Exocrine pancreatic insufficiency and chronic pancreatitis in chronic alcoholic liver disease: coincidence or shared toxicity?

OBJECTIVES: The aims of this study were to determine the prevalence of exocrine pancreatic insufficiency (EPI) and chronic pancreatitis (CP) in patients with chronic alcoholic liver disease and to analyze the possible associated factors. METHODS: This is an analytical observational study of cases and controls for a sample of patients with chronic alcoholic and nonalcoholic liver disease. Exocrine pancreatic insufficiency was diagnosed using the C mixed-triglyceride breath test. Patients with abdominal pain underwent endoscopic ultrasonography for CP evaluation using the Wiersema criteria. RESULTS: A total of 154 patients were included, 129 with alcoholic liver disease (83 with cirrhosis) and 25 with nonalcoholic liver disease. Exocrine pancreatic insufficiency was found in 55.2% versus 16.7% (P < 0.001), 70% of patients without cirrhosis compared with 46.2% of patients with cirrhosis had pancreatic insufficiency (P = 0.017), and 82.7% of patients with alcoholic liver disease and abdominal pain had CP (P < 0.001). Exocrine pancreatic insufficiency was associated with the male sex, alcohol intake, abdominal pain, degree of liver failure, and the absence of portal hypertension. Chronic pancreatitis was correlated with age younger than 55 years and abdominal pain. CONCLUSIONS: Patients with alcoholic liver disease had a high prevalence of EPI and CP; this prevalence was even higher in patients who have not yet developed cirrhosis with liver failure or portal hypertension.

Predominio del gen de la hemocromatosis en pacientes con hepatitis tóxicas / HFE genotype prevalence in patients with drug-induced hepatotoxicity

La toxicidad hepática por fármacos y su mecanismo han sido durante mucho tiempo desconocidos. Se ha observado que los pacientes con hepatitis aguda elevan los niveles séricos de ferritina. El objetivo de este estudio es determinar si existe una asociación de hepatotoxicidad por medicamentos y las mutaciones en el gen HFE asociadas con la hemocromatosis hereditaria. Material y métodos: Se analizaron10 pacientes ingresados en nuestro hospital con el diagnóstico de hepatitis aguda inducida por fármacos. A todos se les hicieron pruebas de laboratorio para el estudio de enfermedades hepáticas, la mutación del gen HFE y las características histopatológicas. Resultados: Un paciente con hepatitis secundaria a fármacos era heterocigoto para la mutación C282Y y uno heterocigoto para las mutaciones C282Y y H63D. Hubo un paciente homocigoto para la mutación H63D y seis fueron heterocigotos para la mutación H63D. La prevalencia general de las mutaciones del gen HFE en pacientes con enfermedad hepática inducida por fármacos fue del 90%. Conclusiones: La prevalencia de las mutaciones del gen HFE asociadas con hemocromatosis hereditaria está muy aumentada entre los pacientes que presentan hepatotoxicidad por medicamentos. Las mutaciones del gen HFE podrían estar involucradas en la hepatotoxicidad por fármacos...

Microalbuminuria e insuficiencia renal en la infección crónica por el virus de la hepatitis C / Microalbuminuria and renal insufficiency in chronic hepatitis C virus infection

