Local therapeutic injection in bleeding peptic ulcer: a comparison of adrenaline to adrenaline plus a sclerosing agent.

OBJECTIVE: a) To analyse the probability of haemodynamic changes in patients with non-variceal upper gastrointestinal bleeding (NV-UGB), as well as the risk of bleeding in cases of peptic ulcer; and b) to compare an injection of epinephrine alone with epinephrine plus an sclerosing agent in ulcers with a high risk of persistent or recurrent bleeding. METHODS: We studied 500 consecutive patients (295 males/205 females) who were admitted because of an NV-UGB episode. Haemodynamic evaluation and upper endoscopy were performed in all patients. They were randomised to receive an injection of epinephrine 1:10.000 or epinephrine plus 2% polidocanol in case of active bleeding, visible vessel or unstable clot. RESULTS: 263/500 (52.6%) were taking NSAIDs before the acute bleeding. 70/96 (72.9%) patients with red haematemesis showed haemodynamic changes vs 15/107 (14%) with dark haematemesis and melena, and 29/281 (10.3%) with melena alone, p < 0.01, OR = 20. Duodenal ulcer was the cause of NV-UGB in 206 cases (40.6%) and gastric ulcer in 134 (27.2%). However, an endoscopic therapy was performed in 85 patients, 58 with gastric ulcers (19 with active bleeding, 33 with visible vessel and 6 with unstable clot) vs 27 with duodenal ulcers (6 with active bleeding, 19 with visible vessel and 2 with unstable clot), p < 0.01, OR = 4.7. 15/85 patients developed recurrent bleeding after injection therapy: 3 with a non-bleeding visible vessel and 10 with active bleeding (10 were treated with epinephrine and 2 with epinephrine plus 2% polidocanol, p < 0.04, OR = 8). A multivariate logistic regression analysis showed that age, active bleeding and type of injected agent were the only independent variables associated with failure of treatment and recurrent bleeding. CONCLUSIONS: a) 52.6% of patients with NV-UGB were taking NSAIDs before acute bleeding; b) epinephrine injection followed by a sclerosing agent is more effective in case of active bleeding; however, there is no difference in case of visible vessel or unstable clot; and c) age, active bleeding and type of treatment were the only independent variables associated with recurrent bleeding.

Inyección local terapéutica en la úlcera gastroduodenal sangrante: estudio comparativo de adrenalina frente a adrenalina más agente esclerosante / Local therapeutic injection in bleeding peptic ulcer: a comparison of adrenaline to adrenaline plus a sclerosing agent

Objetivos: a) analizar la probabilidad de afectación hemodinámica en pacientes con hemorragia digestiva alta no varicosa (HDA-NV), así como el riesgo de recidiva hemorrágica en los casos de úlcera gastroduodenal; b) comparar la inyección de adrenalina frente a la de adrenalina + agente esclerosante en aquellos casos con estigmas de sangrado que aconsejen realizar terapéutica endoscópica. Material y métodos: se estudiaron 500 pacientes consecutivos que fueron sometidos a endoscopia por episodio de HDA-NV.A todos ellos se les realizó historia clínica y valoración hemodinámica. Los casos que presentaban sangrado activo, vaso visible o coágulo inestable fueron aleatorizados a recibir inyección con adrenalina 1/10.000 o bien ésta más un agente esclerosante (polidocanol 2 por ciento).Resultados: 263/500 referían consumo de AAS/AINEs previo al episodio hemorrágico (52,6 por ciento). 96 pacientes presentaron hematemesis de sangre roja, de los cuales 70 presentaban afectación hemodinámica (72,9 por ciento), frente al 14 por ciento de los que referían hematemesis digerida y melenas y 10,3 por ciento de los que sólo referían melenas, p<0,01, odds ratio=20. La úlcera duodenal fue la responsable del sangrado en 206 casos (40,6 por ciento) y la gástrica de 134 (27,2 por ciento), pero en cambio se realizó terapéutica endoscópica en 58 casos de úlcera gástrica (19 con sangrado activo, 33 con vaso visible y 6 con coágulo inestable) frente a 27 de úlcera duodenal (6 con sangrado activo, 19 con vaso visible y 2 con coágulo inestable), p<0,01, odds ratio=4,7. De estos 85 pacientes tratados endoscópicamente, 15 sufren recidiva hemorrágica: 3 con vaso visible y 12 con sangrado activo, de los cuales se trataron 10 con adrenalina y 2 con adrenalina + agente esclerosante, p<0,04, odds ratio=8).El análisis de regresión logística multivariante mostró que sólo la edad, presencia de sangrado activo y tipo de tratamiento fueron variables independientes asociadas a fracaso de tratamiento y recidiva hemorrágica. Conclusiones: a) en nuestro medio el 52,6 por ciento de pacientes con HDA-NV refieren consumo previo de AAS/AINEs; b) la adición de un agente esclerosante a la adrenalina se muestra más eficaz en los casos de sangrado activo para la prevención de la recidiva hemorrágica ulcerosa, sin diferencias frente a la inyección exclusiva de adrenalina en casos de vaso visible o coágulo inestable; y c) la edad, presencia de sangrado activo y tipo de tratamiento fueron las únicas variables asociadas a fracaso de tratamiento endoscópico y recidiva hemorrágica (AU)

