[Clinical practice guidelines for the diagnosis and management chronic infection of hepatitis viral C of the Peruvian Health Social Security (EsSalud)]. / Guía de práctica clínica para el diagnóstico y tratamiento de la infección crónica por el virus de hepatitis C en el Seguro Social de Salud del Perú (EsSalud).

INTRODUCTION: This article summarizes the clinical practice guidelines (CPG) for the diagnosis and treatment of chronic infection of hepatitis viral C of the Peruvian Health Social Security (EsSalud). OBJECTIVE: To provide clinical recommendations based on evidence for the diagnosis and treatment of chronic infection of hepatitis viral C in EsSalud. METHODS: A guideline development group (GDG) was established, including medical specialists and methodologists. The GDG formulated 4 clinical questions to be answered in this CPG. Systematic searches of systematic reviews and primary studies (when pertinent) were conducted in PubMed, and Central (Cochrane) during 2019. The evidence was selected to answer each of the clinical questions. The accuracy of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the GEG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and the treatment flowchart. Finally, the CPG was approved with Resolution No. 151-IETSIESSALUD-2019. RESULTS: The present CPG addressed 4 clinical questions of four topics: screening, diagnosis, staging and treatment. Based on these questions, 13 recommendations (8 strong recommendations and 5 weak recommendations), 27 points of good clinical practice, and 1 flowchart were formulated. CONCLUSION: This paper summarizes the methodology and evidencebased conclusions from the CPG for for the diagnosis and treatment of chronic infection of hepatitis viral C of the EsSalud.

Hepatocellular carcinoma in South America: Evaluation of risk factors, demographics and therapy.

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide. Most studies addressing the epidemiology of HCC originate from developed countries. This study reports the preliminary findings of a multinational approach to characterize HCC in South America. METHODS: We evaluated 1336 HCC patients seen at 14 centres in six South American countries using a retrospective study design with participating centres completing a template chart of patient characteristics. The diagnosis of HCC was made radiographically or histologically for all cases according to institutional standards. Methodology of surveillance for each centre was following AASLD or EASL recommendations. RESULTS: Sixty-eight percent of individuals were male with a median age of 64 years at time of diagnosis. The most common risk factor for HCC was hepatitis C infection (HCV, 48%), followed by alcoholic cirrhosis (22%), Hepatitis B infection (HBV, 14%) and NAFLD (9%). We found that among individuals with HBV-related HCC, 38% were diagnosed before age 50. The most commonly provided therapy was transarterial chemoembolization (35% of HCCs) with few individuals being considered for liver transplant (<20%). Only 47% of HCCs were diagnosed during surveillance, and there was no difference in age of diagnosis between those diagnosed incidentally vs by surveillance. Nonetheless, being diagnosed during surveillance was associated with improved overall survival (P = .01). CONCLUSIONS: Our study represents the largest cohort to date reporting characteristics and outcomes of HCC across South America. We found an important number of HCCs diagnosed outside of surveillance programmes, with associated increased mortality in those patients.

Profile of idiosyncratic drug induced liver injury in Latin America: an analysis of published reports.

INTRODUCTION: Drug-induced liver injury (DILI) remains a major problem for drug development and represents a challenging diagnosis for clinicians. The absence of specific biomarkers for diagnosing DILI precludes the availability of reliable data on the epidemiology of the disease. In this study we aimed to describe the features of idiosyncratic hepatotoxicity reports in Latin American countries. MATERIAL AND METHODS: A literature search was performed using the online version of MEDLINE, EMBASE, Scopus, Google Scholar and specific data bases from Latin America (LA) (Scielo, Lilacs) to identify any case report or case series of published DILI from 1996 to 2012. From 1996 to 2012, a total of 176 patients with DILI were published in LA, involving 53 suspicious drugs. The median age in the adult population of these patients was 55 years (17-82) with prevalence of women (67%). Among main therapeutic classes, the rank order was led by non-steroidal anti-inflammatory (61 cases) and systemic antibacterial drugs (37 cases). Nimesulide was the individual drug responsible for the highest number of cases (53), followed by cyproterone acetate (18), nitrofurantoin (17), antituberculous drugs (13) and flutamide (12). Thirty two percent of published cases evolved to acute liver failure (ALF), and half of the subjects required liver transplantation or eventually died. CONCLUSIONS: This study represents the first structured attempt to assess the spectrum of DILI profile in LA. The establishment of a Latin American registry to collect prospective DILI cases using a standardized protocol will advance our knowledge about idiosyncratic DILI in this region.

