Disease-specific health-related quality of life in patients with esophageal achalasia before and after therapy.

BACKGROUND: To evaluate disease-specific health-related quality of life (HRQoL) in patients with symptomatic esophageal achalasia before and after therapy. METHODS: Symptoms and disease-specific HRQoL were evaluated before and 3 months after therapy. Therapy selection, either dilatation or myotomy, depended exclusively on the opinion of the physician on charge of the patient. Symptom severity was graded from 0 to 3, using a scoring system. A disease-specific questionnaire for achalasia developed and validated in Spanish language with 18 items and four subscales (AE-18) was used to evaluate HRQoL. Changes after therapy in HRQoL and its association with clinical improvement were analyzed. KEY RESULTS: Sixty-five patients were prospectively included in eight hospitals in Spain. Of them, 47 were treated with dilatation, and 18 with laparoscopic Heller myotomy. After therapy, AE-18 global and subscales scores improved significantly. Changes in HRQoL were associated with improvement in symptoms. An important improvement in symptoms (>or=50%) was needed to obtain a minimal clinically important improvement (>or=20%) in HRQoL. CONCLUSIONS & INFERENCES: Disease-specific HRQoL improves in patients with symptomatic achalasia after therapy with dilatation or myotomy. The degree of improvement of HRQoL depends on the degree of improvement of esophageal symptoms.

[Joint disease in inflammatory bowel disease]. / Patología articular en la enfermedad inflamatoria intestinal.

The joint disorders taxonomically included in the group of seronegative spondyloarthropathies under the generic name of enteropathic arthropathy represent the most frequent extra-intestinal manifestation of inflammatory bowel disease (IBD), affecting 33% of patients. Their frequency is similar to that of ulcerative colitis and Crohn's disease. Enteropathic arthropathy consists of two main joint alterations, peripheral and axial arthritis, as well as a variable group of other peri-articular disorders. Type 1, or pauciarticular, peripheral arthritis generally coincides with IBD exacerbations, while type 2, or polyarticular, peripheral arthritis follows an independent course from IBD. Axial involvement precedes and follows an independent course from IBD and can behave as ankylosing spondylitis or asymptomatic sacroiliitis. The treatment of these rheumatologic disorders is based on the application of general measures and the use of nonsteroidal anti-inflammatory agents; intraarticular corticosteroid administration may eventually become necessary. Sulphasalazine and/or infliximab, which are indicated when the previously mentioned measures fail, can be used to treat both the articular and intestinal diseases simultaneously.

Patología articular en la enfermedad inflamatoria intestinal / Joint disease in inflammatory bowel disease

Los trastornos articulares, taxonómicamente incluidos en el grupo de espondiloartropatías seronegativas con la denominación genérica de artropatía enteropática, representan la manifestación extraintestinal más frecuente de la enfermedad inflamatoria intestinal (EII), donde se presentan en el33% de los pacientes, y con una frecuencia similar en la colitisulcerosa y en la enfermedad de Crohn. La artropatía enteropática comprende 2 alteraciones articulares principales, la artritis periférica y la artritis axial, así como un grupo variado de otros trastornos periarticulares. La artritis periférica tipo 1 o pauciarticular generalmente coincide con las exacerbaciones de la EII, mientras que la de tipo 2 o poliarticular sigue un curso independiente de la enfermedad intestinal. La afectación axial precede y sigue un curso independiente de la EII, y puede comportarse como espondilitis anquilosante o como sacroileítis asintomática. El tratamiento de esta enfermedad reumatológica se basa en la aplicación de medidas generales y el empleo de antiinflamatorios no esteroideos; eventualmente puede ser necesaria la infiltración articular con corticoides. El uso de salazopirina y/oinfliximab, indicado cuando las anteriores medidas fracasen, posibilita el tratamiento simultáneo de las enfermedades articular e intestinal

