Experiencia inicial en ecoendoscopía en el Hospital Edgardo Rebagliati, EsSalud, Lima, Perú / Initial Experience in endoscopic ultrasonography in Edgardo Rebagliati Hospital, Essalud, Lima, Peru

La experiencia local que se tiene con la ultrasonografía endoscópica (USE) es aún pequeña debido a la poca cantidad de centros que cuentan con el equipamiento y a la escasez de centros de entrenamiento así como una larga curva de aprendizaje. Objetivo: Reportar la experiencia en ecoendoscopías en el hospital que laboramos. Materiales y Métodos: Se realiza un estudio retrospectivo de las ecoendoscopÍas (USE) realizadas en el Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú, desde enero a diciembre del 2012, recogiendo datos de filiación, diagnóstico endosonográfico, biopsia aspiración con aguja fina y citología. Los resultados se reportaron con estadística descriptiva. Resultados: Se realizaron 205 ecoendoscopías, de las cuales 116 (56,6%) fueron mujeres y 89 (43,4%) hombres. La edad media fue 60,8 +/- 15,6 años (rango: 17-84) 51,3% correspondieron a pacientes mayores de 60 años. De los exámenes realizados, 157 (76,6%) fueron en el tracto digestivo superior y 48 (23,4%) en la región ano-rectal. Los diagnósticos más frecuentes en las USE en el tracto digestivo superior fueron: lesiones sub-epiteliales (23,6%), normal (23,6%), neoplasias malignas (14,0%) siendo la del páncreas la más frecuente (7,6% del total), litiasis de la vía biliar-pancreática (12,7%) y lesiones quísticas del páncreas (12,1%). En cuanto a las USE de la región ano rectal, el diagnóstico más frecuente fue la neoplasia maligna (NM) de recto (47,9%). Se realizaron un total de 20 (9,8%) biopsias aspiración con aguja fina (BAAF). No se reportó complicación alguna...

Report our experience with endoscopic ultrasonography. Material and Methods: In this report we analyze retrospectivement the data of 205 EUS studies done from January to December 2012 at the Hospital. Lima, Peru. Age, sex, endoscopic diagnosis and the results of fine needle aspiration (FNA) are analyzed. Results: In this study 205 patients underwent to EUS. There were 116 patients (56.6%) females and 89 (43.4%) males. Mean age was 60.8 +/- 15.6 years (range: 17 û 84), 51.3% were over 60. 157patients (76.6%) had upper GI EUS tract and 48 (23.4%) of the lower. In upper GI EUS the most frequent diagnosis was: Sub epithelial lesions (22.7%), malignant neoplasm (13.5%) and pancreatic cancer the most frequent one (6.7%). Stones in the biliary and pancreatic duct (12.2%) and pancreatic cystic disease (9.8%) were found. Rectal cancer was the most frequent diagnosis in the ano-rectal EUS (47.9%). 20 fine needle aspiration biopsies were performed. No complications were reported...

[Initial experience in endoscopic ultrasonography in Edgardo Rebagliati Hospital, Essalud, Lima, Peru]. / Experiencia inicial en ecoendoscopía en el Hospital Edgardo Rebagliati, EsSalud, Lima, Perú

OBJECTIVE: Report our experience with endoscopic ultrasonography. MATERIAL AND METHODS: In this report we analyze retrospectivement the data of 205 EUS studies done from January to December 2012 at the Hospital. Lima, Peru. Age, sex, endoscopic diagnosis and the results of fine needle aspiration (FNA) are analyzed. RESULTS: In this study 205 patients underwent to EUS. There were 116 patients (56.6%) females and 89 (43.4%) males. Mean age was 60.8 ± 15.6 years (range: 17 - 84), 51.3% were over 60. 157 patients (76.6%) had upper GI EUS tract and 48 (23.4%) of the lower. In upper GI EUS the most frequent diagnosis was: Sub epithelial lesions (22.7%), malignant neoplasm (13.5%) and pancreatic cancer the most frequent one (6.7%). Stones in the biliary and pancreatic duct (12.2%) and pancreatic cystic disease (9.8%) were found. Rectal cancer was the most frequent diagnosis in the ano-rectal EUS (47.9%). 20 fine needle aspiration biopsies were performed. No complications were reported. CONCLUSION: This one year experience is the first step for the development of endoscopic ultrasonography in our country. Despite of problems with the design and number of patients, we believe we can say that GI EUS is a useful and safe for the diagnosis of different diseases of the GI tract and appropriate training is needed.

