Consenso chileno de diagnóstico y manejo de neoplasias quísticas pancreáticas. Club de páncreas Chile-SCHGE / Chilean consensus on diagnosis and management of pancreatic cystic neoplasms

Pancreatic cystic neoplasms (PCN) are frequently detected on abdominal images performed for non-pancreatic indications. Their prevalence in asymptomatic population ranges from 2.7 to 24.8%, and increases with age. There are several types of pancreatic cysts. Some may contain cancer or have malignant potential, such as mucinous cystic neoplasms, including mucinous cystadenoma (MCN) and intraductal papillary mucinous neoplasms (IPMN). In contrast, others are benign, such as serous cystadenoma (SCA). However, even those cysts with malignant potential rarely progress to cancer. Currently, the only treatment for pancreatic cysts is surgery, which is associated with high morbidity and occasional mortality. The Board of the Chilean Pancreas Club of the Chilean Gastroenterology Society developed the first Chilean multidisciplinary consensus for diagnosis, management, and surveillance of PCN. Thirty experts were invited and answered 21 statements with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree. A consensus was adopted when at least 80% of the sum of the answers "fully agree" and "partially agree" was reached. The consensus was approved by the Board of Directors of the Chilean Pancreas Club for publication.

Herramientas para la interpretación de informes endoscópicos: clasificaciones y escalas en endoscopía digestiva / Classifications and scores used in digestive endoscopy

Interpretation and description of findings detected in upper-endoscopy and colonoscopy are qualitative processes which depend on the experience and skills of the endoscopist performing the procedure. This explains the high variability of endoscopic reports, hampering their interpretation, specially by general practitioners. Classifications, scores and scales give a quantitative support to these qualitative processes. The aim of this review is to describe the classifications, scores and scales most frequently reported in digestive endoscopy, specially those with the highest methodological support in terms of validation and reproducibility. These tools facilitate the description of findings related to gastroesophageal reflux, Barrett's esophagus, gastroesophageal varices, stigmas related to non-variceal gastrointestinal bleeding, advanced and incipient neoplasms, bowel preparation for colonoscopy and severity scores of inflammatory bowel diseases. In summary, these tools enable to standardize endoscopic reports, simplifying their interpretation.

Diagnóstico y manejo de colitis ulcerosa grave: una mirada actualizada / Management of severe ulcerative colitis: an up-to-date

Ulcerative Colitis (UC) is a chronic inflammatory disease involving the colon, with alternating periods of remission and activity. Exacerbations can be severe and associated with complications and mortality. Diagnosis of severe UC is based on clinical, biochemical and endoscopic variables. Patients with severe UC must be hospitalized. First line therapy is the use of intravenous corticoids which achieve clinical remission in most patients. However, 25% of patients will be refractory to corticoids, situation that should be evaluated at the third day of therapy. In patients without response, cytomegalovirus infection must be quickly ruled out to escalate to second line therapy with biological drugs or cyclosporine. Total colectomy must not be delayed if there is no response to second line therapy, if there is a contraindication for second line therapies or there are complications such as: megacolon, perforation or massive bleeding. An active management with quick escalation on therapy allows to decrease the prolonged exposure to corticoids, reduce colectomy rates and its perioperative complications.

Consenso chileno de prevención, diagnóstico y tratamiento de la diarrea asociada a Clostridium difficile / Chilean consensus of prevention, diagnosis and treatment of Clostridium difficile-associated diarrhea