Introducción La infección crónica por el virus de la hepatitis C (VHC) se ha asociado a enfermedad glomerular, que se manifiesta mediante proteinuria con o sin disfunción renal. Método Estudio observacional analítico transversal con 120 pacientes infectados por el VHC y 145 controles VHC-negativos para determinar la prevalencia de daño renal asociada al VHC y su relación con factores de riesgo. Se recogieron datos de la historia clínica y anamnesis y se realizaron al menos 3 análisis de sangre y orina en un año. La insuficiencia renal se definió por un filtrado glomerular estimado inferior a 60ml/min/1,73 m2 y/o una microalbuminuria superior a 20mg/l o un índice microalbuminuria/creatinina mayor de 30 μg/mg. Resultados La prevalencia de microalbuminuria e insuficiencia renal se estimó en el 19,3 y 11,7% en los VHC-positivos vs el 10,5 y 0,7% en los VHC-negativos (p = 0,04), respectivamente. El 26,1% de los pacientes VHC-positivos tenía algún signos de daño renal vs el 11,8% de los VHC-negativos (p = 0,003). La infección por el VHC se asoció de forma independiente y significativa con la probabilidad de deterioro de la función renal. La prevalencia de microalbuminuria e insuficiencia renal se incrementó progresivamente con el aumento de edad. Conclusión Los pacientes VHC-positivos presentan una alta prevalencia de microalbuminuria e insuficiencia renal en comparación con sujetos VHC-negativos. El riesgo de insuficiencia renal asociado al VHC es independiente en presencia de otros factores predisponentes como hipertensión arterial y diabetes (AU)

Introduction Chronic hepatitis C virus (HCV) infection is associated with glomerular disease, which is manifested by proteinuria with or without renal dysfunction. Method To determine the prevalence of HCV-associated renal injury and associated risk factors, we performed an observational, analytic, cross-sectional study of 120 HCV-positive patients and 145 HCV-negative controls. Data were gathered from medical records and history-taking and at least three blood and urine analyses were performed over a 1-year period. Renal insufficiency was defined as an estimated glomerular filtration rate of less than 60ml/min/1.73 m2 and/or microalbuminuria of more than 20mg/l or a microalbumin/creatinine ratio higher than 30 mcg/mg. Results The prevalence of microalbuminuria and renal insufficiency was 19.3% and 11.7% in HCV-positive patients versus 10.5% and 0.7% in HCV-negative controls (p 0.04), respectively. A total of 26.1% of HCV-positive patients had signs of renal injury compared with 11.8% of HCV-negative controls (p 0.003). HCV infection was independently and significantly associated with the probability of worsening of renal function. The prevalence of microalbuminuria and renal insufficiency progressively increased with greater age. Conclusion HCV-positive patients show a high prevalence of microalbuminuria and renal insufficiency compared with HCV-negative individuals. The risk of HCV-associated renal insufficiency is independent of the presence of other predisposing factors such hypertension and diabetes (AU)

[Microalbuminuria and renal insufficiency in chronic hepatitis C virus infection]. / Microalbuminuria e insuficiencia renal en la infección crónica por el virus de la hepatitis C.

INTRODUCTION: Chronic hepatitis C virus (HCV) infection is associated with glomerular disease, which is manifested by proteinuria with or without renal dysfunction. METHOD: To determine the prevalence of HCV-associated renal injury and associated risk factors, we performed an observational, analytic, cross-sectional study of 120 HCV-positive patients and 145 HCV-negative controls. Data were gathered from medical records and history-taking and at least three blood and urine analyses were performed over a 1-year period. Renal insufficiency was defined as an estimated glomerular filtration rate of less than 60ml/min/1.73 m2 and/or microalbuminuria of more than 20mg/l or a microalbumin/creatinine ratio higher than 30 mcg/mg. RESULTS: The prevalence of microalbuminuria and renal insufficiency was 19.3% and 11.7% in HCV-positive patients versus 10.5% and 0.7% in HCV-negative controls (p 0.04), respectively. A total of 26.1% of HCV-positive patients had signs of renal injury compared with 11.8% of HCV-negative controls (p 0.003). HCV infection was independently and significantly associated with the probability of worsening of renal function. The prevalence of microalbuminuria and renal insufficiency progressively increased with greater age. CONCLUSION: HCV-positive patients show a high prevalence of microalbuminuria and renal insufficiency compared with HCV-negative individuals. The risk of HCV-associated renal insufficiency is independent of the presence of other predisposing factors such hypertension and diabetes.