The joint disorders taxonomically included in the group of seronegative spondylo arthropathies under the generic name of enteropathic arthropathy represent the most frequent extra-intestinal manifestation of inflammatory bowel disease(IBD), affecting 33% of patients. Their frequency is similar to that of ulcerative colitis and Crohn’s disease. Enteropathic arthropathy consists of two main joint alterations, peripheral peripheraland axial arthritis, as well as a variable group of other peri-articular disorders. Type 1, or pauciarticular, peripheralarthritis generally coincides with IBD exacerbations, while type 2, or polyarticular, peripheral arthritis follows anin dependent course from IBD. Axial involvement precedesand follows an independent course from IBD and can behaveas ankylosing spondylitis or asymptomatic sacroiliitis. The treatment of these rheumatologic disorders is based on the application of general measures and the use of nonsteroidalanti-inflammatory agents; intraarticular corticosteroid administration may eventually become necessary. Sulphasalazineand/or infliximab, which are indicated when the previously mentioned measures fail, can be used to treat both the articular and intestinal diseases simultaneously

[Value of C-reactive protein level in the detection of necrosis in acute pancreatitis]. / Valor de la proteína C reactiva en la detección de la necrosis en la pancreatitis aguda.

OBJECTIVES: To evaluate the utility of C-reactive protein (CRP) in the detection of necrosis in acute pancreatitis and to determine the best cut-off point for CRP used for this purpose. MATERIAL AND METHODS: We performed a retrospective study of 157 patients with acute pancreatitis who underwent computed tomography (CT) with intravenous contrast material between 72 h and 8 days after the onset of symptoms and whose serum CRP values were determined by nephelometry 24 h or later after the onset of pain. RESULTS: Ninety-four patients were men and 63 were women, with a mean age of 61 years (range, 15-96 years). The cause of pancreatitis was biliary lithiasis in 53.5%, alcohol in 20.4%, and idiopathic in 10.8%. Other causes were found in 15.3%. The mean (standard deviation) time elapsed between symptom onset and extraction to evaluate CRP was 3.21 (1.7) days. The patients were divided into two groups according to the results of CT: 132 patients with acute intersitial edematous pancreatitis and 25 patients with acute necrotizing pancreatitis. The mean CRP concentrations were: 322 mg/l (range, 10.7-538) in patients with acute necrotizing pancreatitis and 133 mg/l (range, 3-442) in those with acute interstitial pancreatitis; this difference was statistically significant (p < 0.001). The area under the ROC curve of CRP vs. the occurrence of necrosis was 0.862 (95% CI, 0.778, 0.946). To evaluate the presence of pancreatic necrosis a cut-off level of 200 mg/l showed a sensitivity of 88% and a specificity of 75% while a cut-off level of 279 mg/l presented a sensitivity of 72% and a specificity of 88%. CONCLUSIONS: In acute pancreatitis, a CRP value of less than or equal to 200 mg/l obtained at 72 h of symptom onset is useful for ruling out, with a high degree of probability, the presence of necrosis. With higher values, additional investigations should be performed to determine the presence of pancreatic necrosis; nevertheless, with values higher than 279 mg/l the risk of necrosis markedly increases.

[Treatment of hepatocellular carcinoma]. / Tratamiento del carcinoma hepatocelular.

Hepatocellular carcinoma develops in more of 90% of patients in the setting of cirrhosis. The increasing prevalence seems related with the wide-spread distribution of hepatitis C virus infection, as 80% of cases arise on chronic infection caused by this agent. Either conventional resection or orthotopic liver transplantation are often curative but suitable for few patients, If the surgical approach is not adequate, percutaneous ablation using ethanol injection or radiofrequency current may be considered. However, only 15-20% of patients can benefit from these therapies. Chemoembolization is considered when the previous options are contra-indicated but benefits on survival are still a matter of debate. The impact of new agents as tamoxifen, interferon o diverse chemotherapies on both survival and symptoms also remains to be stablished.