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.

[Obscure digestive bleeding by ileal carcinoid tumor]. / Sangrado digestivo oscuro por tumor carcinoide ileal.

The patient is an 82 year-old female with a history of osteoarthritis, hypothyroidism and anemia for 14 years (receiving blood transfusions). She was admited to our hospital with a nine months history of malaise, anorexia, fatigue and weakness, associated with intermitten episodes of abdominal pain. She was diagnosed anemia and occult blood positive stools. Physical examination revealed a patient in generally fair condition, obese, with mild edema of lower limbs, no changes in the evaluation of chest, cardiovascular, abdomen, etc. Laboratory data was unremarkable, except for iron deficiency anemia. The upper endoscopy showed duodenal ulcer scar, fundic polyposis and chronic gastritis. Colonoscopy revealed some diverticula, a small sessile polyp and internal hemorrhoids. The diagnosis of obscure gastrointestinal bleeding was made. The CT scan of the abdomen showed gallstones and fatty liver; a radiograph of intestinal transit detected a lesion apparently protruded intestinal loop for distal jejunum; enteroscopy was performed (with one team ball) anterograde and retrograde achieving assess distal jejunum and distal ileum without observing any injuries. The study of capsule endoscopy showed a polypoid tumor intestinal with evidence of having bleeding. Surgery detected the tumor in proximal ileum. The surgical specimen findings showed three tumors 0.7 mm, 10 mm and 15 mm on the proximal ileum. The microscopic examination revealed that these lesions were neuroendocrine tumors (carcinoid). The Ileal carcinoid tumor may rarely presented with obscure gastrointestinal bleeding.

Sangrado digestivo oscuro por tumor carcinoide ileal / Obscure digestive bleeding by ileal carcinoid tumor

Mujer de 82 años con antecedentes de osteoartrosis, hipotiroidismo y anemia desde hace 14 años (ha recibido transfusiones). Refiere desde hace 9 meses malestar general, hiporexia, astenia y sensación de debilidad; asociadas a episodios de dolor abdominal intermitente. En un centro médico le detectaron anemia y Thevenon positivo. En el examen físico observamos a una paciente en regular estado general, obesa, con edema leve de miembros inferiores, sin alteraciones en tórax, cardiovascular, abdomen, etc. Sus exámenes auxiliares fueron normales, excepto que tenía anemia ferropénica. Le realizaron una endoscopia alta y colonoscopia sin detectar alguna fuente potencial de sangrado; se planteó el diagnóstico de hemorragia digestiva de origen oscuro. La evaluación se complementó con una ecografía y tomografía abdominal observando esteatosis hepática y litiasis vesicular; la radiografía de tránsito intestinal detectó una lesión protruida en un asa intestinal aparentemente correspondiente a yeyuno distal; Se le realizó la enteroscopia (con equipo de un solo balón) anterógrada y retrógrada logrando evaluar yeyuno proximal e ileon distal sin observar alguna lesión. El estudio de cápsula endoscópica mostró un tumor polipoideo ûaparentemente en yeyuno- con evidencia de haber sangrado. La intervención quirúrgica detectó el área tumoral en el íleon proximal; en el espécimen quirúrgico se evidenciaron 3 tumoraciones de 0.7mm, 10mm y 15mm cuyo estudio histológico mostró que se trataban de lesiones correspondientes a tumor carcinoide. La presentación del tumor ileal carcinoide como hemorragia digestiva de origen oscuro no es frecuente.