Desaparición de cirrosis hepática por VHB tras tratamiento prolongado con antivirales / Reversibility of hepatitis B virus-induced liver cirrhosis after prolonged antiviral therapy

ResumenLa reversibilidad de la fibrosis o cirrosis hepática implica la restauración completa de la arquitectura normal del hígado. Este hecho ha sido bien documentado en algunas enfermedades crónicas hepáticas como hepatitis autoinmune, obstrucción biliar, hemocromatosis, esteatohepatitis no alcohólica y en hepatitis virales. En la literatura se han descrito muy pocos casos de reversión de cirrosis tras tratamiento antiviral en pacientes con infección crónica por VHB.ResumenDescribimos un caso de desaparición de cirrosis hepática por VHB tras años de tratamiento con distintos antivirales, y que se ha podido documentar mediante sucesivas biopsias hepáticas. Además se ha acompañado de normalización de cifra de plaquetas, gammglobulina y las imágenes radiológicas (AU)

AbstractReversibility of liver fibrosis or cirrhosis involves complete restoration of normal liver architecture. This phenomenon has been well documented in chronic liver diseases such as autoimmune hepatitis, biliary obstruction, hemochromatosis, nonalcoholic steatohepatitis, and viral hepatitis. There are very few reports of reversal of cirrhosis after antiviral therapy in patients with chronic hepatitis B virus (HBV) infection.AbstractWe report a case of disappearance of HBV-induced liver cirrhosis after years of treatment with distinct antiviral drugs, documented by successive biopsy results. This disappearance was accompanied by normalization of platelet count, gammaglobulin titers, and radiologic findings (AU)

[Reversibility of hepatitis B virus-induced liver cirrhosis after prolonged antiviral therapy]. / Desaparición de cirrosis hepática por VHB tras tratamiento prolongado con antivirales.

Reversibility of liver fibrosis or cirrhosis involves complete restoration of normal liver architecture. This phenomenon has been well documented in chronic liver diseases such as autoimmune hepatitis, biliary obstruction, hemochromatosis, nonalcoholic steatohepatitis, and viral hepatitis. There are very few reports of reversal of cirrhosis after antiviral therapy in patients with chronic hepatitis B virus (HBV) infection. We report a case of disappearance of HBV-induced liver cirrhosis after years of treatment with distinct antiviral drugs, documented by successive biopsy results. This disappearance was accompanied by normalization of platelet count, gammaglobulin titers, and radiologic findings.

Nuevas técnicas para extraer prótesis biliares metálicas recubiertas impactadas / New techniques to extract impacted partially covered metallic biliary stents

Uno de los problemas que aparecen en las prótesis metálicas de vía biliar es su dificultad para retirarlas, sobre todo si han pasado meses o han migrado. Para eso se han usado varios métodos a fin de poder extraer las prótesis biliares metálicas, tanto las recubiertas como las no recubiertas, con diferente eficacia.Se describen 2 nuevas formas para poder extraer prótesis parcialmente recubiertas que presentan migración proximal y se han impactado en el área papilar y el colédoco distal. Una prótesis se extrajo mediante papilectomía y la otra con balón de dilatación con colangiografía retrógrada endoscópica; para esto, se usó un duodenoscopio. En ambos casos se pudieron retirar las prótesis sin complicaciones graves para los enfermos y con un buen resultado para el calibre final de la estenosis(AU)

One of the problems affecting metallic biliary stents is the difficulty of removing them, especially after a period of months or if they have migrated. Several approaches have been used to remove both covered and uncovered stents, although with different degrees of effectiveness.We report two new approaches to removing partially covered stents that migrated proximally and that impacted in the papillary area and distal common bile duct. One stent was removed by papillectomy and the other by using duodenoscopy-guided controlled radial expansion balloon dilation. In both cases, the stents were removed without severe complications for the patient, leaving a good caliber in the stenosis(AU)

[New techniques to extract impacted partially covered metallic biliary stents]. / Nuevas técnicas para extraer prótesis biliares metálicas recubiertas impactadas.

