De novo autoimmune hepatitis following liver transplantation for primary biliary cirrhosis.

De novo autoimmune hepatitis (AIH) is a rare disorder first described in 1998. It appears in patients with liver transplants for non-AIH etiology. The few cases in the literature make it a little known entity due to mechanisms that are unclear. We present the case of a woman with a liver transplant whose graft developed de novo AIH. Diagnosed with primary biliary cirrhosis, the patient underwent liver transplantation for refractory pruritus. Sixteen months after transplantation, we detected alterations in the hepatic profile with hypertransaminasemia and elevated alkaline phosphatase, together with elevated antinuclear antibodies. IgG levels were normal. Histological findings indicated AIH. The patient responded rapidly to treatment with prednisolone and azathioprine. De novo AIH in patients transplanted for PBC may cause graft dysfunction. This report also analyzes the case with respect to the other four reported cases, discussing etiologic hypotheses.

[Utility of routine use of reversion after sedation in outpatient colonoscopy]. / Utilidad en la práctica clínica habitual de la reversión tras sedación en colonoscopia ambulatoria.

INTRODUCTION: Randomized clinical trials have demonstrated the effectiveness of flumazenil in reducing recovery time in the endoscopy unit after conscious sedation with midazolam and meperidine. However, its effectiveness in routine clinical practice has not been proved and therefore its use is debated. AIM: To determine the effectiveness of reversion with flumazenil after conscious sedation with midazolam and pethidine in outpatient colonoscopy and to evaluate its cost-effectiveness. MATERIAL AND METHOD: Two hundred consecutive outpatients scheduled for colonoscopy with conscious sedation with midazolam and pethidine in 2 endoscopy units were prospectively included. According to routine clinical practice in each unit, 100 patients were reverted with flumazenil and 100 were not. Medical and demographic data, indications for endoscopy, doses of the medications used and endoscopic findings were collected. Three weeks after the colonoscopy each patient was interviewed by telephone to determine discomfort and complications associated with the endoscopy and/or with the use of sedation. The cost-effectiveness of the use of flumazenil was analyzed. RESULTS: There were no differences between the two groups in age (52.9 +/- 15.5 vs 52.7 +/- 18.3, p = NS), indications for colonoscopy, findings, percentage of full colonoscopies (93 vs 95%; p = NS) or in the doses of sedatives used. The recovery time in each endoscopy unit was similar (19.2 +/- 11.7 vs 15.5 +/- 10.1 minutes, p = NS). In the reversion group there were fewer patients with prolonged stays, defined as those > 20 minutes (23 vs 11%, p < 0.001). The number of patients who remembered discomfort during the colonoscopy was significantly greater in the reversion group (23 vs 13%; p < 0.05). There were no differences in the number of patients who reported discomfort in the days following the endoscopy. The best cost-effectiveness ratio was obtained for a mean stay of 25 min. CONCLUSION: Routine use of reversion does not decrease the mean stay in the endoscopy unit but does decrease the number of prolonged stays. Unpleasant memories of the colonoscopy were more frequent in reverted patients. The effectiveness of the routine use of reversion with flumazenil after conscious sedation with midazolam and pethidine depends on the ratio between the number of daily colonoscopies and the capacity of the recovery room.

Utilidad en la práctica clínica habitual de la reversión tras sedación en colonoscopia ambulatoria / Utility of routine use of reversion after sedation in outpatient colonoscopy

Introducción: La reversión con flumazenilo ha demostrado, en ensayos clínicos aleatorizados, su eficacia para disminuir el tiempo de estancia de los pacientes en la sala de recuperación tras sedación con midazolam y meperidina. Sin embargo, su efectividad en la práctica clínica diaria no ha sido demostrada, por lo que su uso es muy debatido. Objetivo: Determinar la efectividad de la reversión con flumazenilo tras la sedación consciente con midazolam y petidina en colonoscopia ambulatoria y valorar su relación coste-efectividad. Material y método: Se estudió prospectivamente a 200 pacientes ambulatorios remitidos para colonoscopia y sedados con midazolam y meperidina, procedentes de 2 unidades de endoscopia. Siguiendo la práctica habitual de cada una de las unidades, 100 pacientes fueron revertidos con flumazenilo y 100 no. Se recogieron los datos demográficos y médicos, las indicaciones de la colonoscopia, la dosis de fármacos utilizada y los hallazgos de la endoscopia. Tres semanas después se realizó una encuesta telefónica para determinar las molestias y complicaciones asociadas a la endoscopia o la sedación. Se estudió la relación coste-efectividad. Resultados: No hubo diferencias entre ambos grupos en la edad (52,9 ± 15,5 frente a 52,7 ± 18,3 años; p = NS), en las indicaciones de la colonoscopia, en los hallazgos de la prueba, en el porcentaje de colonoscopias completas (el 93 frente al 95%; p = NS) ni en las dosis de midazolam y meperidina utilizadas. La estancia media en la unidad tras la exploración fue similar (19,2 ± 11,7 frente a 15,5 ± 10,1 min; p = NS). En el grupo de reversión había menos pacientes con estancias prolongadas –estancias de más de 20 min– (el 23 frente al 11%; p < 0,001). El número de pacientes que recordaban molestias durante la exploración era significativamente mayor en el grupo de reversión (el 23 frente al 13%; p < 0,05). No existían diferencias en el número de pacientes con molestias en días posteriores. La mejor relación coste-efectividad se conseguía cuando se buscaba una estancia media de 25 min. Conclusión: La reversión no disminuyó la estancia media en la unidad de endoscopia, pero bajó el número de estancias prolongadas. Los pacientes revertidos experimentan mayores recuerdos desagradables de la exploración. La efectividad del uso de la reversión con flumazenilo tras la sedación con midazolam y meperidina depende de la relación entre el número de exploraciones diarias de la unidad de endoscopia y la capacidad de su unidad de recuperación

