticos en pancreatitis crónica para evitar reagudizaciones / Endoscopic extraction of pancreatic stones in chronic pancreatitis with the aim to prevent acute flares

Chronic pancreatitis (CP) is defined by chronic inflammation of the pancreas with progressive replacement by fibrosis that produces characteristic morphological changes. The clinical picture is variable, being the main problem the pain and relapses of pancreatitis with possible local complications. Over time, the result is the development of exocrine and endocrine failure. In the initial phase, flare-ups of CP can not be distinguished from recurrent acute pancreatitis (RAP). If there are intraductal stones in the duct of Wirsung, endoscopic extraction of obstructive stones may be the first step to prevent new relapses and complications. We present the case of a patient with five episodes of acute pancreatitis (AP), three of them in the past five months. The patient was referred for study and management of RAP. His recent imaging study already showed dilatation of the main pancreatic duct, calcifications and pancreatic stones, compatible with CP. Although the hypertriglyceridemia participated in the etiology of AP, the last two episodes already occurred with normal values of triglycerides. Another possible etiologic factor was not found. His laboratory results did not show endocrine or exocrine insufficiency. The patient was treated with papillotomy, pancreatic stone extraction and installation of terapeutic pancreatic stent. He has been asymptomatic, free from new episodes of AP in the past six months. In conclusion, the CP is one of the possible causes of RAP. Endoscopic treatment by obstructive stone extraction is an efficient therapy to avoid new relapse.

La pancreatitis crónica (PC) se define por la inflamación crónica del páncreas con reemplazo progresivo por fibrosis que produce cambios morfológicos característicos. El cuadro clínico es variable, siendo el principal problema el dolor, reagudizaciones de pancreatitis con eventuales complicaciones locales. Con el tiempo, el resultado final es el desarrollo de insuficiencia exocrina y endocrina. En la fase inicial, no se puede distinguir las reagudizaciones de la PC de una pancreatitis aguda recurrente (PAR). Si se encuentran cálculos intraductales en el conducto de Wirsung, la extracción endoscópica de cálculos obstructivos puede ser el primer paso para prevenir nuevas recaídas y complicaciones. Se presenta el caso de un paciente con cinco episodios de pancreatitis aguda (PA), tres de ellos en los últimos cinco meses. El paciente fue derivado para estudio y manejo de PAR. Su estudio imagenológico reciente ya demostró dilatación del conducto pancreático principal, calcificaciones y cálculos pancreáticos, compatible con PC. Aunque la hipertrigliceridemia participó en la etiología de las PA, los últimos dos episodios ocurrieron con valores normales de triglicéridos. No se encontró otro factor etiológico posible. Su estudio de laboratorio no mostró insuficiencia exocrina ni endocrina. El paciente fue tratado mediante papilotomía, extracción de cálculos pancreáticos e instalación de prótesis pancreática terapéutica. Ha estado asintomático, libre de nuevos episodios de PA en los seis meses transcurridos. En conclusión, la PC es una de las posibles causas de PAR. El tratamiento endoscópico mediante extracción de cálculos obstructivos es una terapia eficiente para evitar nuevas recaídas.

Pancreatitis autoinmune: desafío diagnóstico y tratamiento actual / Autoimmune pancreatitis: diagnostic challenges and current treatment

Autoimmune pancreatitis (AIP) is an inflammatory disease of the pancreas. The mechanism of the disease is not completely known. However, AIP shows cellular and humoral immunity elements, the most important being helper and regulatory T lymphocytes as well as B-lymphocytes and plasmocytes, participating in the fibroinflammatory process. Two histologic types have been described with different clinical characteristics. Type 1 AIP is part of a systemic condition associated with an increase of IgG4, while type 2 is a pancreatic disease, frequently associated with inflammatory bowel disease. From the clinical point of view, a third category is described when the classification is not possible at the moment of the diagnosis. The most important differential diagnosis of AIP is pancreatic cancer and it can be difficult, because current diagnostic methods used, including biopsy, have low specificity and sensitivity. AIP patients recover rapidly after steroid therapy, which can be useful even in differential diagnosis. Long-term prognosis is good: more than half of type 1 and almost all cases of type 2 patients have favorable outcome without recurrence and without severe consequences.