Tratamiento del carcinoma hepatocelular / Treatment of hepatocellular carcinoma

El carcinoma hepatocelular aparece en el 90% de los casos sobre una cirrosis hepática. Su alta prevalencia está relacionada con el ascenso de la infección por el virus de la hepatitis C a nivel mundial. De hecho, en el 80% de los casos el tumor se desarrolla en hepatopatías causadas por este virus. El tratamiento quirúrgico, resección o trasplante hepático, continúa siendo de elección pero son pocos los casos en los que está indicado. Las terapias ablativas percutáneas, como inyección de alcohol o radiofrecuencia, son la otras opciones terapéuticas con intención radical cuando el tumor no es tributario de resección o trasplante. Desafortunadamente, tan sólo un 15-20% pueden beneficiarse de estos tratamientos con intención curativa. La quimioembolización constituye una alternativa cuando las opciones previas están contraindicadas aunque sus beneficios sobre la supervivencia continúan siendo controvertidos. Los nuevos fármacos, como tamoxifeno, interferon y quimioterapia no han conseguido demostrar ningún efecto sobre la sintomatología o la supervivencia (AU)

Tratamiento de la colitis por radiación con enemas de sucralfato / Treatment of radiation-induced proctosigmoiditis with sucralfate enemas

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[Lymphadenomegaly in patients with chronic liver disease]. / Linfadenomegalias en pacientes con hepatopatía crónica.

Abdominal lymphadenomegaly is a frequent ultrasonographic finding in patients with chronic liver disease. Its clinical significance is not well understood. The aim of this study was to determine the relationship between this finding and several characteristics of liver disease in 44 patients with chronic liver disease (79.5% due to hepatitis C virus). To do this, all patients underwent simultaneous liver biopsy and abdominal ultrasonography, in which the number and localization of the enlarged abdominal lymph nodes were confirmed. Viral load in patients with chronic hepatitis C virus infection was determined. No significant differences were found in serum hepatitis C RNA concentrations between patients who presented lymphadenomegaly and those who did not. However, the presence of lymphadenomegaly was associated with greater histological activity. If this finding were confirmed in studies with larger samples, the presence of ultrasonographically-detected enlarged abdominal lymph nodes in patients with chronic liver disease due to hepatitis C virus infection would indicate more severe histological lesions.

Prevalence of hepatitis A virus antibodies in patients with chronic liver diseases.

OBJECTIVE: The age of persons with hepatitis A virus (HAV) infection in the general population has risen; these persons are at increased risk of clinically severe disease, especially patients with chronic liver disease. The aim of the present study was to analyze the prevalence of total antibodies against HAV in patients with chronic liver disease. METHODS: In a prospective study carried out between September 1998 and June 1999, 180 patients seen in the chronic liver disease outpatient department were studied. The prevalence of total anti-HAV antibodies was determined by age group, etiology and degree of histological damage, and according to the antecedents of risk for parenteral infection. A nonconditional logistic regression model was fitted with anti-HAV positivity as the dependent variable. RESULTS: Mean age was 44.1 years, with an anti-HAV prevalence of 77.2% (varying from 42.9% in the 21-25-year-old group to more than 83% in patients > 56-years old). Differences across groups regarding other categories (histological damage, etiology and history of parenteral or drug use) were not statistically significant, but the probability of anti-HAV positivity increased with age and a history of drug addiction. CONCLUSIONS: The prevalence of total anti-HAV antibodies is high among patients with chronic liver disease. We therefore recommend this test before vaccination against HAV, until current recommendations on universal childhood vaccination are implemented, in order to prevent hepatitis A epidemics in the general population.