Rebrote virológico en el tratamiento de hepatitis B con entecavir: ¿resistencia? / Virological breakthrough in treating hepatitis B with entecavir: It means resistance?

Paciente varón de 45 años natural de Lima, casado con antecedentes de , múltiples parejas sexuales y operado de fimosis, que debuta con eritema nodoso y diagnosticado de hepatitis B crónica en Agosto del 2008, en controles por consultorio se realiza diagnóstico de cirrosis hepática child A y hepatocarcinoma. Inicia tratamiento para la hepatitis B con Entecavir 0,5mg y luego se realiza hepatectomía del segmento V, En Febrero 2009 en controles de imágenes se evidencia recidiva de hepatocarcinoma en el segmento VI (lesión de 14mm) con AFP de 68 ng/dl, se realiza etanolización, con evolución final favorable. Durante el seguimiento no se observa evidencia de recidiva de HCC, continua con Entecavir 0,5 mg /d y en abril 2010, luego de 72 semanas de tratamiento con adecuada adherencia al tratamiento presenta rebrote virológico (carga viral positiva de 646 UI/dl), y se decide agregar a la terapia Tenofovir. Actualmente paciente con buena evolución con última carga viral de Abril del 2012 negativa recibiendo terapia doble para VHB. Reportamos el caso por ser uno de los primeros en nuestro país de resistencia probable a Entecavir y donde se pone de manifiesto la necesidad de examenes complementarios que confirmen dicha sospecha.

A 45 year- old - married man, with several sexual partners, initiated symptoms with nodosum erythema and in August 2008, is diagnosed of chronic hepatitis due to hepatitis B virus (HBV). Later he was diagnosed of Child A cirrhosis and hepatocarcinoma. He began HBV treatment with Entecavir 0,5 mg; then he underwent a V segment hepatectomy. In February 2009 he presented a relapse with a tumor of 14 mm on VI segment with AFP values of 68 ng/dl, so he underwent an ethanolization with good evolution. During the follow up, he has not presented evidence of relapse of hepatocarcinoma and continued with Entecavir 0,5 mg/d. In April 2010, after 72 weeks of therapy with good compliance, the patient presented a virological breakthrough (viral load 646 UI/dl) and Tenofovir was added to his therapy. Nowadays the patient is receiving double therapy for HBV and his last viral load, April 2012, was negative. This could be the first case in our country of a probable resistance to Entecavir; complementary tests are needed in order to rule out this suspicion.

[Virological breakthrough in treating hepatitis B with entecavir: it means resistance?]. / Rebrote virológico en el tratamiento de hepatitis B con entecavir ¿resistencia?

A 45 year-old married man, with several sexual partners, initiated symptoms with nodosum erythema and in August 2008, is diagnosed of chronic hepatitis due to hepatitis B virus (HBV). Later he was diagnosed of Child A cirrhosis and hepatocarcinoma. He began HBV treatment with Entecavir 0.5 mg; then he underwent a V segment hepatectomy. In February 2009 he presented a relapse with a tumor of 14 mm on VI segment with AFP values of 68 ng/dl, so he underwent an ethanolization with good evolution. During the follow up, he has not presented evidence of relapse of hepatocarcinoma and continued with Entecavir 0.5 mg/d. In April 2010, after 72 weeks of therapy with good compliance, the patient presented a virological breakthrough (viral load 646 UI/dl) and Tenofovir was added to his therapy. Nowadays the patient is receiving double therapy for HBV and his last viral load, April 2012, was negative. This could be the first case in our country of a probable resistance to Entecavir; complementary tests are needed in order to rule out this suspicion.

[Prognosis factors in acute hepatic insufficiency]. / Factores pronósticos en insuficiencia hepática aguda.