La pancreatitis autoinmune (PAI) es una enfermedad inflamatoria del páncreas. El mecanismo fisiopatológico no es completamente conocido. Sin embargo, presenta elementos de inmunidad celular y humoral, siendo de mayor importancia los linfocitos T-helper, T-reguladores, linfocitos B y plasmocitos, que participan en el desarrollo de la enfermedad. Se reconocen dos tipos histológicos con características clínicas también distintas. El tipo 1 forma parte de una enfermedad sistémica relacionada a aumento de IgG4, mientras el tipo 2 es una enfermedad pancreática, aunque con frecuencia asociada a enfermedad inflamatoria intestinal. Desde el punto de vista clínico, existe una tercera categoría, que se presenta cuando en el momento del diagnóstico de PAI la tipificación clínicamente no es posible. El diagnóstico diferencial más importante de la PAI es el cáncer de páncreas y puede ser clínicamente difícil. Los métodos actuales de diagnóstico incluyen la biopsia pero tienen un rendimiento bajo. La PAI responde rápidamente al tratamiento con esteroides, hecho que puede ser útil aún en el diagnóstico diferencial. Su pronóstico a largo plazo es bueno: más de la mitad de los casos tipo 1 y casi todos los casos tipo 2 evolucionan sin recaída y sin consecuencias graves a largo plazo.

Opciones terapéuticas actuales en el manejo de la coledocolitiasis asociada a colecistolitiasis / Current therapeutic options in the management of choledocholithiasis associated with cholecyllithiasis

The term Choledocholithiasis refers to the presence of biliary stones in the extrahepatic bile ducts, which are found in 5 to 10% of patients undergoing cholecystectomy for gallstones. Nowadays, with the adoption of the laparoscopic cholecystectomy(LC) as a standard, multiple minimally invasive treatment options for bile duct stones are feasible, with no consensus to date on the procedure of choice. The two stage endoscopic techniques involve the use of Endoscopic Retrograde Cholangiopancreatography(ERCP) before or after performing a LC, which has the main advantage of separating the bile duct procedure from the LC. However, the need for two separate anesthesia times, the possibility of blank or failed ERCP, and the chance for calculi migration between procedures increase the length of hospital stay and associated costs. The single stage procedures include the Laparoscopic Bile Duct Exploration (LBDE), and more recently, the performance of a laparoscopy guided intraoperative ERCP(Rendez Vous). The LBDE, when performed by an experienced surgical team, is an effective and safe technique. Nonetheless, it is considered a technically demanding procedure, whose results cannot be extrapolated to the general surgical community. Recently, the Rendez Vous has become a treatment alternative that simplifies both the surgical and the endoscopic procedures, decreases morbidity, and requires a single anesthesia time. On the downside, Rendez Vous technique involves complex operating room (OR) logistics, requiring both a trained surgical and endoscopic team at the same time. (AU)

¿Es la pancreatitis crónica una enfermedad rara en Chile?: ¿Subdiagnóstico, baja prevalencia o ambos? / Chronic pancreatitis: retrospective review of 121 cases

Background: Chronic pancreatitis (CP) is a rare disease in Chile, without a clear explanation for this low prevalence. Aim: To analyze the characteristics of our patients with pancreatitis. Material and Methods: Retrospective analysis of a database of patients with pancreatitis of a clinical hospital. Morphological proof of diagnosis (calcifications/calculi, alterations of ducts, local complication or histology) was obtained for every patient. History of acute pancreatitis was recorded and exocrine-endocrine function was assessed. Results: We retrieved information of 121 patients with pancreatitis (86 males) in a period of 20 years. The number of cases increased markedly every five years. The calculated incidence and prevalence was 0.8/100,000/year and 6/100,000, respectively. Pancreatic calcifications were initially observed in 93 patients and became evident during the follow-up in another six patients. Severe pain or local complications occurred in 27 patients, requiring surgery in 10 or endoscopic treatment in 15. During the years of follow-up, 55 patients were free of symptoms. Exocrine and endocrine insufficiency was demonstrated and treated in 81 and 67 patients, respectively. Alcoholic etiology was evident in 40% of patients. In 29% no etiology was identified. Mapuche origin was exceptional. Conclusions: Late diagnosis of CP is common, since most of our patients presented with advanced stages. Even though CP is increasingly diagnosed in our hospitals, the number of cases is still far fewer when compared to other countries. Underdiagnosis alone cannot explain this difference and genetic factors might be of importance.

Pancreatitis post quirúrgica: una entidad clínica para recordar / Postoperative pancreatitis: a clinical entity to remember

Postoperative pancreatitis is a rare entity characterized by the presence of clinical and imagenological pancreatic inflammation after surgery of the near or far gastrointestinal tract. The cause is probably multifactorial, with no preventive measures. Diagnostic dilemma and morbidity and mortality associated with this condition makes this case interesting. We describe the case of a 65 years old female presenting acute pancreatitis attributed to surgery performed 3 days before to resolve intestinal obstruction.