Background: Clostridium dijfficile-associated diarrhea (CDAD) has become very important due to the increase in its incidence, severity, recurrence and the associated economic burden. Having a national consensus guideline is essential to improve its management. Objective: To build a multidisciplinary and evidence-based consensus in prevention, diagnosis and treatment of CDAD. Methods: We convened a panel of experts in the field of infectious diseases, gastroenterology, evidence-based medicine and consensus methodology. The panel conducted a structured review of published literature in CDAD evaluating evidence levels and recommendation degree according to the methodology proposed by the GRADE working-group. A modified three-round Delphi technique was used to reach a consensus among the experts. Results: A group of 16 experts was established, 12 of them answered 18 clinically relevant questions. The levels of agreement achieved by the panel of 16 experts were 79% in the first round and 100% in the second and third round. The main consensus recommendations in prevention are: restricting the use of proton-pump inhibitors, primary prophylaxis with probiotics in antibiotics users, education of health personnel, isolation for patients hospitalized with CDAD, and cleaning the rooms exposed to C. difficile with products based in chlorine or hydrogen peroxide. In the diagnosis: use of biology molecular-based techniques is preferred and if not available, glutamate dehydrogenase-based algorithms may be recommended. With regard to treatment: the use of oral metronidazole in mild-moderate CDAD and oral vancomycin in severe CDAD are recommended. Treat the first recurrence with the same antibiotics according to severity. In the case of second and subsequent recurrences consider prolonged therapy with vancomycin, rifaximin or fecal microbiota transplant. Conclusion: The first Chilean consensus on prevention, diagnosis and treatment of CDAD is presented, which is a major step in improving national standards in the management of this disease.

Introducción: La diarrea asociada a Clostridium difficile (DACD) ha adquirido gran relevancia debido al aumento en su incidencia, gravedad, capacidad de recurrencia y carga económica asociada. Contar con una guía de consenso local es fundamental para mejorar su manejo. Objetivo: Elaborar un consenso multidisciplinara y basado en la evidencia en la prevención, diagnóstico y tratamiento de la DACD. Métodos: Se convocó a un panel de expertos en el área de enfermedades infecciosas, gastroenterología, medicina basada en la evidencia y metodología de consenso. El panel realizó una revisión estructurada de la literatura científica publicada en DACD evaluando el nivel de la evidencia y recomendación utilizando el sistema GRADE. Una técnica de Delfi modificada de tres rondas fue utilizada para alcanzar un consenso entre los expertos. Resultados: Se estableció un grupo de 16 expertos, 12 de ellos respondieron 18 preguntas de relevancia clínica. Los niveles de acuerdo alcanzados por el panel de 16 expertos fueron de 79% en la primera ronda y 100% en la segunda y tercera ronda. Las principales recomendaciones en prevención son: restricción del uso de inhibidores de la bomba de protones, profilaxis primaria con probióticos en usuarios de antimicrobianos de corto plazo, educación del personal de salud, aislamiento de contacto en pacientes hospitalizados con DACD y aseo de las habitaciones expuestas a C. difficile con productos en base a cloro o peróxido de hidrógeno. En el diagnóstico se recomienda: el uso de técnicas basadas en biología molecular y como alternativa algoritmos en base a glutamato deshidrogenasa. Con respecto al tratamiento, se recomienda el uso de metronidazol oral en DACD leve-moderada y vancomicina oral en DACD grave. El tratamiento de la primera recurrencia es con los mismos antimicrobianos de acuerdo a la gravedad, considerando en la segunda recurrencia y posteriores terapia prolongada con vancomicina, rifaximina o trasplante de microbiota fecal. Conclusión: Se presenta el primer consenso chileno en prevención, diagnóstico y tratamiento de DACD, paso trascendental en mejorar los estándares locales en el manejo de esta enfermedad.

A doença vascular do enxerto diagnosticada pela tomografia computadorizada de múltiplos detectores como preditora de eventos maiores em pacientes submetidos a transplante cardíaco / Cardiac allograft vasculopathy diagnosed by multidetector computed tomography predicts major events in heart transplant patients

A insuficiência cardíaca congestiva (ICC) é uma condição em que o coração não consegue bombear o sangue de acordo com as necessidades metabólicas dos tecidos. Quando a ICC entra em seu estágio final, já refratária ao tratamento medicamentoso, ou outras opções terapêuticas, o transplante cardíaco constitui-se em medida salvadora destes pacientes. Após o primeiro ano de evolução do procedimento, a doença vascular do enxerto (DVE) é a complicação mais temida nestes pacientes. Esta doença caracteriza-se por aterosclerose acelerada, com acometimento concêntrico do vaso, predominando nos terços médios e distais. Sintomas isquêmicos geralmente não estão presentes devido ao coração denervado destes pacientes. Daí a importância em se ter um método com boa acurácia e que possibilite o diagnóstico da DVE em seus estágios iniciais, que, muitas vezes, não é demonstrado pela cineangiocoronariografia (CINE)...

