Pharmacologic therapy for inflammatory bowel disease refractory to steroids.

Although corticosteroids are an effective treatment for induction of remission in inflammatory bowel disease (IBD), many patients are dependent on or refractory to corticosteroids. This review is based on scrutinizing current literature with emphasis on randomized controlled trials, meta-analyses, and Cochrane reviews on the management of IBD refractory to corticosteroids. Based on this evidence, we propose algorithms and optimization strategies for use of immunomodulator and biologic therapy in IBD refractory to corticosteroids.

Diferencias en las presiones del canal anal y la sensibilidad rectal en pacientes con incontinencia anal, estreñimiento crónico y sujetos sanos / No disponible

Introducción: Existe gran variabilidad en los hallazgos manométricos entre pacientes con incontinencia anal (IA) y sujetos sanos. La correlación entre las presiones del canal anal y la IA no es exacta por el amplio rango de valores normales. Objetivos: Estudio prospectivo para evaluar diferencias en las presiones del canal anal y en la sensibilidad rectal en pacientes con IA, estreñimiento crónico (EC) y sujetos sanos. Material y métodos: Noventa y cuatro pacientes con IA, 36 pacientes con EC y 15 sujetos sanos. Se obtuvieron: edad, sexo, presión de reposo, longitud del canal anal (LCA), presión de máxima contracción voluntaria (PMCV), duración de la contracción voluntaria, primera sensación, sensación de urgencia y máximo volumen tolerado (MVT). Estudio estadístico: test de Kruskal-Wallis, test de Mann-Whitney, regresión logística multinomial. Resultados: Se encontraron diferencias significativas en la edad (p < 0,001), la presión de reposo (p < 0,001), la LCA (p < 0,001) y la PMCV (p < 0,01) en el grupo de IA con respecto a los otros dos grupos. El volumen para la primera sensación fue significativamente más bajo en los sujetos sanos que en los otros dos grupos (p < 0,05). El volumen de urgencia y el MVT fueron menores en el grupo con IA con respecto a los otros dos grupos (p < 0,001). En el análisis multivariante la edad, la presión de reposo y el volumen de la primera sensación y de la urgencia aumentan el riesgo relativo de IA. Conclusiones: La mayor edad, la disminución presión basal del canal anal y la alteración del umbral sensorial rectal aumentan el riesgo de IA(AU)

Introduction: There exist a great variability in the manometric findings between patients with anal incontinence (AI) and healthy subjects. The correlation between the pressures of the anal canal and the AI is not exact by the wide rank of normal values. Objectives: Prospective study to evaluate differences in the pressures of the anal canal and in rectal sensitivity in patients with AI, chronic constipation (CC) and healthy subjects. Material and methods: Ninety four patients with AI, 36 patients with CC and 15 healthy subjects were included. The following data were obtained: age, sex, resting pressure, anal canal length (ACL), squeeze maximum pressure (SMP), squeeze pressure duration (SPD), first sensation, urge and maximum tolerated volume (MTV). Statistical study: test of Kruskal-Wallis, test of Mann-Whitney, and multinomial logistic regression test. Results: There were significant differences in the resting pressure (p < 0.001), the ACL (p < 0.001) and the SMP (p < 0.01) in the group of AI with respect to the other two groups. The volume for the first sensation was significantly lower in the healthy subjects than that in the other two groups (p < 0.05). The urge volume and the MVT were smaller in the group with AI with respect to the other groups (p < 0.001). In multivariate analysis the age, the resting pressure and the volume for the first sensation and urge increase the relative risk for AI. Conclusions: The greater age, the decrease in anal canal resting pressure and the alteration of rectal sensation increase the risk for AI(AU)

Differences in the pressures of canal anal and rectal sensitivity in patients with fecal incontinence, chronic constipation and healthy subjects.

INTRODUCTION: There exists a great variability in the manometric findings between patients with anal incontinence (AI) and healthy subjects. The correlation between the pressures of the anal canal and the AI is not exact by the wide rank of normal values. OBJECTIVES: Prospective study to evaluate differences in the pressures of the anal canal and in rectal sensitivity in patients with AI, chronic constipation (CC) and healthy subjects. MATERIAL AND METHODS: Ninety four patients with AI, 36 patients with CC and 15 healthy subjects were included. The following data were obtained: age, sex, resting pressure, anal canal length (ACL), squeeze maximum pressure (SMP), squeeze pressure duration (SPD), first sensation, urge and maximum tolerated volume (MTV). Statistical study: test of Kruskal-Wallis, test of Mann-Whitney, and multinomial logistic regression test. RESULTS: There were significant differences in the resting pressure (p < 0.001), the ACL (p < 0.001) and the SMP (p < 0.01) in the group of AI with respect to the other two groups. The volume for the first sensation was significantly lower in the healthy subjects than that in the other two groups (p < 0.05). The urge volume and the MVT were smaller in the group with AI with respect to the other groups (p < 0.001). In multivariate analysis the age, the resting pressure and the volume for the first sensation and urge increase the relative risk for AI. CONCLUSIONS: The greater age, the decrease in anal canal resting pressure and the alteration of rectal sensation increase the risk for AI.

Hepatitis crónica vírica: ¿biopsia hepática sí o no? / Chronic viral hepatitis: liver biopsy, yes or no?

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Chronic viral hepatitis: liver biopsy, yes or no?