La pancreatitis post-cirugía es una entidad poco frecuente caracterizada por la presencia clínica e imagenológica de inflamación del páncreas luego de una cirugía del tracto gastrointestinal. La causa es probablemente multifactorial, y no existen medidas preventivas. El dilema del diagnóstico y la morbi-mortalidad asociadas a esta condición hace que este caso sea muy interesante. Describimos el caso de un sujeto de sexo femenino de 65 años, con pancreatitis aguda atribuida a una cirugía realizada 3 días antes con el objetivo de resolver una obstrucción intestinal.

Pancreatitis recurrente por disquinesia hipertónica del esfínter de oddi: tratamiento endoscópico y seguimiento a largo plazo en un caso clínico / Recurrent pancreatitis caused by oddi sphincter’s hypertonic dyskinesia: case report of endoscopic treatment and long-term follow-up

It is frequently difficult to determine the exact cause of recurrent acute pancreatitis (RAP), which can be life threatening in several cases. Not detected biliary microlithiasis is the most frequent etiology, buthypertonic dyskinesis of Oddi’s sphincter also can cause RAP. Non-invasive diagnosis of this functional disorder is difficult, endoscopic manometry of Oddi’s sphincter allows measuring pressure in the choledochus,in the pancreatic duct and specifically in the sphincter region. Once hypertonic dyskinesis is demonstrated, the treatment option is the partial or total ablation of the sphincter, via endoscopic or surgical methods. This intervention results in an improvement or complete resolution in about 70 percent of the patients, preventing new bouts of acute pancreatitis and eventual progression to chronic disease. In this paper, we describe the history of one of our patients, who consulted more than ten years after cholecystectomy for recurrent abdominal pain and presented three episodes of acute pancreatitis. Endoscopic manometry of Oddi’s sphincter was performed in 1997, with the detection of very high pressure in biliary and pancreatic segments of the sphincter, demonstrating hypertonic dyskinesis involving both segments. A dual endoscopic sphincterotomy was performed, followed by marked reduction in the pressure of biliopancreatic ducts and Oddi’s sphincter and in abolition of choledocho-duodenal and pancreatic-duodenal gradient. She was asymptomatic till 2002, later on, she required endoscopic pneumatic dilatation of the sphincterotomy. She had no more acute pancreatitis episodes and CT scan in 2014 showed a normal pancreas.

Con frecuencia resulta difícil determinar la etiología de la pancreatitis aguda recurrente (PAR), que puede amenazar hasta la vida del paciente. Aparte de la patología litiásica biliar no diagnosticada, la disquinesia hipertónica del esfínter de Oddi (EO) causa con cierta frecuencia PAR. Su diagnóstico no invasivo es difícil, la manometría del esfínter de Oddi permite medir los valores de la presión en la vía biliar, en el conducto pancreático y en la región del esfínter. Una vez que la disquinesia hipertónica se demuestra, su tratamiento es la ablación parcial o total del esfínter, con método endoscópico o quirúrgico, con resolución del cuadro clínico en aproximadamente 70 por ciento de los pacientes, logrando evitar los nuevos brotes de pancreatitis aguda (PA) y la eventual progresión hacia pancreatitis crónica. En este trabajo describimos la historia de una paciente colecistectomizada, quien después de varios años de dolor abdominal recurrente, presentó tres brotes de PA. Manometría de EO fue realizada en 1997, detectando presiones muy elevadas, comprobando disquinesia hipertónica de los segmentos biliar y pancreático del esfínter. Se realizó esfinterotomía endoscópica doble, seguida por gran disminución de los valores de presión, abolición del gradiente colédoco-duodenal y pancreático-duodenal. Estuvo asintomática hasta el 2002, y posteriormente requirió dilatación neumática de los orificios de esfinterotomías. No ha tenido más recaídas de pancreatitis, la tomografía computada de control en noviembre de 2014 mostró un páncreas normal.