Diagnóstico de progressão de doença coronária em pacientes previamente tratados com stents pela tomografia computadorizada de múltiplos detectores / Diagnosis of the progression of coronary artery disease in patients previously treated by stents using multislice computed tomography

INTRODUÇÃO: Pacientes previamente submetidos a intervenção coronária percutânea podem apresentar progressão de doença aterosclerótica ao longo do tempo, com o desenvolvimento de novas lesões em outros locais da árvore arterial coronária, o que pode representar um desafio diagnóstico. O objetivo deste trabalho foi avaliar a eficácia da tomografia computadorizada por múltiplos detectores na detecção da progressão de doença arterial coronária. MÉTODO: Entre julho de 2007 e julho de 2008, foram avaliados 60 pacientes previamente submetidos a implante de stents coronários e que apresentassem quadro clínico suspeito de recorrência de isquemia miocárdica tardia. Os pacientes foram divididos em dois grupos: grupo I (GI), 30 pacientes avaliados pela tomografia computadorizada por múltiplos detectores; e grupo II (GII), 30 casos avaliados com cintilografia miocárdica. Todos os pacientes foram posteriormente submetidos a cinecoronariografia. RESULTADOS: Os dados demográficos, a artéria tratada e o número de stents por paciente não diferiam entre os grupos. A tomografia computadorizada por múltiplos detectores identificou progressão de doença em 9 (30%) pacientes e reestenose em 2 (6,7%); a cintilografia miocárdica identificou 8 (26,7%) casos de progressão de doença e 3 (10%) de reestenose. A cinecoronariografia identificou 10 casos de progressão de doença no GI (3 com estenoses entre 55% e 60%) e 12 no GII (4 com obstruções entre 50% e 60%) e confirmou todas as suspeitas de reestenose. CONCLUSÃO: A tomografia computadorizada por múltiplos detectores demonstrou, em nossa casuística, bom desempenho na identificação da progressão de doença aterosclerótica em pacientes previamente tratados com stents. Caso trabalhos adicionais, com maior número de pacientes, confirmem estes achados, a tomografia computadorizada por múltiplos detectores poderá incorporar mais essa indicação a seu espectro diagnóstico.

BACKGROUND: Patients undergoing percutaneous coronary intervention may present progression of coronary artery disease in the late follow-up, leading to the development of new lesions in different sites of the coronary arteries, which may represent a diagnostic challenge. The goal of this paper was to evaluate the contribution of multislice computed tomography in this setting. METHOD: From July 2007 to July 2008 we analyzed 60 patients with suspect late myocardial ischemia after coronary stent implantation. Patients were divided in two groups. In Group I, 30 patients were evaluated by multislice computed tomography and in Group II, 30 patients were evaluated by myocardial scintigraphy. All patients were subsequently submitted to coronary angiography. RESULTS: Demographic data, the treated vessel and the mean number of stents per patient were not significantly different in both groups. Multislice computed tomography identified progression of coronary disease in 9 patients (30%) and restenosis in 2 (6.7%); myocardial scintigraphy identified 8 cases (26.7%) of disease progression and 3 cases (10%) of restenosis. Coronary angiography revealed 10 cases of disease progression (3 cases with obstructions between 55% and 60%) in Group I and 12 in Group II (4 patients with obstructions between 50% and 60%) and confirmed all suspected restenosis. CONCLUSION: Multislice computed tomography proved to be sensitive to detect progression of coronary artery disease in patients previously treated with stent implantation. Should larger scale studies confirm such findings this method could have an important role in the clinical evaluation of these patients.

Prescrição de clopidogrel para pacientes submetidos à intervenção coronária percutânea / Prescrição de clopidogrel para pacientes submetidos à intervenção coronária percutânea

Atualmente, as intervenções coronárias percutâneas, denominadas quand de sua introdução como angioplastia transluminal coronária, tornaram-se uma importante opção terapêutica para revascularizar o miocárdio...

Proyecto industrial Licor de naranjas

Los licores son todos, sin excepción, mezclas de alcohol, agua, azúcar y extratos de plantas y frutos la variedad puede existir de uno a otros depende solo de la proporción de los componentes y de la fabricación.Existen licores claros, licores con pulpa, licores crema, y el producto a ser obtenido es licor tipoclaro