[Spontaneous regression of hepatocellular carcinoma in a cirrhotic patient]. / Regresión espontánea de carcinoma hepatocelular en paciente cirrótico.

Hepatocellular carcinoma mainly affects patients with liver disease and rarely develops in healthy liver. Cirrhosis greatly increases the risk of developing this malignancy and consequently these patients are candidates for close follow-up and surveillance. The most commonly used screening programs are abdominal ultrasonography and serum alpha-fetoprotein determination. Without treatment, the prognosis of hepatocellular carcinoma is poor and mortality continues to be significant even in patients with small tumors detected during follow-up. We present the case of a 71-year-old male patient with alcoholic cirrhosis. The patient was diagnosed during follow-up of a single hepatocellular carcinoma of 4 cm in diameter. Although he refused all treatment, evolution was favorable, serum alpha-fetoprotein levels returned to normal and ultrasonographic images compatible with hepatocellular carcinoma disappeared. Three years after diagnosis, the patient was completely asymptomatic.

Infección por virus C, aumento de ferritina sérica e hiperinsulinemia / Hepatitis C virus infection, increased serum ferritin and hyperinsulinemia

Objetivos: estudios recientes han encontrado una alta prevalencia de diabetes mellitus en pacientes infectados por el virus C (VHC). En este trabajo nos planteamos un doble objetivo: a) sustentar la hipótesis de la hiperinsulinemia como factor de riesgo para diabetes en estos pacientes, estudiando prospectivamente los valores de insulinemia basal en pacientes cirróticos no diabéticos infectados por el virus C, comparándola con la de cirróticos no diabéticos no virus C; y b) investigar en ambos grupos los factores implicados en el aumento de resistencia periférica a la insulina.Material y métodos: se realizó un estudio que incluyó a 32 pacientes cirróticos no diabéticos por VHC (grupo I) y 41 cirróticos no diabéticos de otras etiologías (grupo II). En ambos grupos se compararon las concentraciones de insulinemia basal, así como los factores asociados a resistencia insulínica: edad, índices antropométricos, estadio evolutivo de la cirrosis empleando la clasificación de Child-Pugh, ferritina plasmática y tratamiento con fármacos inductores de resistencia a la insulina.Resultados: la media de los valores de insulinemia basal en el grupo I fue de 21,5 µU/ml (18,6-24,4), frente a 14 µU/ml (1018) en el grupo II (p<0,001), y el porcentaje de hiperinsulinemia del 87,5 por ciento (72,5-95,9) frente al 56,1 por ciento (40,8-70,6), respectivamente (p<0,01). No se encontraron diferencias entre ambos grupos con respecto a las siguientes variables: edad [54,4 (48,360,6) frente a 59,5 años (56,3-62,7) NS], peso [72,9 (69,5-76,3) frente a 74,2 kg (70,8-77,7) NS], talla [163,6 (160,5166-7) frente a 161,3 cm (159,4-163,2) NS], índice de masa corporal [27,6 (26,1-29,1) frente a 28,4 kg/m2 (27,3-29,5) de talla NS] ni estadio de Child-Pugh (A: 31 frente a 27, B: 0 frente a 7, C: 1 frente a 7, NS). En cambio los valores de ferritina sérica en los pacientes del grupo I fueron más elevados que los del grupo II [123,3 (12,4-289,3) frente a 65,5 ng/ml (2,4-306) p<0,05], mientras que en el momento de inclusión en este estudio 3 pacientes del grupo I recibían diuréticos o bloqueantes no selectivos beta adrenérgicos, frente a 14 pacientes del grupo II, p<0,01.El estudio de regresión logística multivariado demostró que los valores de insulinemia (OR=1,21; IC 95 por ciento 1,09-1,34, p<0,001) y ferritina (OR=1,21; IC 95 por ciento 1,02-2,69, p<0,04) fueron variables independientes asociadas a la infección por VHC.Conclusiones: Los pacientes cirróticos no diabéticos debido al VHC tienen unos valores de insulinemia basal más elevados, así como una mayor prevalencia de hiperinsulinemia que la cirrosis debida a otras causas. Esta característica podría explicarse por un aumento de resistencia periférico a la insulina, mediado por el incremento de los depósitos de hierro que igualmente presentan estos pacientes, y puede ser el factor responsable del riesgo aumentado de desarrollar diabetes mellitus (AU)