INTRODUCTION: Acute Hepatic Insufficiency (AHI) is a rare syndrome but has a high mortality rate. The purpose of this study was to determine the clinico-epidemiological characteristics of AHI. MATERIALS AND METHODS: Open study, prospective, descriptive of patients diagnosed with AHI in the Liver Unit of the Edgardo Rebagliati Martins State Hospital (HNERM) from February 1999 until January 2003. RESULTS: Fifteen (15) cases were studied. The average age was 63 (30-81), the M-F ratio was 2/1. The diagnosis was viral Hepatitis B (53.3%), toxic idiosyncratic reactions (20%), undetermined (20%) and Hepatitis A (6.7%). At the time of diagnosis 80% had Grade I encephalopathy and 20% Grade III encephalopathy; 13.3% did not have ascites and 86.7% had mild-moderate ascites; 53.3% had a history of chronic illness (diabetes, chronic renal insufficiency, cardiopathy and others). Average laboratory values were: albumin 2.5 gr./dl, bilirubin 25.9 mg/dl, prothrombin time 29 and Factor V 40.7%. The most frequent complications were sepsis and cerebral oedema. Global mortality was 80%. The average survival time was 16.6 days. CONCLUSIONS: In most cases the patients were over 60 years of age. The main cause of AHI was viral Hepatitis B, a disease which can be prevented with active immunisation. Infection and cerebral oedema were common causes of death. AHI, although rare, is a rapidly degenerative and fatal condition.

Factores pronósticos en insuficiencia hepática aguda / Prognoses factors in acute hepatic insufficiency

Introducción. La insuficiencia hepática aguda (IHA) es un síndrome poco frecuente aunque con elevada mortalidad. El objetivo de este estudio fue determinar las características clínico-epidemiológicas de la IHA. Materiales y métodos: Estudio abierto, prospectivo, descriptivo de pacientes con diagnóstico de IHA hospitalizados en la Unidad de Hígado del HNERM desde Febrero 1999 hasta Enero 2003. Resultados. Se estudiaron 15 casos. La edad promedio fue 63 años (30-81), la relación M/F fue 2/1. La etiología fue hepatitis viral B (53.3 por ciento), reacciones tóxicas por idiosincracia (20 por ciento), indeterminada (20 por ciento) y hepatitis A (6.7 por ciento). En el momento del diagnóstico el 80 por ciento presentó encefalopatía Grado I y el 20 por ciento encefalopatía III. El 13.3 por ciento no tuvo ascitis y el 86.7 por ciento ascitis leve-moderada. El 53.3 por ciento tenía como antecedente una enfermedad crónica (diabetes, insuficiencia renal crónica, cardiopatía y otros). Los valores de laboratorio fueron: albúmina media 2.5 gr./dl, bilirrubina media 25.9 mg/dl, tiempo de protrombina media 29'' y Factor V media 40.7 por ciento. Las complicaciones más frecuentes fueron la sepsis y el edema cerebral. La mortalidad global fue 80 por ciento. El tiempo de sobrevida media fue 16.6 días. Conclusiones. La mayoría de casos tuvieron más de 60 años. La principal causa de IHA fue la hepatitis viral B, esta enfermedad puede prevenirse con la inmunización activa. La infección y el edema cerebral fueron causas importantes de muerte. La IHA aunque rara, es una entidad rápidamente progresiva y fatal.

Introduction. Acute Hepatic Insufficiency (AHI) is a rare syndrome but has a highmortality rate. The purpose of this study was to determine the clinico-epidemiological characteristics of AHI. Materials and Methods. Open study, prospective, descriptive of patients diagnosed with AHI in the Liver Unit of the Edgardo Rebagliati Martins State Hospital (HNERM) from February 1999 until January 2003. Results. Fifteen (15) cases were studied. The average age was 63 (30-81), the M-Fratio was 2/1. The diagnosis was viral Hepatitis B (53.3 per cent), toxic idiosyncratic reactions(20 per cent), undetermined (20 per cent) and Hepatitis A (6.7 per cent). At the time of diagnosis 80 per cent had Grade I encephalopathyand 20 per cent Grade III encephalopathy; 13.3 per cent did not have ascites and 86.7 per cent had mild-moderate ascites; 53.3 per cent had a history of chronic illness (diabetes, chronic renal insufficiency, cardiopathy and others). Average laboratory values were: albumin 2.5 gr./dl, bilirubin 25.9 mg/dl, prothrombin time 29” and Factor V 40.7 per cent. The most frequent complications were sepsis and cerebral oedema. Global mortality was 80 per cent. The average survival time was 16.6 days.Conclusions. In most cases the patients were over 60 years of age. The main cause of AHI was viral Hepatitis B, a disease which can be prevented with active immunisation. Infection and cerebral oedema were common causes of death. AHI, although rare, is a rapidly degenerative and fatal condition.