Gammagrafía con leucocitos marcados en la pancreatitis aguda. Resultados preliminares / Scintigraphy with labelled leukocytes in acute pancreatitis. Preliminary results

El propósito de este trabajo es analizar la aportación del estudio con leucocitos marcados con 99mTcHMPAO en la valoración pronóstica de los enfermos con pancreatitis aguda. Para ello, hemos comparado los métodos habituales de evaluación pronóstica, la tomografía computarizada (TC) y la escala clínica de Ranson con los hallazgos gammagráficos en 23 pacientes consecutivos, con diagnóstico de pancreatitis aguda leve o severa. Todos los pacientes con diagnóstico de pancreatitis severa (6 pacientes), presentaron captación y esta fue mayoritariamente poco intensa. 9 de los pacientes con diagnóstico de pancreatitis leve (17 pacientes) mostraron captación, también predominantemente poco intensa. Al comparar el índice de severidad de la TC con los resultados de los leucocitos, el único paciente con índice de severidad alto mostró captación de grado 3. Sin embargo, en más de la mitad de los pacientes con índice de severidad bajo se encontró captación, generalmente poco intensa. Al comparar el grado de captación con el nivel de gravedad según la clasificación de Ranson, se observó un predominio de la captación leve tanto en los pacientes con pancreatitis leve como en los pacientes con pancreatitis severa. Antes estos resultados, pensamos que la ausencia de captación en el estudio con leucocitos en pacientes con pancreatitis aguda, puede interpretarse como signo de buen pronóstico. El hallazgo de captación en área pancreática tiene un significado incierto y es necesario el estudio con muestras de mayor tamaño. (AU)

Prevalencia de anticuerpos antivirus de la hepatitis A en pacientes con hepatopatías crónicas / Prevalence of hepatitis A virus antibodies in patients with chronic liver diseases

OBJETIVO: la edad de infección por el virus de la hepatitis A (VHA) ha aumentado en la población, con un mayor riesgo de gravedad clínica, sobre todo en pacientes con hepatopatía crónica. Se pretende conocer la prevalencia de anticuerpos totales frente al VHA en pacientes con hepatopatía crónica. PACIENTES Y MÉTODOS: se estudió de forma prospectiva a 180 pacientes atendidos consecutivamente en nuestra consulta de Hepatopatías Crónicas desde septiembre de 1998 hasta junio de 1999. Se determinó la prevalencia de anticuerpos totales anti-VHA por grupos de edad, etiologías, grado de afectación histológica y antecedentes de riesgo de infección por vía parenteral. Finalmente se ajustó un modelo de regresión logística no condicional con variable dependiente la presencia de anti-VHA. RESULTADOS: la edad media fue de 44,1 años, con una prevalencia de anti-VHA del 77,2 por ciento (desde el 42,9 por ciento entre 21-25 años hasta más del 83 por ciento a partir de 56 años). No existieron diferencias estadísticamente significativas según la afectación histológica, etiología o antecedentes de riesgo parenteral o de drogadicción, pero la probabilidad de tener anti-VHA aumentaba con la edad y con el antecedente UDVP. CONCLUSIONES: los pacientes con hepatopatía crónica presentan una alta prevalencia de anticuerpos totales anti-VHA, En consecuencia, en estos pacientes recomendamos su determinación previamente a la vacunación frente al VHA hasta que se introduzcan las recomendaciones actuales de vacunación generalizada de la población infantil para evitar epidemias de hepatitis A en la población general (AU)

Hepatic and splanchnic perfusion and oxygenation after transjugular intrahepatic portosystemic shunt.

OBJECTIVE: in patients with cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) decreases the pressure in the portal vein by rerouting nearly all the portal blood flow to the systemic circulation. This may lead to hypoperfusion of the liver and worsening function. Our aim was to investigate whether TIPS actually reduced hepatic and splanchnic perfusion. METHODS: we studied 25 patients who required placement of a TIPS (20 for variceal bleeding and 5 for refractory ascites). We evaluated the clinical condition, laboratory results, blood velocity in the portal vein and hepatic artery by echo-Doppler ultrasonography, systemic hemodynamic-oxygenation status and hemodynamic-oxygenation status in the portal and suprahepatic veins before TIPS, 15 min after the procedure, and 30 days later. Hepatic and splanchnic perfusion were evaluated as the arteriovenous difference in O2 content and as the O2 extraction rates in the hepatic and splanchnic territories. RESULTS: TIPS induced an immediate decrease in portal pressure, a significant increase in systemic hyperdynamic state, and an increase in blood flow velocity in the portal vein and hepatic artery. Thirty days after the procedure these changes persisted, although they were somewhat attenuated. Although splanchnic and liver perfusion were not changed 15 min or 30 days after TIPS, there was a slight tendency toward a decrease in liver perfusion during follow-up. CONCLUSIONS: TIPS increased the hyperdynamic state in the systemic side. However, portal blood shunting did not change liver or splanchnic perfusion.

