[Current status of endoscopic retrograde cholangiopancreatography. What is the effect of the introduction of magnetic resonance cholangiography?]. / Estado actual de la CPRE. Cómo se refleja la introducción de la colangiorresonancia magnética?

AIM: To determine the current status of endoscopic retrograde cholangiopancreatography (ERCP) and the effects of the introduction of magnetic resonance cholangiography (MRC) on ERCP and to evaluate the diagnostic yield of MRC since its introduction in obstructive biliary disease. MATERIAL AND METHODS: We performed a retrospective analysis of the ERCP carried out between January 1998 and December 2000 and of the MRC performed for suspected obstructive biliary disease from May 1999 to December 2000. When both techniques were performed, the diagnostic yield of MRC was evaluated. RESULTS: We performed 927 ERCP. A total of 45.3% of the patients were men. Mean age was 69.2 14.6 years. Treatment was performed on 688 occasions (77%), mainly sphincterotomy (69.9%) and placement of polyethylene (21.8%) or self-expanding (9.9%) prostheses. The number of ERCP performed each year was 261, 330 and 336 in 1998, 1999 and 2000, respectively; of these 76.6%, 80% and 76.9% were therapeutic. MRC was performed in 63 patients with suspected biliary disease. In 27 of 59 patients (45.8%) MRC was sufficient for diagnosis, avoiding the need for ERCP. In the 35 patients in whom both techniques (MRC and ERCP) were performed, the diagnostic yield of MRC compared with that of ERCP was: sensitivity 100%, specificity 50%, positive predictive value 87.1%, negative predictive value 100% and overall value 89%. The cases responsible for the low specificity (all due to choledocholithiases) were analyzed and a significant time lapse was found between the performance of MRC and ERCP (range: 7-35 days) during which choledocholithiasis probably resolved spontaneously. CONCLUSIONS: a) Contrary to what could be expected, the number of ERCP seems to be increasing with a high percentage of endoscopic treatment; b) Because of its diagnostic sensitivity, MRC is the ideal technique for eliminating the need for diagnostic ERCP, thus allowing greater development of the therapeutic aspect of ERCP.

[Multiple hepatic focal nodular hyperplasia: its presentation in childhood and atypical evolution]. / Hiperplasia nodular focal múltiple hepática: presentación en la infancia y evolución atípica.

Multiple focal nodular hyperplasia is an uncommon benign liver tumor although its incidence has been increasing in the last few years. A case of focal nodular hyperplasia in a young woman is described, which was discovered in infancy and which presented two nodules in each lobe. The diagnosis was subsequently confirmed by large surgical biopsy. Conservative therapy was given for 16 years during which time there was progressive tumor growth, increase of pain and cholestatic enzymes. The unusual presentation this benign lesion may have, a strategy for its diagnosis and the generally conservative management that is currently favored are discussed.

[Color duplex Doppler ultrasonography in the evaluation of the risk of esophageal varices bleeding in cirrhotic patients]. / Ultrasonografía Doppler dúplex color en la valoración del riesgo de sangrado por varices esofágicas en pacientes cirróticos.

The risk of variceal bleeding (VB) in patients with cirrhosis and esophageal varices may be determined by the portal pressure gradient. The value of Color Duplex Doppler Ultrasonography (CDDU) in the identification of patients at risk for variceal bleeding has been discussed in the literature. In patients with esophageal varices at risk for bleeding, CDDU did not detect patients who presented variceal bleeding during a mean follow-up of 7 months. However, patients with a low Congestion Index (< 0.05) and a mean upper portal vein velocity of > 9 were at lower risk for variceal bleeding. The Congestion Index was higher in patients with bleeding during the follow-up (0.09 vs. 0.057 (p = 0.03) and the mean portal vein velocity was lower in these patients (10.7 vs. 14).

[Spontaneous bacterial peritonitis caused by Listeria monocytogenes]. / Peritonitis bacteriana espontánea por Listeria monocytogenes.

We present a 68 year old male with alcoholic cirrhosis that was admitted with abdominal pain and fever. Hepatocarcinoma and spontaneous bacterial peritonitis by Listeria monocytogenes was diagnosed. The patient was treated with ampicillin and tobramycin during 25 days following a favorable course although ascitic fluid remained abnormal during 21 days. It is noted the rarity of Listeria as a cause of bacterial peritonitis in cirrhotic patients although they are immunodeficient. It is also important to establish the etiological origin because standard treatment of spontaneous bacterial peritonitis is cefotaxime and Listeria is resistant to this antibiotic. The 66% of spontaneous bacterial peritonitis secondary to Listeria monocytogenes infection in cirrhotic patients has been reported in Spain and this might be due to a higher incidence of human listeriosis in this country.

