The effect of liver transplantation on circulating levels of estradiol and progesterone in male patients: parallelism with hepatopulmonary syndrome and systemic hyperdynamic circulation improvement.

The correction of hepatopulmonary syndrome (HPS) after liver transplantation (LT) remains controversial. The aims of our study were to: 1) analyze whether LT reverses HPS; 2) note any relationship between HPS and the systemic hemodynamic disturbance; and 3) note changes in circulating sex hormones and the possible association with pulmonary and systemic hemodynamic changes. Systemic hemodynamic parameters, cardiac output and systemic vascular resistance (SVR), sex hormones, and intrapulmonary vasodilatation assessed by contrast transesophageal echocardiography, and gas exchange abnormalities were investigated in 19 patients with advanced cirrhosis prior to and 6 months (176.8+/-30 days) after LT. LT was followed by a marked reduction in cardiac output (6.6+/-1.7 vs 3.5+/-0.5 l/min; p<0.001) and SVR (1039+/-460 vs 1978+/-294 dyn x sec x cm(-5); p<0.005). Before LT, circulating estradiol and progesterone levels were invariably elevated (66+/-22 pg/ml and 1.8+/-1.1 ng/ml, respectively, normal values <31 pg/ml and 0.35 ng/ml, respectively), and dropped after LT (28+/-12 pg/ml p<0.001 and 0.38+/-0.2 ng/ml; p<0.001, respectively). Seventeen of 19 patients had intrapulmonary vasodilatation and increased alveolar-arterial oxygen difference, thereby fulfilling diagnostic criteria for HPS. Patients with HPS presented higher cardiac output (p<0.05), lower SVR (p<0.01), and higher progesterone and estradiol levels than patients without HPS (p<0.05). LT produced normalization of intrapulmonary vasodilatation in all patients. LT normalized hyperdynamic circulation and is a useful therapeutic option in patients with HPS. Normalization of sex hormone levels after LT suggests that they could play a pathogenic role in the development of HPS.

Association of Helicobacter pylori infection with cardiovascular and cerebrovascular disease in diabetic patients.

OBJECTIVE: Infection by Helicobacter pylori has been epidemiologically linked to some extradigestive conditions, including ischemic heart disease. Diabetic patients are an at-risk population for cardiovascular and thrombo-occlusive cerebral disease. The aim of the study was to examine a possible relationship between H. pylori infection and cardiovascular or cerebrovascular disease in diabetic patients. RESEARCH DESIGN AND METHODS: This was a cross-sectional case-control study with 127 diabetic patients (both IDDM and NIDDM). Special emphasis was placed on the detection of clinical macro- and microvascular complications, cardiovascular risk factors, acute phase reactants, and serological markers of increased cardiovascular disease risk. H. pylori infection was assessed through the determination of specific Ig-G titers, measured by a commercial enzyme-linked immunosorbent assay. RESULTS: Coronary heart disease was more prevalent in diabetic patients with than without H. pylori (odds ratio [OR] 4.07; 95% CI 1.21-13.6; P < 0.05). A history of thrombo-occlusive cerebral disease was also more frequent in H. pylori-positive diabetic patients (OR 4.8; 95% CI 1.24-18.51; P < 0.05). Other complications such as peripheral arteriopathy, advanced nephropathy, neuropathy, or retinopathy were no differently distributed according to serological status. Alterations in the levels of the following acute-phase reactants and blood chemistry determinations were significantly more profound in H. pylori-positive diabetic patients: high fibrinogen (P < 0.05), high erythrocyte sedimentation rate (P < 0.001), high triglycerides (P < 0.001), and low HDL cholesterol (P < 0.001). There values were also more deeply altered in H. pylori-positive diabetic patients with a history of coronary heart disease, thrombo-occlusive cerebral disease, or both, when compared with H. pylori-positive diabetic patients without those complications. CONCLUSIONS: Our data indicate a possible association of H. pylori infection and the development of coronary heart disease, thrombo-occlusive cerebral disease, or both, in diabetic patients. The importance of this link is highlighted by the possibility of an effective intervention against H. pylori infection.

Helicobacter pylori infection is markedly increased in patients with autoimmune atrophic thyroiditis.