One of the problems affecting metallic biliary stents is the difficulty of removing them, especially after a period of months or if they have migrated. Several approaches have been used to remove both covered and uncovered stents, although with different degrees of effectiveness. We report two new approaches to removing partially covered stents that migrated proximally and that impacted in the papillary area and distal common bile duct. One stent was removed by papillectomy and the other by using duodenoscopy-guided controlled radial expansion balloon dilation. In both cases, the stents were removed without severe complications for the patient, leaving a good caliber in the stenosis.

[Effect of Helicobacter pylori eradication on iron deficiency anemia of unknown origin]. / Efecto de la erradicación de Helicobacter pylori en la anemia ferropénica de origen incierto.

UNLABELLED: Iron deficiency anemia of unknown origin is a frequent cause of anemia in which etiological diagnosis is often not achieved, despite currently available diagnostic techniques. Recent studies suggest that, in the absence of digestive tract lesions, Helicobacter pylori infection could be the cause of iron deficiency anemia, due to the alterations produced in gastric iron absorption. OBJECTIVES: To evaluate whether H. pylori eradication resolves iron deficiency anemia and removes the need for oral iron administration. PATIENTS AND METHODS: We performed an observational descriptive study in patients with iron deficiency anemia refractory to treatment with oral iron administration and with out causes that could explain their anemia. Gastroscopy, ileocolonoscopy, intestinal transit study and/or endoscopic capsule were performed. Female patients also underwent gynecological study. All patients were H. pylori-positive and standard eradication therapy was administered until elimination was achieved. The patients were followed-up for a minimum of 3 months after H. pylori eradication and the need for oral iron intake after eradication was evaluated. RESULTS: Ten patients, aged 53+/-8.2 years, were included. Hemoglobin (Hbg) before treatment was 10.06+/-0.53 mg/dl, mean corpuscular volume (MCV) was 75.43+/-6.02 fl and ferritin was 6.1+/-3.28 ng/ml. Eradication therapy was administered until elimination of H. pylori. The mean time before disappearance of anemia was 4.5 months. Laboratory parameters after treatment were as follows: Hgb 12.86+/-0.75 mg/dl, MCV 85.02+/-4.8 fl and ferritin 28+/-22.19 ng/dl. CONCLUSIONS: In the absence of lesions that could explain iron deficiency anemia, this disease can be related to H. pylori infection. Eradication of this infection is closely followed by disappearance of anemia and ferropenia.

Efecto de la erradicación de Helicobacter pylori en la anemia ferropénica de origen incierto / Effect of Helicobacter pylori eradication on iron deficiency anemia of unknown origin

La anemia ferropénica (AF) de origen incierto es una causa frecuente de ferropenia. A pesar de las técnicas disponibles en la actualidad, no se llega a establecer su diagnóstico etiológico. Recientes estudios sugieren que la infección por Helicobacter pylori podría ser causa de AF en ausencia de lesiones del tracto digestivo, debido a la alteración que se produce en la absorción gástrica de hierro. Objetivos: Evaluar si la eliminación de H. pylori consigue la desaparición de la AF y suprime la necesidad del consumo de hierro oral. Pacientes y métodos: Estudio observacional descriptivo, en el que se han incluido pacientes con AF refractaria al tratamiento con hierro oral y sin causas que la justifiquen. Se realizó una gastroscopia, una ileocolonoscopia, un tránsito intestinal y/o una cápsula endoscópica, así como un estudio ginecológico a las mujeres. Todos los pacientes presentaban H. pylori positivo, por lo que se realizó un tratamiento erradicador estándar hasta su eliminación. Se hizo un seguimiento mínimo de 3 meses tras la eliminación de H. pylori y se valoraron las necesidades de hierro oral tras la erradicación. Resultados: Se incluyó a 10 pacientes con una media ± desviación estándar de edad de 53 ± 8,2 años. La hemoglobina (Hb) antes del tratamiento era de 10,06 ± 0,53 mg/dl, el volumen corpuscular medio (VCM) de 75,43 ± 6,02 fl y la ferritina de 6,1 ± 3,28 ng/ml. Se llevó a cabo un tratamiento erradicador hasta la desaparición de H. pylori. El tiempo medio hasta la desaparición de la anemia fue de 4,5 meses. Los parámetros analíticos tras el tratamiento fueron: Hb 12,86 ± 0,75 mg/dl, VCM 85,02 ± 4,8 fl y ferritina 28 ± 22,19 ng/dl. Conclusiones: La AF de origen incierto, en ausencia de lesiones que la justifiquen, puede relacionarse con la infección por H. pylori. La eliminación de esta infección se sigue a corto plazo con la desaparición de la anemia y de la ferropenia