[Autoimmune hepatitis: clinical forms and related factors to their response to treatment]. / Hepatitis autoinmune: formas clínicas y factores relacionados con la respuesta al tratamiento.

Chronic liver disease is a clinical entity of different origins. It is most frequently caused by viral infection and alcohol consumption. The entities of immunological origin are listed in third place including autoimmune hepatitis, primary biliar cirrhosis, primary sclerosing cholangitis, as well as superposition syndromes. In Peru report of cases relating to autoimmune hepatitis are very few and its frequency is unknown. In 2002, autoimmune etiology represented 13% of all the cases admitted in the Hepathology Unit of Edgardo Rebagliati Martins National Hospital ("HNERM") for chronic hepatic disease. In this article, 30 cases of autoimmune hepatitis clinically and serologically diagnosed are reported. Biopsy was performed on 97% of the cases, of which 70% showed cirrhosis. The relationship F/M was 5/1, the average age was 48.59 years, and in 6.7% of the cases the initial picture was acute hepatic insufficiency. Antinuclear antibodies were found in 73.33%, smooth antimuscle antibodies in 43.33%, and antimitochondrial antibodies in 16.7%, with a coexistence of autoantibodies in 40%. The endoscopy performed revealed the presence of varices in 20% of the cases, but only one case of variceal hemorrhage. In most cases, therapy was initiated based on prednisone and azathioprine. Of 26 cases that were treated, 80% had an initial remission, 2 responded partially, and 3 did not respond. There were complications related to the treatment with immunosuppressants in 16.7% of the cases, and especially severe infections in 3 cases. In conclusion, autoimmune hepatitis is a substantial cause of chronic hepatic disease that has similar clinical characteristics to those reported in international medical journals. In most cases it responds to treatment with immunosuppressants. However, adequate follow-up is recommended to detect secondary complications in the treatment with immunosuppressants, especially in infections which represent a high risk of mortality in the immunosuppressed patient.

[Hepatotoxicity and pancreatitis associated with gold salts: case report]. / Hepatotoxicidad y pancreatitis por sales de oro: reporte de caso.

The case of a patient, 37 years old, born and resident of Lima, suffering rheumatoid arthritis who underwent treatment with prednisone, methotrexate, and chloroquine is reported. This therapy was substituted for gold salts one month before her admission. After the third dose she presented symptoms of abdominal pain and diarrhea, itching, and jaundice, associated with asthenia and a feverish sensation. Liver biochemistry demonstrated elevated transaminase, bilirubin, alkaline phosphatase, eosinophilia, inversion of the rate albumin/globulin, higher titer of immunoglobulin G, as well as an elevation of amylase and lipase. The anatomopathological study showed cholestasis, hepatocyte ballooning, spotty necrosis, predominantly in zone 3 of the acinus. These findings where found consistent with a toxic reaction.

Hepatitis autoinmune: formas clínicas y factores relacionados con la respuesta al tratamiento / Hepatitis autoinmune: clinical forms and factors related to the answer to the treatment