The patient is an 82 year-old female with a history of osteoarthritis, hypothyroidism and anemia for 14 years (receiving blood transfusions). She was admited to our hospital with a nine months history of malaise, anorexia, fatigue and weakness, associated with intermitten episodes of abdominal pain. She was diagnosed anemia and occult blood positive stools. Physical examination revealed a patient in generally fair condition, obese, with mild edema of lower limbs, no changes in the evaluation of chest, cardiovascular, abdomen, etc. Laboratory data was unremarkable, except for iron deficiency anemia. The upper endoscopy showed duodenal ulcer scar, fundic polyposis and chronic gastritis. Colonoscopy revealed some diverticula, a small sessile polyp and internal hemorrhoids. The diagnosis of obscure gastrointestinal bleeding was made. The CT scan of the abdomen showed gallstones and fatty liver; a radiograph of intestinal transit detected a lesion apparently protruded intestinal loop for distal jejunum; enteroscopy was performed (with one team ball) anterograde and retrograde achieving assess distal jejunum and distal ileum without observing any injuries. The study of capsule endoscopy showed a polypoid tumor intestinal with evidence of having bleeding. Surgery detected the tumor in proximal ileum. The surgical specimen findings showed three tumors 0.7mm, 10mm and 15mm on the proximal ileum. The microscopic examination revealed that these lesions were neuroendocrine tumors (carcinoid). The Ileal carcinoid tumor may rarely presented with obscure gastrointestinal bleeding.

[Bleeding in digestive tract caused by jejunal angiodysplasia: complementary value of capsule endoscopy and double-balloon enteroscopy]. / Hemorragia digestiva oscura por angiodisplasia yeyunal: valor complementario de la cápsula endoscópica y la enteroscopia de doble balón.

We report the case of a 35-year-old male patient, with a history of six months of pallor and dyspnea associated with severe iron deficiency anemia and positive fecal occult blood tests. Endoscopy of the lower and upper gastrointestinal tract, and a small bowel follow-through were performed, but did not reveal the origin of the bledding. Later, a capsule endoscopy study were performed and detected an elevated area - not well defined - with active bleeding in the jejunal portion of the small bowel, for that reason we decided to complement the study with a double balloon enteroscopy, that allowed us to see more clearly the jejunal lesion: an elevated and ulcerated lesion; the area was marked with India ink to guide the surgeon. In the surgical intervention a resection of the involved jejunal segment was performed; the study of pathological anatomy established the diagnosis of jejunal angiodysplasia. We present this case of obscure gastrointestinal bleeding to emphasize the diagnostic utility of capsule endoscopy and double balloon enteroscopy.

Hemorragia digestiva oscura por angiodisplasia yeyunal: valor complementario de la cápsula endoscópica y la enteroscopia de doble balón / Bleeding in digestive tract caused by jejunal angiodysplasia: complementary value of capsule endoscopy and double-balloon enteroscopy

Reportamos el caso de un paciente varón de 35 años con historia de seis meses de palidez y disnea de esfuerzo, asociadas a anemia ferropénica severa y pruebas de sangre oculta en heces positivas. Se le realizaron videoendoscopia digestiva alta, videocolonoscopía y Rx tránsito gastrointestinal, las cuales no revelaron el origen del sangrado. Posteriormente se le realizó estudio con cápsula endoscópica que detectó en el yeyuno un área elevada -no bien definida- con sangrado, por esa razón se decidió complementar con una enteroscopía de doble balón, que permitió ver mas claramente la lesión yeyunal: una lesión elevada y ulcerada, además el área fue marcada con tinta china para orientar al cirujano. En la intervención quirúrgica se realizó resección del segmento yeyunal comprometido; el estudio de anatomía patológica estableció el diagnóstico de angiodisplasia yeyunal. Presentamos este caso de hemorragia digestiva de origen oscuro para resaltar la utilidad diagnóstica de la cápsula endoscópica complementada con la enteroscopia de doble balón.