Infection by viral or bacterial pathogens has been suspected in playing a role in the development of autoimmune thyroid disease. Because Helicobacter pylori might be involved in the development of nongastrointestinal conditions such as rosacea, ischemic heart disease, and diabetes mellitus, we evaluated the prevalence of H. pylori infection in patients with autoimmune thyroid disease. Fifty-nine patients with autoimmune thyroid disease were included: autoimmune atrophic thyroiditis (n=21), Hashimoto's thyroiditis (n=18), and Graves' disease (n=20). Twenty patients with nontoxic multinodular goiter served as controls for nonautoimmune thyroid disease, and 11 patients with Addison's disease served as controls for nonthyroid endocrine autoimmune disease. The levels of anti-H. pylori immunoglobulin G (IgG) were determined, and a radiolabeled urea breath test were performed. The prevalence of H. pylori infection was markedly increased in the patients with autoimmune atrophic thyroiditis (85.7%), compared with the controls with nontoxic multinodular goiter (40%) and Addison's disease (45.4%). Infection by H. pylori resulted in increased levels of gastrin, pepsinogen I, and pepsinogen II in the H. pylori-positive groups, compared with the H. pylori-negative groups. A positive linear regression was found between the levels of microsomal autoantibodies and those of anti-H. pylori IgG in patients with autoimmune atrophic thyroiditis (n=21; r=0.79; p < 0.01). Finally, and although the overall prevalence of H. pylori infection was not increased, the anti-H. pylori IgG levels and the results from the breath test were higher in the patients with Graves' disease and Hashimoto's thyroiditis patients than in the controls. Clearly, the prevalence of H. pylori infection is increased in autoimmune atrophic thyroiditis and results in abnormalities of gastric secretory function. The strong relation between the levels of anti-H. pylori IgG and the levels of microsomal antibodies suggests that H. pylori antigens might be involved in the development of autoimmune atrophic thyroiditis or that autoimmune function in autoimmune atrophic thyroiditis may increase the likelihood of H. pylori infection.

Fulminant acute Budd-Chiari syndrome stemming from an adrenal tumor.

Adrenal neoplasm is a rare cause of Budd-Chiari syndrome. We report a case of fulminant acute Budd-Chiari syndrome due to inferior vena cava thrombosis stemming from invasion by a clinically nonfunctioning adrenal neoplasm. We also review briefly the clinical characteristics of the seven previously reported cases.

[Prevalence of Helicobacter pylori infection in gastrectomy and vagotomy]. / Prevalencia de la infección por Helicobacter pylori en la gastrectomía y en la vagotomía.

OBJECTIVE: To report the prevalence of Helicobacter pylori infection in patients undergoing gastrectomy or vagotomy plus pyloroplasty because of peptic ulcer disease. METHODS: Eighty-five patients were studied (mean age = 61 years; 85% males) who had undergone gastric surgery: Billroth I gastrectomy (n = 25), Billroth II (n = 51) and vagotomy plus pyloroplasty (n = 9). During endoscopy biopsy specimens were obtained from fundus and both sides of anastomosis for histological (hematoxylin-eosin) and microbiological (Gram stain and culture) investigations. RESULTS: The overall percentage of Helicobacter pylori infection was 43.6% (Billroth I = 40%; Billroth II = 37%; vagotomy = 89%) and no differences were observed between both types of surgical reconstruction. However, differences were indeed observed (p < 0.01) when comparing percentages of infection between patients undergoing gastrectomy and vagotomy. Among infected gastrectomized patients H. pylori was detected in fundus in 93% of cases, whereas the recovery rate from anastomotic mouth biopsies was only 72% (p < 0.05). CONCLUSIONS: The prevalence of H. pylori infection in gastrectomized patients (Billroth I and II) was low regarding the cause of surgery (peptic ulcer disease), and no differences were observed between both types of surgical reconstruction. The prevalence of infection after vagotomy and pyloroplasty was significantly higher. Among infected gastrectomized patients, H. pylori was detected more frequently in gastric fundus compared with biopsy specimens obtained from the anastomotic mouth.

Bronchobiliary fistula secondary to biliary lithiasis. Treatment by endoscopic sphincterotomy.

Bronchobiliary fistula is a rare condition, defined by the presence of a passage between the biliary tract and the bronchial tree. Many conditions can give rise to the development of such a communication. Biliary lithiasis is one of those and is perhaps the one most amenable to endoscopic management. We describe a case of bronchobiliary fistula secondary to the development of choledocholithiasis in a cholecystectomized patient. The clinical suspicion was raised by the presence of bilioptosis (bile-stained sputum), and the diagnosis established by endoscopic retrograde cholangiopancreatography. The patient was submitted to endoscopic sphincterotomy and stone extraction, achieving frank clinical alleviation. This case gives us the chance to review bronchobiliary fistulas secondary to biliary lithiasis, placing particular emphasis on the opportunities of endoscopic management.

[Choledocholithiasis following cholecystectomy: what is the real effectiveness of endoscopic sphincterotomy?]. / Coledocolitiasis postcolecistectomía: cuál es la eficacia real de la esfinterotomía endoscópica?