La enfermedad hepática crónica es una entidad clínica que tiene varias causas; siendo la enfermedad viral y el consumo crónico de alcohol las más frecuentes. Las entidades de origen inmunológico son las que en conjunto ocupan el tercer lugar, incluyéndose la hepatitis autoinmune, la cirrosis biliar primaria, la colangitis esclerosante primaria, así como los síndromes de superposición. En el Perú hay escasos reportes en relación a la hepatitis autoinmune, y su frecuencia es desconocida. En la Unidad de Hígado del HNERM. La etiología autoinmune corresponde al 13 por ciento del total de casos hospitalizados por enfermedad hepática crónica en el año 2002. En este artículo reportamos 30 casos de hepatitis autoinmune con diagnóstico clínico y serológico, se hizo biopsia en el 97 por ciento de casos, demostrándose cirrosis en el 70 por ciento. La relación F/M fue de 5/1, la edad promedio fue 48.59 años, y en 6.7 por ciento de casos el debut del cuadro fue como insuficiencia hepática aguda. Se halló anticuerpos antinucleares en 73.33 por ciento, anticuerpos antimúsculo liso en 43.33 por ciento y antimitocondriales en 16.7 por ciento, habiendo coexistencia de autoanticuerpos en 40 por ciento. La endoscopía reveló la presencia de várices en 20 por ciento, pero solo 1 caso debutó con hemorragia variceal. La terapia instaurada fue a base de prednisona y azatioprina en la mayoría de casos. Recibieron tratamiento 26 casos, de los cuales el 80 por ciento tuvo remisión inicial, 2 tuvieron respuesta parcial y 3 no respondieron. En 16.7 por ciento de casos ocurrieron complicaciones relacionadas con el tratamiento inmunosupresor, sobre todo infecciones severas (3 casos). En conclusión, la Hepatitis autoinmune es una causa importante de enfermedad hepática crónica, que tiene características clínicas similares a las reportadas en la literatura internacional, responde al tratamiento inmunosupresor en la mayoría de casos, aunque debe hacerse un adecuado seguimiento del caso...

Chronic liver disease is a clinical entity of different origins. It is most frequently caused by viral infection and alcohol consumption. The entities of immunological origin are listed in third place including autoimmune hepatitis, primary biliar cirrhosis, primary sclerosing cholangitis, as well as superposition syndromes. In Peru report of cases relating to autoimmune hepatitis are very few and its frequency is unknown. In 2002, autoimmune etiology represented 13 per cent of all the cases admitted in the Hepathology Unit of Edgardo Rebagliati Martins National Hospital (“HNERM”) for chronic hepatic disease. In this article, 30 cases of autoimmune hepatitis clinically and serologically diagnosed are reported.Biopsy was performed on 97 per cent of the cases, of which 70 per cent showed cirrhosis. The relationship F/M was 5/1, the average age was 48.59 years, and in 6.7 per cent of the cases the initial picture was acute hepatic insufficiency. Antinuclear antibodies were found in 73.33 per cent, smooth antimuscle antibodies in 43.33 per cent, and antimitochondrial antibodies in 16.7 per cent, with a coexistence of autoantibodies in 40 per cent. The endoscopy performed revealed the presence of varices in 20 per cent of the cases, but only one case of variceal hemorrhage. In most cases, therapy was initiated based on prednisone andazathioprine. Of 26 cases that were treated, 80 per cent had an initial remission, 2 responded partially,and 3 did not respond. There were complications related to the treatment with immunosuppressants in 16.7 per cent of the cases, and especially severe infections in 3 cases. In conclusion, autoimmune hepatitis is a substantial cause of chronic hepatic disease that has similar clinical characteristics tothose reported in international medical journals. In most cases it responds to treatment with immunosuppressants. However, adequate follow-up is recommended to detect secondarycomplications in the treatment with...

[DIAGNOSTIC AND THERAPEUTIC COLONOSCOPY IN PEDIATRICS] / Colonoscopía diagnótica y terapéutica en pediatría.