Pancreatitis autoinmune: sospecha, diagnóstico diferencial y manejo / Autoimmune pancreatitis: suspicion, differential diagnosis and management

Autoimmune pancreatitis was described only in the second half of the last century. Two types of the disease have been identified: Type 1; Lymphoplasmacytic sclerosing pancreatitis (LPSP), and Type 2, idiopathic duct centric pancreatitis (IDCP). Type 1 AIP is characterized by IgG4 positive lymphoplasmacytic infiltration, storiform periductal fibrosis and obstructive venulitis. It is frequently associated with other autoimmune diseases, it forms part of a systemic IgG4 dependent autoimmune disease, with a tendency of recurrence or progressive pancreatic damage in about 30 percent of the cases. In Type 2, histology reveals ductal destruction by granulocytic epithelial lesions. This type is considered as a pancreas-specific disease, the only association observed is with inflammatory bowel disease. After a successful treatment, recurrence of this disease is an exception. The basis of the diagnosis of AIP is serology and imaging methods. Computed Tomography (CT) scan and magnetic resonance have a good sensibility in the differential diagnosis of pancreatic lesions. Endosonography (EUS) with fine-needle aspiration (FNA) would be the best method to exclude pancreatic cancer. However, its limited accessibility in Chile and high costs make its use rather exceptional. The treatment of AIP is steroids, 0.5-1 mg/kg/day Prednisone for a relatively short period, without the need of permanent treatment in most cases. While possibility of recurrence or progressive pancreatic damage exists, the prognosis is generally good.

La pancreatitis autoinmune es una enfermedad descrita en la segunda mitad del siglo pasado. Se diferencian dos tipos, la pancreatitis esclerosante linfoplasmocítica (PELP-Tipo 1) y la pancreatitis idiopática conducto-destructivo (PICD-Tipo 2). El Tipo 1 está caracterizado por infiltración linfoplasmocitaria por células IgG4 positivas, fibrosis periductal y venulitis obstructiva. Se asocia con otras enfermedades autoinmunes, probablemente forma parte de una enfermedad sistémica IgG4 dependiente, clínicamente tiene la tendencia de recaídas o progresión del daño pancreático en 30 por ciento de los casos. En el Tipo 2 se ve la destrucción de conductos por lesiones granulocíticas epiteliales, considerada como enfermedad específica del páncreas, se asocia sólo con enfermedad inflamatoria intestinal. Después de su recuperación, la recaída es una excepción. El diagnóstico de la PAI se basa en métodos serológicos y morfológicos. Tomografía computada y resonancia nuclear magnética son de buen rendimiento en el diagnóstico diferencial de las enfermedades pancreáticas. Endosonografía con biopsia con aguja fina sería el mejor método para descartar cáncer de páncreas; su disponibilidad en Chile es más bien de excepción. El tratamiento es prednisona 0,5- 1,0 mg/kg/día por un período relativamente corto, sin necesidad de tratamiento de mantención en la gran mayoría de los casos. El pronóstico es bueno, aunque existe posibilidad de recaída o progresión hacia la cronicidad.

Ligadura endoscópica, una nueva opción terapéutica para la ectasia vascular antral: presentación de dos casos clínicos / Endoscopic band ligation, for gastric antral vascular ectasia: Report of two cases

Gastric antral vascular ectasia is an uncommon cause of chronic anemia, occasionally associated with cirrhosis. The most accepted therapy is argon plasma coagulation (APC), however there are refractory cases. We report two females with cirrhosis, aged 60 and 72 years, in whom management with APC was insufficient and in whom the need for hospital admissions and transfusions were reduced using the technique of endoscopic band ligation.

Pancreatología: presente y futuro en Chile / Pancretology: present and future in Chile

The pancreas is a hidden organ. The level of our knowledge in the pancreatology is lower as compared to other issues of gastroenterology and hepatology. The history of pancreatology is rich in famous discoveries with considerable impact on the physiology and the medical sciences. However, pancreatic diseases nowadays have no specific treatment. The situation of pancreatology in Chile is even worse than in other parts of the world. In this paper, we share some reflection about current and future possibilities.

El páncreas es un órgano de difícil acceso. El nivel de desarrollo de la pancreatología queda atrás comparando con otras ramas de la gastroenterología, como la hepatología y la endoscopía digestiva. La historia de la pancreatología está ligada a grandes descubrimientos de la fisiología y de la medicina. Sin embargo, las enfermedades pancreáticas en la actualidad no tienen tratamiento específico. La situación de la pancreatología en Chile es aun más pobre que en el resto del mundo. Compartimos algunas reflexiones sobre las posibilidades actuales y futuras.