Iron deficiency anemia of unknown origin is a frequent cause of anemia in which etiological diagnosis is often not achieved, despite currently available diagnostic techniques. Recent studies suggest that, in the absence of digestive tract lesions, Helicobacter pylori infection could be the cause of iron deficiency anemia, due to the alterations produced in gastric iron absorption. Objectives: To evaluate whether H. pylori eradication resolves iron deficiency anemia and removes the need for oral iron administration. Patients and methods: We performed an observational descriptive study in patients with iron deficiency anemia refractory to treatment with oral iron administration and with out causes that could explain their anemia. Gastroscopy, ileocolonoscopy, intestinal transit study and/or endoscopic capsule were performed. Female patients also underwent gynecological study. All patients were H. pylori-positive and standard eradication therapy was administered until elimination was achieved. The patients were followed-up for a minimum of 3 months after H. pylori eradication and the need for oral iron intake after eradication was evaluated. Results: Ten patients, aged 53 ± 8.2 years, were included. Hemoglobin (Hbg) before treatment was 10.06 ± 0.53 mg/dl, mean corpuscular volume (MCV) was 75.43 ± 6.02 fl and ferritin was 6.1 ± 3.28 ng/ml. Eradication therapy was administered until elimination of H. pylori. The mean time before disappearance of anemia was 4.5 months. Laboratory parameters after treatment were as follows: Hgb 12.86 ± 0.75 mg/dl, MCV 85.02 ± 4.8 fl and ferritin 28 ± 22.19 ng/dl. Conclusions: In the absence of lesions that could explain iron deficiency anemia, this disease can be related to H. pylori infection. Eradication of this infection is closely followed by disappearance of anemia and ferropenia (AU)

Efficacy of rifabutin-based triple therapy in Helicobacter pylori infected patients after two standard treatments.

BACKGROUND AND AIM: Even with the current most effective treatment regimens for Helicobacter pylori infection, a considerable number of patients will be resistant to eradication. The aim of the present study was to evaluate the H. pylori eradication rate in patients resistant to standard therapies when treated with a triple therapy of pantoprazole, rifabutin and amoxicillin. METHODS: Ninety-two consecutive patients diagnosed with H. pylori infection resistant to two previous treatment regimens were treated with pantoprazole, rifabutin and amoxicillin for 10 days. The persistence or eradication of H. pylori was determined by a 13C-urea breath test performed 4 weeks after the treatment. RESULTS: Per protocol eradication was achieved in 62.2% of patients and the intention-to-treat eradication was 60.8%. Only two patients were excluded for adverse events related to the treatment. CONCLUSIONS: The eradication rate is acceptable as a third-line therapy, particularly in centers with high cure rate for first line therapy. Another important value of this study is the good tolerance for the treatment observed in our patients. It is possible that rifabutin-based triple therapy may be of use in hospital centers that do not have disposable culture and susceptibility methods against H. pylori.

[Efficacy of Helicobacter pylori eradication in non-ulcer dyspepsia]. / Eficacia de la erradicación de Helicobacter pylori en la dispepsia no ulcerosa.