Introduction: Randomized clinical trials have demonstrated the effectiveness of flumazenil in reducing recovery time in the endoscopy unit after conscious sedation with midazolam and meperidine. However, its effectiveness in routine clinical practice has not been proved and therefore its use is debated. Aim: To determine the effectiveness of reversion with flumazenil after conscious sedation with midazolam and pethidine in outpatient colonoscopy and to evaluate its cost-effectiveness. Material and method: Two hundred consecutive outpatients scheduled for colonoscopy with conscious sedation with midazolam and pethidine in 2 endoscopy units were prospectively included. According to routine clinical practice in each unit, 100 patients were reverted with flumazenil and 100 were not. Medical and demographic data, indications for endoscopy, doses of the medications used and endoscopic findings were collected. Three weeks after the colonoscopy each patient was interviewed by telephone to determine discomfort and complications associated with the endoscopy and/or with the use of sedation. The cost-effectiveness of the use of flumazenil was analyzed Results: There were no differences between the two groups in age (52.9 ± 15.5 vs 52.7 ± 18.3, p = NS), indications for colonoscopy, findings, percentage of full colonoscopies (93 vs 95%; p = NS) or in the doses of sedatives used. The recovery time in each endoscopy unit was similar (19.2 ± 11.7 vs 15.5 ± 10.1 minutes, p = NS). In the reversion group there were fewer patients with prolonged stays, defined as those > 20 minutes (23 vs 11%, p < 0.001). The number of patients who remembered discomfort during the colonoscopy was significantly greater in the reversion group (23 vs 13%; p < 0.05). There were no differences in the number of patients who reported discomfort in the days following the endoscopy. The best cost-effectiveness ratio was obtained for a mean stay of 25 min. Conclusion: Routine use of reversion does not decrease the mean stay in the endoscopy unit but does decrease the number of prolonged stays. Unpleasant memories of the colonoscopy were more frequent in reverted patients. The effectiveness of the routine use of reversion with flumazenil after conscious sedation with midazolam and pethidine depends on the ratio between the number of daily colonoscopies and the capacity of the recovery room

[Intense icterus in the course of EBV infectious mononucleosis]. / Intensa ictericia en el curso de una mononucleosis infecciosa por EBV.

Infectious mononucleosis induced by the Epstein Barr Virus (EBV) is a benign illness that is frequently accompanied by a slight hepatic disfunction. On occasion it may be accompanied by autoimmune hemolytic anemia of little clinical importance. Nevertheless, this association can cause a serious set of symptoms that can put the patient's life in danger if it is not treated quickly. We present the case of a 21-year-old male with infectious mononucleosis and severe jaundice (total bilirubin 40 mg/dl) due to the combination of diseased liver and secondary autoimmune hemolytic anemia, caused by the EBV infection.

Squamous papilloma of the esophagus: report of six cases with long-term follow-up in four patients.

Squamous papilloma of the esophagus is a benign tumor. The diagnosis is usually made accidentally when an upper gastrointestinal endoscopy is performed due to upper abdominal or esophageal symptoms. After having reviewed 14,900 upper gastrointestinal endoscopies during the past 8 yr, we report six additional cases of esophageal squamous papilloma. The lesion seems to be relatively quiescent without apparent malignant changes, at least on a short-term basis. The etiology is unknown; however, we conclude that gastroesophageal reflux may predispose to the lesion and that endoscopic follow-up on these patients may be unnecessary due to the benign nature of the lesion.