Perfusión y oxigenación hepáticas y esplácnicas tras la derivación percutánea portosistémica intrahepática / Hepatic and splanchnic perfusion and oxygenation after transjugular intrahepatic portosystemic shunt

OBJETIVO: en pacientes cirróticos, la creación de una derivación percutánea portosistémica intrahepática reconduce el flujo portal hacia la circulación sistémica, lo que puede motivar una hipoperfusión del hígado con deterioro de su función residual. El objetivo del estudio fue valorar si dicha derivación reducía realmente la perfusión hepática y esplácnica. MÉTODOS: se estudiaron 25 pacientes que requirieron una derivación percutánea portosistémica intrahepática por hemorragia, por varices esofágicas en 20 y por ascitis refractaria en cinco. Se evaluó el estado clínico y bioquímico general, la función hepática, la velocidad del flujo en la porta y arteria hepática por eco-Doppler y el estado hemodinámico y oxigenación sistémico, en venas suprahepáticas y en la porta. Las determinaciones hemodinámicas se realizaron en situación basal, a los 15 minutos y a los treinta días tras la derivación. La perfusión hepática y esplácnica se valoraron con los gradientes arterio-venosos de contenido de 02 y con los índices de extracción de02 correspondientes a ambos territorios. Los cambios se contrastaron con el Test de Wilcoxon para medidas apareadas. RESULTADOS: la derivación percutánea portosistémica intrahepática provocó un descenso inmediato de la presión portal, un aumento del estado hiperdinámico sistémico y de las velocidades del flujo portal y arterial hepático. Estos cambios persistían al mes, aunque atenuados. No se apreciaron cambios significativos en la perfusión hepática y esplácnica durante el mes de seguimiento, aunque se observó una ligera tendencia a disminuir. CONCLUSIONES: la derivación percutánea portosistémica intrahepática aumentó el estado hiperdinámico sistémico. Sin embargo, el desvío del flujo portal no cambió la perfusión global hepática y esplácnica (AU)

[Scintigraphy with labelled leukocytes in acute pancreatitis. Preliminary results]. / Gammagrafía con leucocitos marcados en la pancreatitis aguda. Resultados preliminares.

This study aims to evaluate the contribution of the 99mTc-HMPAO labelled leukocyte in the prognostic assessment of patients with acute pancreatitis. We have compared the usual methods of prognostic evaluation (computed tomography CT and the Ranson clinical score scale) with the scintigraphic findings in 23 consecutive patients with a clinical diagnosis of mild or severe acute pancreatitis. All 6 patients with severe pancreatitis showed an uptake which was mostly mild. 9/17 patients with mild pancreatitis showed uptake, which also frequently had a low intensity. When the severity index of CT was compared with the leukocyte results, the only patient with a high severity index showed a grade 3 uptake. However, in over 50% of the patients with a low severity index, uptake, generally having a low intensity, was found. When the uptake degree was compared with the Ranson score level, we observed a predominance of mild uptake in both patients with mild and severe pancreatitis. Considering these results, we believe that the lack of uptake in the leukocyte study in a patient with acute pancreatitis can be interpreted as a good prognosis sign. The significance of the finding of uptake in the pancreatic area is uncertain and studies should be performed in larger sized samples.