Gastrointestinal bleeding in childhood is an uncommon problem, althought when it happens it maybe an emergency. Upper bleeding predominates, and when we consider lower bleeding, the principal cause are polyps. Recent evidence points out that polyps are responsible for bleeding in 77% of cases.We decided to study the clinical course, histologic characteristics and treatment in children with lower gastrointestinal bleeding. This investigation was held at Edgardo Rebagliati National Hospital during 1990 to 1996. Inclusion criteria were: younger than 14 years, gastrointestinal bleeding, and colonoscopy exam.100 colonoscopies were done in 74 children. Polyps were the cause for gastrointestinal bleeding in 71.6% of cases. In 14 children more than one colonoscopy was done. More than one polyp in 16 children were found. Ulcerative colitis was diagnosed in two cases, and intestinal tuberculosis in other two cases. Average age was 8.8 years, and 100% presented rectorragia and anemia.Polyps were located principally in rectum and sigmoid. Polipectomy was done in 94.34% of the cases, and it was technically succesful. We had only one complication (snare wire was trapped) but with no morbidity.Histological examination demonstrated that juvenile polyp was the most frequent type (56.66%), followed by tubular adenoma (11.32%), and Peutz-Jegher polyp in 3.77%. Treatment was polipectomy in all cases. Eleven procedures were done in the surgical room, and 19 in the endoscopy unit, with no complications in any of the cases.CONCLUSION: In children the main cause for lower gastrointestinal bleeding are polyps. All cases present with rectorragia or anemia, and juvenile polyps are the most frequent type. Colonoscopy is a safe method for diagnosis and treatment, which can be done in the endoscopy unit with mild sedation and with an anesthesist or pediatrician as assistants.

Hepatitis alcohólica / Alcoholic hepatitis

Actualmente, la relación entre consumo de alcohol y el desarrollo de daño hepático está claramente definida. Sin embargo, también debe considerarse la influencia de los factores genéticos, la existencia de enfermedades asociadas y el uso concomitante de otros agentes hepatotóxicos. Durante el etilismo crónico se producen grandes cantidades de radicales libres de oxígeno, se altera el equilibrio redox y se sobrepasa la capacidad defensiva de los antioxidantes naturales. Todos estos factores originan "stres oxidativo", que distorciona completamente la función hepatocelular. Asismismo, el incremento en la concentración intracelular de acetaldehido, modifica diversas proteinas celulares, lo que deteriora aún más la actividad hepática. Está aún por definirse la importancia de los "neoantígenos", entre componentes celulares y el acetaldehido, así como su rol en la formación de los cuerpos de Mallory. por otro lado, la complicada red de comunicaciones inter e intracelulares que comprende a las citoquinas, a las moléculas de adherencia y a los receptores de membrana son elementos indispensables a considerar en la génesis de la hepatopatía alcohólica. La endotoxina, el TNF-a, la IL-8, así como la producción de ROIs son al parecer los factores más importantes. En relación a hepatitis alcohólica, el desarrollo de una respuesta inflamatoria exagerada y mediada por neutrófilos sería el mecanismo básico de injuria hepatocelular. El diagnóstico definitivo de hepatitis alcohólica es histológico. Este permite además, graduar la severidad del daño y determinar la presencia de fibrosis y/o cirrosis en cuyo caso el pronóstico es más sombrío. Clínicamente el diagnóstico puede plantearse teniendo el antecedente de ingesta exagerada de alcohol. Existe gran variabilidad en el cuadro clínico, y no es infrecuente que algunos pacientes presenten las complicaciones de la hepatopatía crónica. Los que desarrollan insuficiencia hepática severa, presentarán leucocitosis, ictericia y fiebre. En estos casos la mortalidad puede llegar hasta 80 por ciento. La alteración de las pruebas de función hepática no guardan relación con al severidad del daño. La utilidad de los antioxidantes en cirrosis ha sido demostrada en modelos animales y en algunos estudios en voluntarios humanos. Su rol como terapia en el contexto de hepatitis alcohólica, esta por ser definida...

[ALCOHOLIC HEPATITIS] / Hepatitis Alcohólica.