We report the case of a 35 years male patient, with a history of six months of pallor and dyspnea associated with severe iron deficiency anemia and positives fecal occult blood tests. Endoscopy of the lower and upper gastrointestinal tract, and a small bowel follow through were performed, but did not reveal the origin of the bledding. Later, a capsule endoscopy study were performed and detected an elevated area û not well defined û with active bleeding in the jejunal portion of the small bowel, for that reason we decided to complement the study with a double balloon enteroscopy, that allowed to see more clearly the jejunal lesion: an elevated and ulcerated lesion; the area was marked with Indian ink to guide the surgeon. In the surgical intervention a resection of the involved jejunal segment was performed; the study of pathological anatomy established the diagnosis of jejunal angiodysplasia. We present this case of obscure gastrointestinal bleeding to emphasize the diagnostic utility of the capsule endoscopy and the double balloon enteroscopy.

[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...

[Serologic prevalence of HCV antibodies in health personnel in Peru]. / Prevalencia serológica de anticuerpos al virus de la hepatitis c en personal de salud en el Perú.

In Peru, new cases of asymptomatic HCV infection are reported with certain frequency in patients with or without antecedents of blood transfusion. Although serologic screening has improved notoriously in the last years, there is still a population of polytransfused patients with high HCV risk (e.g. hemodialyzed patients), making up a major reservoir. Based on this premise, we decided to study the risk of the health worker population in Peru as another major HCV risk group. A total of 2,769 health workers from 7 Public Hospitals and 2 Private Hospitals in the City of Lima and from 7 Public Hospitals in 4 major/main cities of Peru (Chiclayo, Trujillo, Arequipa, and Cusco) were studied. All those workers, who due to their area of work had higher contact with blood and/or blood derivatives (Surgery, ICU, Traumatology, Gynecology, Gastroenterology, Hemodialysis and Laboratories-Blood Banks) were studied. The studied population accounts for 30% of the total health worker population in these services. All serums underwent the EIA-3 test (HCV-Cobas-Core, Lab. Roche, USA). The positive results were confirmed by RT-HCV (Ampiclor, Roche). The positive serums were confirmed by PCR and the positive results with high viral load underwent HCV genotyping (AMPICLOR-Roche Diagnostic, IGEN Diagnostic USA). Of the 2,769 health workers studied in Peru, 32 were positive for HCV antibodies (1.16% of the total number). Lima showed a prevalence slightly higher than the provinces: 26 out of 2,112 vs. 6 out of 657, or 1.23% vs. 0.91%, respectively. The higher risk is assumed by professional with higher level of contact with blood: 2 physicians (Hemodialysis), 5 nurses (HD) and Lab-Blood Bank technicians. The physicians and nurses share the same risk. If we segregate Lima from provinces, it can be seen that the highest risk is in Lima (1.34% compared to 1.07% in provinces). There is a major risk in health workers and the figures are slightly above those that were suspected for Peru (between 0.4 and 1.0). Finally, we can conclude that the group with the highest HCV risk among health workers is the group specialized in hemodialysis, followed by laboratory (1.79%), surgery (1.40%), and gastroenterology (0.8%). This is the first report at national level of HCV sero-prevalence in Peru.

Durabilidad de la respuesta inmune antihepatitis B en trabajadores de la salud peruanos con 6 años de vacunados