BACKGROUND AND OBJECTIVE: The relationship between Helicobacter pylori infection and functional dyspepsia (FD) is disputed. Although there is a greater prevalence of infection by H. pylori in subjects with non-ulcer dyspepsia than in healthy subjects, results regarding the eradication of infection have been inconclusive so far in terms of disease improvement. In this study, we administered eradicating treatment to a group of patients with both FD and infection by H. pylori to determine the possible beneficial effect of such a treatment. Thus, our objective was to study the effectiveness of eradication therapy for H. pylori in the clinical course of FD. PATIENTS AND METHOD: This was a randomized, double-blind study in 93 consecutive patients diagnosed with FD and infection by H. pylori who received eradicating treatment with omeprazol, amoxicillin and clarythromicin for 7 days (group A, n = 47) vs. placebo, amoxicillin and clarythromicin for 7 days (group B, n = 46). We analyzed the clinical evolution of the disease within the following 9 months. RESULTS: Both groups of treatment were comparable concerning all the variables studied except for the consumption of alcohol, with a greater prevalence in group A, yet no patient consumed more than 40 g per day. The average age of patients was 42 (18-65). Eradication of H. pylori occurred in 65.9% of patients in group A and 4.3% of patients in group B. 40% of all patients included in the study had improved symptoms. In 60.6% of patients whose infection was eradicated, their symptoms improved, as opposed to 25% of patients whose infection was not eradicated (p = 0.001). Among patients whose symptoms improved following eradication, 70% had had an FD duration of less than 3 years and in 30% FD had lasted for more than 3 years (p < 0.05). CONCLUSIONS: The eradication of H. pylori in patients with short-lasting FD may lead to a significant clinical benefit, especially in those whose duration of symptoms is below 3 years.

Eficacia de la erradicación de Helicobacter pylori en la dispepsia no ulcerosa / Efficacy of Helicobacter pylori eradication in nonulcer dyspepsia

FUNDAMENTO Y OBJETIVO: La relación de la infección por Helicobacter pylori y la dispepsia funcional (DF) constituye un tema controvertido. Si bien existe mayor prevalencia de infección por H. pylori en sujetos con DF que en sujetos sanos, los resultados de la erradicación de la infección no parecen concluyentes, en términos de mejoría de la enfermedad, en los diversos estudios publicados. En el presente trabajo se realiza tratamiento erradicador a un grupo de pacientes con DF e infección por H. pylori para determinar el posible efecto beneficioso de la erradicación. PACIENTES Y MÉTODO: Se realizó un estudio aleatorizado y doble ciego en 93 pacientes consecutivos diagnosticados de DF e infección por H. pylori que recibieron tratamiento erradicador con omeprazol, amoxicilina y claritromicina durante 7 días (grupo A, n = 47), frente a tratamiento con placebo de omeprazol, amoxicilina y claritromicina durante 7 días (grupo B, n = 46); durante los 9 meses posteriores se analizó la evolución clínica de la enfermedad. RESULTADOS: Los dos grupos de tratamiento fueron homogéneos en todas la variables estudiadas excepto en el uso de alcohol con una mayor prevalencia en el grupo A, aunque ningún paciente consumía más de 40 g/día. La edad media de los pacientes incluidos fue de 42 años (18,65 años). La erradicación de H. pylori se produjo en el 65,9 por ciento de pacientes del grupo A y en el 4,3 por ciento de pacientes del Grupo B. El 40 por ciento de todos los pacientes incluidos en el estudio mejoraron sus síntomas. En el grupo A, el 53,2 por ciento de los pacientes mejoraron sus síntomas al final del estudio mientras que sólo lo hizo el 32,6 por ciento de los del grupo B. El 60,6 por ciento de los pacientes con erradicación de la infección mejoraron la sintomatología frente al 25 por ciento de los pacientes en que la erradicación no se produjo (p = 0,001). De los pacientes que mejoraron los síntomas tras la erradicación se observó que el 70 por ciento tenía una duración de la DF inferior a 3 años y el 30 por ciento superior (p < 0,05), fenómeno no observado en los pacientes que mejoraban sus síntomas y no presentaban erradicación de la infección. CONCLUSIONES: En nuestra serie, la erradicación de H. pylori en pacientes con DF mejora el curso evolutivo de la enfermedad, especialmente el grupo de pacientes con una duración de los síntomas inferior a los 3 años (AU)