At present, the relation between alcoholic consumption and the development of hepatic injury is clearly defined. However, the influence of genetic factors, the existence of associated pathologies, and the concomitant use of other hepatotoxic agents should also be considered.During chronic drunkenness, great quantities of oxygen free radicals are produced, redox balance is disturbed, and the defensive capacity of natural antioxidants is exceeded. All these factors originate an "oxidative stress," that totally distorts the hepatocellular function. Llkewise, an increase in the acetaldehyde intracellular concentration modifies several cellular proteins, deteriorating even more the hepatic activity. The importance of the "neo-antigens" between cellular components and acetaldehyde is still undefined, as well as their role in the formation of the Mallory Bodies.On the other hand, the complex network of intercellular and intracellular communications that includes cytokines, adherence molecules and membrane receptors are essential elements to be considered in the alcoholic liver disease genesis. The endotoxin, the TNF-a, the IL-8, as well as the ROIs production seem to be the most important factors.With reference to Alcoholic Hepatitis, the development of an exaggerated inflammatory response with the existence of neutrophiles may be the main mechanism of hepatocellular injury (82, 167, 168.)The final diagnosis of Alcoholic Hepatitis is histological. This also enables to measure the injury severity and to determine the presence of fibrosis and/or cirrhosis, in which case prognosis is more uncertain.Should a history of exaggerated alcoholic ingestion exist, diagnosis could be clinically determined. There is a great variability of clinical symptoms, and some patients present chronic liver disease complications frequently. Those who develop severe liver insufficiency will present leukocytosis, icterus and fever. In these cases, mortality can be as high as 80 per cent. There is no relationship between the alteration of liver function tests and the injury severity.The usefulness of antioxidants in cirrhosis has been demonstrated in animal modeis and in some studies made in human voluntarles. However, their role as therapy within the context of Alcoholic Hepatitis has not been yet defined.In conclusion, several therapeutic approaches have been investigated and from all of them, only steroids have proven to be effective on patients properly selected. The discriminative function (DF) benefit has been confirmed in certain studies. Should a patient have a DIF of more than 93, he/she may receive corticosterold treatment. Contral ndicati ons are a bsol ute when the patientpresents infection, renal insufficiency or gastrointestinal bleeding.Once the patient has been compensated, ABSTINENCE is essential. Likewise, an appropriate nutritional support is an important part of the treatment.Where the possibility of Liver Transplant exists, this should be planned if there is a deterioration of the patient's general condition or if he/she compiles with the necessary criteria, since the survival rate in these cases is similar to those who received a transpiant due to other causes.

Tratamiento con inyección endoscópica de la úlcera péptica sangrante / Endoscopic injection treatment of bleeding peptic ulcer

Objetivos: Fueron dos, 1)Determinar la eficacia de la terapia de inyección endoscópica (TIE) en pacientes con sangrado por úlcera péptica con .alto riesgo de recurrencia, y 2)Reconocer los factores de riesgo clínico-endoscópicos que influyen en la recurrencia de hemorragia y la mortalidad por esta patología. Métodos: Es un estudio retrospectivo que incluye 121 pacientes admitidos a una unidad especializada en el manejo de hemorragia digestiva debido a una úlcera péptica con sangrado activo o vaso visible no sangrante, entre Marzo de 1994 y Febrero de 1996, y a los que se les realizó TIEcon adrenalina. Resultados: Se logró éxito en la hemostasia endoscópica inicial en 119 pacientes (99.1 por ciento), en un paciente la hemorragia persistió (0.9 por ciento), y en otro no se pudo realizar la TIE por inaccesibilidad. La hemostasia definitiva se alcanzó en 93 pacientes (77.5 por ciento), y hubo recurrencia en 28 (23.5 por ciento).Se remitió a cirugía a 26 pacientes (21.5 por ciento). El examen univariado demostró que la recurrencia de la hemorragia estuvo relacionada con la presencia de shock (p=0.002), hematemesis (p=0.02),edad mayor de 60 años (p=0.009), número de unidades transfundidas (p=O.OOOOO) y tamaño de la úlcera mayor de 2cm (p=0.018). La mortalidad global en nuestros pacientes fue de 10 por ciento, y la mortalidad operatoria de 34.6 por ciento. Los factores asociados significativamente con la mortalidadfueron la recurrencia de la hemorragia (p=0.000003), presencia de enfermedad concomitante (p=0.05), la presencia de úlcera gástrica (p=0.021), además de la edad (mayores de 60años), presencia de.shock y tamaño de la úlcera mayor de 2cm (P=0.05). Conclusiones: La TIE es un procedimiento útil en el tratamiento de la hemorragia por úlcera péptica con alto riesgo de recurrencia (hemorragia activa o vaso visible), habiéndose obtenido la hemostasia definitiva en el 77.5 por ciento...