Partiendo de la importancia que la Organización Mundial de la Salud y el Centro para el Control de las Enfermedades le atribuyen a la protección de los trabajadores de la salud contra la hepattis viral tipo B (VHB), en 1993 el Instituto Peruano del Seguro Social (hoy ESSALUD), orientó la vacunación del personal de riesgo en los 4 hospitales nacionales, mediante la vacuna cubana Heberbiovac HB (20 mg, esquema 0-1-2 meses). El propósito fue evaluar la persistencia de los anticuerpos en los vacunados después de 6 años de la inmunización y la posible existencia de marcadores de infección por el virus B. Se estudiaron los sueros de 144 trabajadores de la salud, para una cobertura de 70,24 % en relación con los seroprotegidos en el estudio inicial. Para la detección de los marcadores en el suero se emplearon métodos inmunoenzimáticos comerciales. El AgsHB y el anti-AgcHB fueron negativos en todas las muestras serológicas, por lo que se afirmó que en ninguno de los vacunados hubo evidencias de infección por este virus. El anti-AgsHB fue positivo, todos presentaban seroconversión, con seroprotección e hiperrespuesta de 91,6 y 43,7 %, respectivamente. El tiempo de vida media del anti-AgsHB (t ½) es de 3 años, se pronosticó que los niveles de anticuerpos serían superiores a 10 UI/L hasta después de 15 años de finalizado el esquema. Los menores de 40 años tuvieron niveles de seroprotección e hiperrespuesta significativamente mayores; las mujeres se mantuvieron en categorías de respuesta superiores. Se recomendó evaluar la memoria pos-refuerzo en los casos de seroconversión, no seroprotegidos, y extender el trabajo con ESSALUD a otros hospitales del país.

On the basis of the importance given by the Health World Organization and the Disease Control Center to the protection of health workers against viral hepatitis B(HBV), the Peruvian Institute of Social Security(presently ESSALUD) instructed in 1993 the vaccination of health personnel at risk in 4 national hospitals by using the Cuban vaccine called Herberbiovac HB(20 mg, 0,1,and 2 month schedule). The purpose was to evaluate the persistence of antibodies in the immunized workers six years after the immunization program and the possible presence of HB virus infection markers. Sera from 144 health workers were studied covering 70.24% of seroprotected subjects in comparison with seroprotected subjects in the initial study. Conventional immunoenzymatic methods were used to detect markers in the serum, HbsAg and antibodies to HbcAg were negative in all the serological samples, an outcome that showed that any of the vaccinated persons had traces of HB virus infection. The anti-HbsAg was positive, seroconversion was 100% whereas seroprotection and hyperesponse amounted to 91.6 and 43.7% respectively. The mean lifetime of anti-HbsAg is 3 years but it was predicted that the levels of antibodies would reach over 10 UI/L after 15 years of the vaccination schedule completion. Subjects aged under 40 years had significantly higher levels of seroprotection and hyperesponse, being females those in the higher response categories. The evaluation of the post-vaccination reinforcement immunological response in seroconverted non-seroprotected cases and the extension of the work with ESSALUD to other hospitals in the country were recommended.

Tuberculosis digestiva en el Hospital Nacional Edgardo Rebagliati Martins (HNERM): un estudio retrospectivo de 5 años (1993-1998) / Digestive tuberculosis in the Edgardo Rebagliati Martins Hospital (HERM): a retrospective study over a five-year period (1993-1998)