Pancreatitis autoinmune: experiencia clínica y revisión de la literatura / Autoimmune pancreatitis: report of 10 cases

Background: Autoimmune pancreatitis is a special form of chronic pancreatitis, more common in men and usually presenting as obstructive jaundice or abdominal pain. It may be associated with other immunological disorders and sometimes it is possible to find positive serological markers. Typical images show pancreatic enlargement with focal or diffuse stenosis of the pancreatic duct but sometimes it presents as a focal pancreatic mass that is difficult to differentiate from pancreatic carcinoma. Aim: To report ten cases of autoimmune pancreatitis. Material and Methods: Retrospective review of clinical records of 10 patients aged 26 to 56 years (six males) with autoimmune pancreatitis. Results: The clinical presentation was obstructive jaundice in six cases, acute pancreatitis in two, persistent increase in serum amylase and Upase in one, and permanent abdominal pain and weight loss in one. On imaging studies, a circumscribed mass was founded in six patients. An endoscopic retrograde colangiopancreatography was performed in four patients showing an abnormal pancreatic duct in all. Six patients were operated and tissue for pathological study was obtained in five, showing inflammatory infiltration. Vive patients were treated with steroids with a good clinical response. Conclusions: Autoimmune pancreatitis must be borne in mind in the differential diagnosis of pancreatic lesions.

Estudio de test de ureasa en exámenes endoscópicos con patologías benignas: ¿algún cambio en diez años? / Positivity of urease tests: results of its application in an open-access unity after a decade is there any change?

Epidemiological studies have shown changes in upper digestive diagnosis in recent times. It has been observed especially in developed countries, consisting in a diminution of duodenal peptic ulcers and non cardial gastric cancer and an increase of symptoms and lesions attributable to gastroesophageal reflux. Both circumstances have been considered as a consequence of a reduction in the prevalence, of infection with Helicobacter pylori and its more aggressive strains. There is little information of Possible changes in our country, so we have studied our experience in years 1996 and 2006 observing the results of Helicohacter pylori presence through urease tests and biopsies in a 10 year period. Patients were assessed with endoscopy indicated for upper digestive symptoms in an open access University Endoscopy Center. The accuracy of the test compared with biopsies was similar in both years. We observed after a decade: increase in the number of examinations and urease tests similar percentages of normal endoscopies and those with esophagitis, gastritis, or ulcers. In patients studied for suspected gastroesophageal reflux, there were similar percentages of those with and without esophageal erosions. The Urease Test was positive in similar high percentage in duodenal ulcers, but showed decreased values in patients studied for reflux, both erosive and non erosive esophagitis and also in erosive gastritis. In conclusion, Helicobacter pylori infection is still important in duodenal ulcer, with reductions in other diagnosis, possibly as a consequence of differences in patients social status or the very common medication aiming at the eradication of the infection or control of gastroesophageal symptoms.

Estudios epidemiológicos han mostrado cambios en la incidencia de patologías digestivas consistentes en disminución de úlceras duodenales y cáncer gástrico y aumento de cuadros atribuidos a reflujo gastroesofágico. Ambas tendencias se han asociado a disminución de la tan difundida infección por Helicobacter pylori y sus cepas genéticamente más agresivas. El presente estudio tuvo come objeto revisar retrospectivamente los resultados de endoscopias en 1996 y 2006 para observar eventuales cambios en la patología de esófago y gastroduodenal. Los resultados en la última década indican: aumento del número de exámenes y de tests de ureasa; proporción similar, de: endoscopias normales, esofagitis erosiva, síntomas de reflujo no erosivo, gastritis erosiva, úlcera gástrica, úlcera duodenal; porcentaje similar de esofagitis erosiva y reflujo no erosivo en pacientes estudiados por síntomas sugerentes de reflujo gastroesofágico y disminución de la positividad del TU, significativamente en EE y GE. Pensamos que el Hp continúa siendo factor patogénico en UD y que la disminución de positividad en pacientes con RGE puede atribuirse a cambios en la composición de la población examinada y al uso de medicación que puede modificar su presencia en la mucosa de estómago, siendo similar la reducción en reflujo con y sin esofagitis erosiva.