AIM: To assess real efficacy of endoscopic sphincterotomy in the setting of postcholecistectomy choledocolitiasis (i.e., without excluding for analysis any patient referred for the procedures) traditionally the evaluation has been done after excluding those cases in which the procedure failed or was not attempted. DESIGN: Retrospective analysis of a series of cholecystectomized patients with choledocolithiasis. Patients were included for analysis on an "intention to treat" basis, without excluding cases in which the procedure either was not attempted or failed. RESULTS: Out of 122 patients (47.1%) with a firm diagnosis of choledocholithiasis, endoscopic sphincterotomy was performed in 108 (88.5%); in the remaining 13 (10.7%), it was not attempted due to various reasons (among other, five cases of unsuccessful diagnostic cholangiography). In one patient, with a previous surgical sphincteroplasty, calculi were directly extracted. On the whole, stone extraction/expulsion was achieved in 92 cases (including the one patient with previous surgical sphincteroplasty), what represents a success rate of 75.4% on 122 cholecistectomized patients with known choledocolitiasis. Morbidity and mortality reached 9% and 1%, respectively. CONCLUSIONS: If each referred patient is included for analysis of the results of endoscopic sphincterotomy for postcholecistectomy choledocolithiasis (independently of technical success), the therapeutic yield of this procedure lowers significantly compared with the usual estimations.

[Carney's triad: a short review apropos a case]. / Tríada de Carney: breve revisión a propósito de un caso.

We communicate a case with the Carney triad (gastric leiomyosarcoma, pulmonary chondromatosis and extra-adrenal paraganglioma). It is, to our knowledge, the first case to be communicated in the Spanish scientific literature. We discuss some peculiar aspects of the debut and clinical evolution of this syndrome, together with its prognosis. We conclude that in clinical practice, the appearance in a young subject, specifically females, of multiple gastric myogenic tumors, should elicit the performance of further noninvasive procedures, needed to discard the diagnosis of the Carney triad.

[Long-term results of endoscopic sphincterotomy in the treatment of residual/recurrent choledocholithiasis]. / Resultados a largo plazo de la esfinterotomía endoscópica en el tratamiento de la coledocolitiasis residual/recidivante.

Endoscopic sphincterotomy is widely accepted as the technique of choice in the treatment of residual or recidivant choledocholithiasis since the results obtained with this technique are favorable when compared to biliary surgery in most series. However, the experience of long term follow up of patients with choledocholithiasis in whom this technique would have been applied as the only treatment is still scarce up to date. We have studied 40 patients (mean age 65.6 +/- 11.1 years) with residual or recidivant choledocholithiasis who had undergone endoscopic treatment successfully before the 30th of June 1985, who could be contacted by a mailed questionnaire or by phone by August 1990. The follow up time 70.7 +/- 19.4 months (mean +/- typical deviation). Out of them, 36 (90%) had been asymptomatic up to the contact date (30 cases) or up to death due to causes not related to biliary pathology (6 patients). Out of the 4 remaining patients, 2 presented mild dyspepsia and another patient has probably developed recidivant choledocholithiasis (according to I.V. cholangiography). The fourth patient presented a severe episode of cholangitis and acute pancreatitis, related to a new episode of choledocholithiasis and died 5 and a half years after the endoscopic sphincterectomy. This represents a 2.5% mortality. These long term results of endoscopic sphincterotomy in patients with residual or recidivant choledocholithiasis are an other point in favour of using this technique as the single treatment of choice in patients above 60 years old.

[Treatment of residual choledochal calculi in patients with Kehr's T drainage: role and results of endoscopic sphincterotomy]. / Tratamiento de los cálculos coledocianos residuales en pacientes portadores de drenaje en T de Kehr: papel y resultados de la esfinterotomía endoscópica.

The results of sphincterotomy in the treatment of residual gallstones after cholecystectomy in a series of 62 patients, bearers of a T tube are reported. The mean time after surgery was 26.4 +/- 19.2 days. The procedure was technically successful in 59/62 (95.1%). Stones were passed spontaneously or were retrieved in 55/62 patients (88.7%). In four patients gallstones persisted in spite of sphincterotomy. All were operated with favorable results. Complications were observed in 4 patients (6.4%), without mortality. Sphincterotomy is a safe and relatively efficient technique in the treatment of cholecystectomized patients with residual gallstones and a T tube drainage.

[Endoscopic choledochoduodenostomy in the treatment of impacted calculi in Vater's papilla]. / La coledocoduodenostomía endoscópica en el tratamiento de los cálculos impactados en la papila de Vater.

In a series of 204 patients with common duct stones, sphincterotomy was not possible in 10, due to an impacted stone in the papilla. An endoscopic choledocho-duodenostomy was performed which was effective in all cases. One patient suffered a retroperitoneal perforation which was managed medically. This technique is an effective alternative to sphincterotomy in the treatment of impacted papillary stones. Retroperitoneal perforation is a major risk to be taken into account.