Introducción: La Tuberculosis es una patología bastante común en el Perú. Aunque hay evidencia de una disminución de la afección pulmonar, las variedades extrapulmonares, como la Tuberculosis Digestiva muestra un importante incremento en nuestro medio. El presente estudio tiene como finalidad determinar la incidencia, características clínicas, métodos diagnósticos, órganos comprometidos y tratamiento empleado en Tuberculosis Digestiva en el Area de Hospitalización del Departamento de Enfermedades del Aparato Digestivo del HNERM. Material y Método: Se revisaron 77 historias clínicas de pacientes egresados y diagnosticados de Tuberculosis Digestiva entre Enero de 1993 y Mayo de 1998. De estas 58 cumplieron criterios planteados. Resultados: La duración media de síntomas fue de 5.39 meses. Las características clínicas son inespecíficas. Los síntomas más frecuentes han sido baja de peso, diarrea crónica, dolor abdominal, y fiebre (más de 70 por ciento de casos). Los signos más comunes han sido dolor abdominal, ascitis y caquexia en más de 50 por ciento. Los exámenes de Laboratorio son típicos de enfermedad crónica y resaltan la Velocidad de sedimentación globular(VSG), elevada en 98 por ciento de casos, y el dosaje de Adenosin deaminasa (ADA) en líquido ascítico, elevado en 95 por ciento de casos cuando ha sido utilizado. Los exámenes Radiológicos son adyuvantes, permiten determinar la localización intestinal, compromiso de órganos, además de servir de ayuda para realización de exámenes invasivos. Un 27.58 por ciento de casos ha tenido localización gastrointestinal pura, 43 por ciento afección peritonal únicamente y 27.58 por ciento compromiso mixto (enteroperitoneal). Los exámenes endoscópicos han permitido el diagnóstico hasta en 90 por ciento de casos. La Laparoscopía ha permitido precisar compromiso peritoneal en 70 por ciento de casos. Seis pacientes de nuestra serie han requerido Laparotomía exploratoria para el diagnóstico. El tratamiento ha sido efectivo en 86 por ciento de casos evaluados con esquemas cortos de 6 a 9 meses. Conclusión: El diagnóstico de la Tuberculosis Digestiva sigue siendo tedioso, largo y costoso. La incidencia de ésta en nuestro Servicio de Hospitalización se ha incrementado desde 1993. Requiere de exámenes invasivos para el diagnóstico definitivo en la totalidad de casos revisados.

[DIGESTIVE TUBERCULOSIS IN THE EDGARDO REBAGLIATI MARTINSHOSPITAL (HNERM): A RETROSPECTIVE STUDY OVER A FIVE-YEAR PERIOD (1993-1998)] / Tuberculosis digestiva en el Hospital NacionalEdgardo Rebagliati Martins(HNERM): Un estudio retrospectivo de 5 años(1993-1998).

INTRODUCTION: Tuberculosis is a common disease in Peru.Although there is evidence of the decrease in lung infections, abdominaltuberculosis and other extrapulmonary varieties show an increase in incidence. This study was performed in order lo determine incidence, clinical picture, diagnostic methods and procedures, compromised tissues and organs and treatment given to patients with Digestive Tuberculosis in the Hospitalization Area of the Digestive Disease Department of the Peruvian "Edgard Rebagliati Martins" Hospital in Lima-Peru, a 1-500 bed Center. METHODS: 77 clinical records were reviewed, of patients discharged and diagnosed with Abdominal or Digestive Tuberculosis between January 1993 to May 1998. Fifty eight of these records fuifilled the requirements. Results: The mean duration of symptoms was 5.49 months. The clinical characteristics are unspecific. The most frequent symptoms were weight loss, chronic diarrhea, abdominal pain and fever (over 70% of cases). The most common signs were abdominal pain, ascites and cachexia in more than 50% of the cases. The Laboratory tests are typical for chronic diseases and emphasize the erythrocite sedimentation rate that was high in 98% of cases. Adenosin Deaminase Assay (ADA) in ascific fluid was high in 95% of cases when peritoneal compromise was present and fluid could be obtained. The Radiology tests such as barium colon enema and intestinal transit tests were helpful together with Ultrasound and Computerized Tomography in detecting the intestinal location of the disease, the organs that had been affected as well assisting as to the decision to perform further invasive tests. We found 27.58% with gastrointestinal location, 43% with only peritoneal affection and 27.58% of mixed forms (gastrointestinal plus peritoneal). The endoscopic procedures have been decisive for the diagnosis of up to 90% of cases and Laparascopy has been of value, in up to 70% of the cases, for the detection of peritoneal affection. Six patients of our series have required exploratory Laparascopy for diagnosis. Treatment has been effective in 86% of cases. CONCLUSION: The diagnosis of Digestive Tuberculosis continues to be long, tedious and expensive. The incidence of this disease has increased in our Hospitalization Center since 1993. All cases reviewed require invasive procedures (endoscopic) or surgery for their final diagnosis. We emphasize the use of Laparoscopy tests for the evaluation of p0eritoneal affection.