LB increases costs and has--although minimal--potential risks; however, LB is: a) the gold standard to get to know lesion severity (grade and stage); b) the only method for the diagnosis of an F3 stage, which progresses to liver cirrhosis in approximately 10 years; c) the only method for the certain diagnosis of compensated liver cirrhosis, which requires early diagnosis programs for oesophageal varices and hepatocarcinoma; and d) the only method for the certain diagnosis of lesions predicting a good therapeutic response. On all these grounds--save for exceptions (contraindications, clinical and/or ultrasonographic cirrhosis)--liver biopsy should be carried out in the initial study of all patients. In non-responders to anti-viral therapy liver biopsy should be repeated once or twice with 5-10-year intervals to ascertain fibrosis growth rate and, according to this, plan a most appropriate follow-up. Assuming hepatitis progresses rapidly in all HIV co-infected patients, anti-viral therapy could be administered with no previous LB; such biopsy would be performed in non-responders to decide their course of therapy.

Trombosis de las venas porta y mesentérica superior asociada a déficit de proteína S / Portal and mesenteric thrombosis and protein "S" deficiency

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Successful in vitro immortalization of human intestinal mucosal lymphocytes with Herpesvirus saimiri.

Mucosal intestinal lymphocytes form the first immune-cell line of defense in the intestine. Several methodologies, most of them cumbersome and time consuming, have been used to obtain T-cell clones to unveil their physiological role. In the present work we take advantage of the recently described technique of transformation of T lymphocytes using Herpesvirus saimiri to show that it is possible to immortalize intestinal T-cell lines derived from healthy and diseased colonic samples and thence easily obtain in vitro intestinal T-cell lines as a model for physiopathological studies. Intestinal samples were obtained by colonoscopy and digested with dispase and collagenase. Mucosal lymphocytes (assessed by the expression of the CD3 and CD103 markers) were isolated using a Percoll gradient centrifugation and transformed with Herpesvirus saimiri. Sustained growth was observed 3 months later, showing that the cells were successfully transformed, a finding further confirmed by PCR. All cell lines were CD8+TcRalphabeta+ and HLA-DR+. CD25 was expressed on 1% of Crohn's disease-derived cells and on 25% of cells derived from patients with ulcerative colitis. CD80 expression was found on 80-90% of the cells. These immortal cell lines of intestinal origin may be useful in future experiments aimed at elucidating the role of mucosal lymphocytes in health and disease.

[Non alcoholic steatohepatitis. Mid-term clinical and histologic course in 10 patients]. / Esteatohepatitis no alcohólica. Evolución clínica e histológica a medio plazo de diez pacientes.

BACKGROUND: The progressive character of the hepatic lesions in nonalcoholic steatohepatitis (NASH) has not been well established. In the present study, the clinical and histological course of this condition was evaluated at medium term. METHODS: Then patients (6 females and 4 males) with NASH, in a non-cirrhotic stage at the time of diagnosis, were followed up during 58 +/- 7 months (range 24 to 88 months). RESULTS: Nine patients were obese, but a significant reduction of body weight was found at the end of the study (p = 0.0072). Other clinical, physical or laboratory changes were not found, although in two cases hepatic biochemical tests were within normal limits when the follow-up biopsy was performed. Changes in the characteristic hepatic features were also absent, although fat infiltrates disappeared in three cases. Six patients had increased fibrosis and a progression of the hepatic architectural distortion; four reached the stage of cirrhosis. The evolution of the hepatic lesion correlated with the interval between diagnostic and follow-up biopsies (r = 0.69; p less than 0.05) and with the reduction in body weight (r = 0.64; p less than 0.05). CONCLUSIONS: In most cases, NASH results in a progressive hepatic distortion with can end in cirrhosis, although the change is slow and silent.

[The prognostic factors and evolution of the quality of life in primary biliary cirrhosis]. / Factores pronósticos y evolución de la calidad de vida en la cirrosis biliar primaria.

The prognostic factors and the evolution of the quality of life were evaluated in 38 patients with primary biliary cirrhosis (94.7% females, mean age 52.6 +/- 2.0 years) followed up for more than 36 months (mean 65.3 +/- 3.7 months). Karnofsky's index significantly declined during follow up (p less than 0.05) in a parallel fashion to modified Child's hepatic functional class (p less than 0.05) and to the days of hospital readmission (p less than 0.05). Eleven patients (28.9%) died, and the median survival was 88.7 months. The comparison of the actuarial curves showed the following to be significant poor prognostic factors at the time of diagnosis: a) clinical: more than one associated autoimmune disease, weight loss of more than 10% of the ideal weight, jaundice, upper gastrointestinal hemorrhage associated with portal hypertension, portal-systemic encephalopathy and a modified Child's hepatic functional class of 9 or more; b) biochemical: serum albumin lower than 3.5 g/dl and bilirubin higher than 2 mg/dl; c) histological: Total histological activity index of 10 or more and erosive necrosis index of 2 or more (Knodell et al.), lobular granulomas, and stage IV (Ludwig et al). A significant correlation was found (p less than 0.001) between the R index of the Mayo Clinic and the mean survival time of our patients. As a temporary policy, we indicate hepatic transplant when R is 9.2 or higher (life expectancy lower than 24 months), awaiting our own probabilistic prognostic model with the inclusion of quality of life criteria.

[Esophageal tuberculosis. Presentation of a case and review of the literature]. / Tuberculosis esofágica. Presentación de un caso y revisión de la literatura.

We describe the case of a 63-year-old woman who had recently developed dysphagia. Oral endoscopy revealed an ulcerated fungating lesion in the middle third of the esophagus. The histologic examination showed granulomas with caseous central necrosis, and the culture in a Lowenstein medium produced M. tuberculosis. There were mediastinic adenopathies, but no other organic involvement with this mycobacterium was demonstrated. We review the other 21 cases reported in the English and Spanish literature over the past ten years.