[Systemic amyloidosis presenting as cholestatic jaundice]. / Ictericia colestásica como forma de presentación de una amiloidosis sistémica.

We present a case of a 68 year old man with general deterioration and recent onset of jaundice that was admitted for clinical evaluation. Previous records were: treated bone tuberculosis, hypertrophic myocardiopathy and ischemic cardiopathy. Physical examination showed liver enlargement without evidence of chronic liver disease. Laboratory studies and other explorations such as abdominal ultrasound, CAT and ERCP did not leed to an objective diagnosis. Therefore, a liver biopsy was performed, showing liver amyloidosis AA type with amyloid deposits in portal spaces. The patient died three months later. The rarity of this clinical presentation is discussed and its poor prognosis outlined. Some peculiarities of liver deposits are reviewed.

[Incidence of malignancy in millimetric polyps]. / Incidencia de malignidad en los pólipos milimétricos.

This paper is based on the analysis of 178 polyps of 5 mm or less (polyps we have termed "millimetric") studied in the Endoscopy Department of "La Paz" Hospital, Madrid, during 1993. All polyps fulfilling these characteristics detected during this period are included. The 178 polyps represent 43.4% of all polyps (N = 410) found on colonoscopy in this department in this period. The variables considered in the study protocol include age, sex, localization, morphology and histological examination, with particular attention to high risk histological lesions such as signs of possible malignancy.; we also performed a comparative study between the results obtained from the 178 millimetric polyps (Group I) and the 232 polyps greater than 5 mm (Group II) obtained during the same period. The endoscopic technique for the resection of the polyps was evaluated together with its possible complications. Although there were no significant differences found in respect to age, sex and location, there were morphological differences with a greater number of pediculated or semi-pediculated polyps in Group I whilst there were more sessile polyps in Group II. Adenomatous polyps were the most frequent (84%) in both groups. There was a greater incidence of signs of possible early malignant changes in Group II polyps (10) than in Group I (3.3%). The conclusions which may be drawn from our study are that it is clinically advisable to excise all polyps of 5 mm or less as the frequency of high risk histological changes is not negligible (3.3%), and excision is not problematic as the technique is easy and there have been no complications in our series.

[Hepatocellular carcinoma: is spontaneous regression possible?]. / Carcinoma hepatocelular: es posible la regresión espontánea?

We present the case of a patient with liver cirrhosis secondary to hepatitis C who developed a large (6 cms) hepatocellular carcinoma, diagnosed by raised alphafetoprotein (AFP) levels (> 10000 ng/ml) and imaging techniques (ultrasonography and abdominal CT with and without contrast). During follow-up there was normalization of the AFP levels and disappearance of the lesion on U.S. and CT. Spontaneous regression is exceptional in hepatocellular carcinoma. We describe the characteristics of our case and of the 10 patients described in the literature.

[Upper digestive hemorrhage in the operated stomach (Billroth I and II): clinical course and prognosis]. / Hemorragia digestiva alta en el estómago operado (Billroth I y II): curso y pronóstico.

AIM: To determine course and prognosis of upper gastrointestinal bleeding in gastrectomized patients. MATERIALS AND METHODS: We have conducted a retrospective study on 34 patients (one female, mean age 38.2 +/- 12.14 years) admitted with upper gastrointestinal bleeding between November 1989 and August 1991. All patients had been previously gastrectomized because of benign gastric pathology. Eight had a Billroth I type gastrectomy, and 26 a Billroth II. RESULTS: The causes of gastrointestinal bleeding were recurrent ulcer in 20 patients and alkaline reflux gastritis in 13 patients, both located at the surgical anastomosis; in one case it was not possible to determine the lesion responsible of the bleeding. Initial symptoms were maelena in 16 patients (47%), hematemesis in 12 patients (35.2%) and hematemesis and maelena in 6 (17.6%). Only one patient developed hemodynamic changes (systolic arterial tension < 10 mm Hg and pulse > 100 pm). After admission 3 patients rebled (8.8%) and the mortality reached 8.8%. Although rebleeding and mortality rates were higher than the rates for peptic ulcer in non gastrectomized patients, mortality and rebleeding occurred in patients with severe diseases (chronic hepatopathy), whose evolution conditioned in 2 of 3 patients the course of the upper gastrointestinal bleeding. CONCLUSIONS: The evolution of bleeding was not influenced by the causal lesion or the gastric resective procedure. We conclude that the course and prognosis of upper gastrointestinal bleeding in gastrectomized patients is not severe; hemostatic surgical procedures are indicated in only a minority of patients.