Sobrecrecimiento bacteriano intestinal en pacientes con pancreatitis crónica / Small intestine bacterial overgrowth in patients with chronic pancreatitis

Background: Previous reports describe 30-40 percent of small intestine bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP), SIBO is a cause of persistent symptoms in this group of patients even when they are treated with pancreatic enzymes. Aim: To asses the frequency of SIBO in patients with CP. Patients and methods: We studied 14 patients with CP using an hydrogen breath test with lactulose to detect SIBO, a nonabsorbable carbohydrate, whose results are not influenced by the presence of exocrine insufficiency. Main symptoms and signs were bloating in 9 (64 percent), recurrent abdominal pain in 8 (57 percent), intermittent diarrhea in 5 (36 percent) and steatorrhea in 5 (36 percent). At the same time we studied a healthy control group paired by age and sex. Results: SIBO was present in 13 of 14 patients with CP (92 percent) and in 1 of 14 controls (p<0.001). The only patient with CP and without SIBO was recently diagnosed and had minimal morphologic alterations in computed tomography and endoscopic pancreatography Conclusions: SIBO is common in CP and may be responsible for persistent symptoms. Proper diagnosis and treatment could alleviate symptoms and improve quality of life.

Enfermedad inflamatoria intestinal y su asociación con cáncer colorectal: experiencia en un hospital universitario / Inflammatory bowel disease and its relationship with colorectal cancer: experience from the university hospital

The risk of colorectal cancer (CCR) in inflammatory bowel disease (IBD) patients is increased. The risk is associated mainly with longer duration and greater extent of disease and the presence of primary sclerosing cholangitis. Aim: to report our experience with a large group of IBD patients from the University Hospital of the University of Chile and to characterize the clinical features of patients with IBD who developed CCR during the course of disease. Patients and Methods: Retrospective review of 318 patients with IBD (age range of 30-57 years, 120 women) treated between January 1987 and December 2006. Results: Two hundred forty one patients had ulcerative colitis (UC) and 77 had Crohn's disease (CD). Five patients (1.6 percent), three UC and two CD, developed CCR during this period. The average time between the diagnosis of IBD and CCR was 12.5 years (range 10-12). All patients had pancolitis. Two patients, one UC and one CD, had primary sclerosing cholangitis. Conclusion: Chilean patients with IBD have a risk develop CCR during the course of the disease. The longer duration, greater anatomic extent of colitis and the presence of primary sclerosing cholangitis are risk factors of this complication. Chemoprevention and surveillance guidelines with new endoscopic techniques might be best approach to decrease the incidence of CCR in patients with IBD.

El riesgo de cáncer colorectal (CCR) en pacientes con enfermedad inflamatoria intestinal (EII) está aumentando. Este riesgo está asociado principalmente con la duración prolongada de la enfermedad, extensión del área comprometida y la presencia de colangitis esclerosante primaria. Objetivo: Analizar nuestra experiencia en pacientes con EII controlados en el Hospital Clínico de la Universidad de Chile y describir las características clínicas de los pacientes con EII que desarrollaron CCR durante su evolución. Pacientes y Métodos: Estudio retrospectivo con 318 pacientes con EII (rango de edad de 30-57 años, 120 mujeres) tratadas entre Enero de 1987 y Diciembre de 2006. Resultados: Doscientos cuarenta y un pacientes con colitis ulcerosa (CU) y 77 con Enfermedad de Crohn (EC). Cinco pacientes (1,6 por ciento), tres CU y dos EC, desarrollaron CCR durante ese período. El tiempo promedio entre el diagnóstico de EII y el de CCR fue de 12,5 años (rango: 10-12 años). Todos los pacientes tenían una pancolitis. Dos pacientes, uno con CU y otro con EC, presentaron una colangitis esclerosante primaria. Conclusión: Los pacientes chilenos con EII tienen un riesgo de desarrollar CCR durante su evolución: Larga duración de la enfermedad, extensión del área comprometida y la presencia de colangitis esclerosante primaria son factores de riego de esta complicación. La quimioprevención y programas de vigilancia con nuevas técnicas endoscópicas podrían ser las principales estrategias para disminuir la incidencia de CCR en pacientes con EII.

Hepatitis aguda alcohólica asociada a pancreatitis aguda grave / Acute alcoholic hepatitis and severe acute pancreatitis

Alcohol is a common cause of hepatic and pancreatic damage. Despite the widespread alcohol consumption simultaneous presentation of acute alcoholic hepatitis and pancreatitis is uncomnon. We describe a case of a patient with alcoholic hepatitis in association acute pancreatitis, who developed multiorgan failure and died. The association of liver and pancreatic disease in clinical practice is discussed.

El alcohol es un factor etiológico común de daño hepático y pancreático. A pesar de su extenso consumo la presentación simultánea de hepatitis y pancreatitis aguda alcohólica es excepcional. Se presenta un caso de esta situación, que evolucionó hacia la falla orgánica múltiple con desenlace fatal. Se discute la asociación de daño hepático y pancreático agudo en la práctica Clínica.