Background: Objectives were two. (1) to determine the efficiency of the endoscopic injection therapy (EIT) in patients suffering from bleeding caused by peptic ulcer disease with high risk of recurrence, and (2) to recognize clinical and endoscopical risk factors that influence recurrence of hemorrhage and mortality from this pathology. Methods: This is a retrospective study that included 121 patients, who were admitted by a unit specialized in managing gastrointestinal hemorrhage owing to peptic ulcer with active bleeding or non-bleeding visible vessel, and who underwent EIT with epinephrine between March, 1994 and February, 1996. Results: Initial success was achieved in 119 patients who underwent EIT (99.1 per cent). Bleeding persisted in one patient (0.9 per cent), and in another one, EIT was not successful because of inaccessible location. Definite hemostasis was achieved in 93 patients (77.5 per cent) and there was recurrence in 28 cases (23.5 per cent). Twenty-six patients underwent surgical therapy (21.5 per cent).The univariable analysis showed that hemorrhage recurrence was related to the presence of shock (p=0.002), hematemesis (p=0.2), age over 60 (p=0.009), number of blood units transfused (p=O.OOOOO) and ulcer diameter larger than 2 cm (p=0.018). The global mortality in our patients was of 10 per cent, and surgical mortality was of 34.6 per cent. Factors significantly related to mortality were hemorrhage recurrence (p=0.000003), presence 01concomitant disease (p=0.05), and presence of gastric ulcer (p=0.021), in addition to age (over 60), presence of shock and ulcer diameter larger than 2 cm (p=0.05). Conclusion: EIT is a valuable procedure for the treatment of hemorrhage caused by peptic ulcer with high risk of recurrence (active hemorrhage or visible vessel), with a definite hemostasis of 77.5 per cent...

[ENDOSCOPIC INJECTION TREATMENT OF BLEEDING PEPTIC ULCER] / Tratamiento con Inyección endoscópicade la úlcera péptica sangrante.

BACKGROUND: Objectives were two. (1) to determine theefficiency of the endoscopic injection therapy (EIT) in patients suffering from bleeding caused by peptic ulcer disease with high risk of recurrence, and (2) to recognize clinical and endoscopical risk factors that influence recurrence of hemorrhage and mortality from this pathology. METHODS: This is a retrospective study that included 121 patients, who were admitted by a unit specialized in managing gastrointestinal hemorrhage owing to peptic ulcer with active bleeding or non-bleeding visible vessel, and who underwent EIT with epinephrine between March, 1994 and February, 1996.RESULTS: Initial success was achieved in 119 patients who underwent EIT (99,1%). Bleeding persisted in one patient (0,9%), and in another one, EIT was not sucessful because of inaccessible location. Definite hemostasis was achieved in 93 patients (77,5%) and there was recurrence in 28 cases (23,5%). Twenty-six patients underwent surgical therapy (21,5%). The univariable analysis showed that hemorrhage recurrence was related to the presence of shock (p = 0,002), hematemesis (p = 0,2), age over 60 (p = 0,009), number of blood units transfused (p = 0,00000) and ulcer diameter larger than 2 cm (p = 0,018). The global mortality in our patients was of 10%, and surgical mortality was of 34,6%. Factors significantly related to mortality were hemorrhage recurrence (p = 0,000003), presence of concomitant disease (p = 0,05), and presence of gastric ulcer (p = 0,021), in addition to age (over 60), presence of shock and ulcer diameter larger than 2 cm (p = 0,05).CONCLUSION: EIT is a valuable procedure for the treatment of hemorrhage caused by peptic ulcer with high risk of recurrence (active hemorrhage or visible vessel), with a definite hemostasis of 77,5%. The presence of shock, hematemesis, age over 60, transfusion requirements of more than 3 blood units, and ulcer diameter of more than 2 cm are factors that increase the probability of hemorrhage recurrence after EIT. Mortality is significantly related to the presence of hemorrhage recurrence, concomitant diseases and gastric ulcer in addition to clinical and endoscopical factors mentioned above, with the exception of hematemesis and transfusion requirement. A prompt surgery after detection of a major bleeding recurrence in patients with the risk factor already described and a coordinate action with a surgery team experienced in digestive hemorrhage would influence favorably the mortality rate of this disease.