Pancreatitis aguda inducida por eritromicina / Acute pancreatitis caused by erythromycin

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[Good response to colchicine in amyloidosis secondary to inflammatory bowel disease]. / Respuesta favorable a la colchicina en la amiloidosis secundaria a la enfermedad inflamatoria intestinal.

Acquired systemic amyloidosis may develop during the course of a number of chronic inflammatory diseases, including inflammatory bowel disease. Amyloidosis, although rare, is life-threatening, especially when it involves the kidneys. It is important to recognize this complication, especially since colchicine has been proposed as a possible treatment.We present a 25-year-old female diagnosed at the age of 13 years with Crohn's disease with involvement of the terminal ileum and right colon. Surgery was performed because of inflammatory activity unresponsive to corticosteroid and immunosuppressive drugs. She subsequently presented nephrotic syndrome due to secondary amyloidosis, which responded well to colchicine treatment.

[Hyperinsulinemia in cirrhotic patients infected with hepatitis C virus]. / Hiperinsulinemia en pacientes cirróticos infectados por el virus de la hepatitis C.

AIMS: a) To prospectively study the frequency of diabetes mellitus in cirrhotic patients with hepatitis C virus (HCV) infection, comparing it with that in cirrhotic patients without HCV infection and b) to investigate basal insulinemia values in both groups, as well as the possible factors causing insulinemia. MATERIAL AND METHODS: Fifty patients with cirrhosis due to HCV infection (group I) and 50 patients with cirrhosis due to other etiologic agents (group II) were studied. In both groups the percentage of diabetic patients, basal insulinemia values and the factors associated with insulin resistance were compared: age, anthropometric indexes, stage of cirrhosis according to Child-Pugh score, plasmatic ferritin concentrations and treatment with drugs inducing insulin resistance. RESULTS: The percentage of diabetics in group I was 36% (18/50) compared with 18% (9/50) in group II (p < 0.05) and basal insulinemia values were 23.5 +/- 9.7 microU/ml compared with 15.7 +/- 9.9 microU/ml respectively (p < 0.05). No differences between the groups were found in the following variables: age (58.7 +/- 16.2 vs. 60.6 +/- 10.0 years), weight (73.2 +/- 10.7 vs 73.9 +/- 11.2 Kg), height (161.9 +/- 8.8 vs. 161.1 +/- 6.8 cm), body mass index (28.2 +/- 3.1 vs. 28.5 +/- 5.2 Kg/height m2) or Child-Pugh stage (A: 40 vs 34, B: 7 vs. 10, C: 3 vs. 6, NS). In contrast, serum ferritin concentrations were much higher in patients in group I than in those in group II [137.7 (12.4-410.2) vs. 87.6 (2.4-420.0) ng/ml p < 0.05]. At the time of inclusion in this study 10 patients in group I were receiving diuretics or non-selective beta adrenergic blockers compared with 24 patients in group II (p < 0.05). CONCLUSIONS: Diabetes mellitus is more prevalent in patients with cirrhosis due to HVC than in those with cirrhosis due to other etiologic agents. Moreover, basal insulinemia values are higher in these patients, which could be explained by an increase in half insulin resistance associated with an increase in iron deposits.

Hepatitis C virus infection, increased serum ferritin and hyperinsulinemia.

OBJECTIVES: Recent studies have reported a high prevalence of diabetes mellitus in populations infected with Virus C (HCV). The aim of this study is two-fold: a) to support the hypothesis of hyperinsulinemia as a risk factor for developing diabetes in these patients, with a prospective determination of baseline insulinemia in non-diabetic cirrhotic patients infected with HCV, comparing their values with those of a group of non-HCV non-diabetic cirrhotic patients; b) to investigate in both groups the factors associated to increased peripheral resistance to insulin. MATERIAL AND METHODS: Thirty two HCV cirrhotic diabetic patients (group I) and 41 non-diabetic cirrhotic patients of other etiologies (group II) participated in the study. Baseline insulinemia, as well as factors related to insulin resistance such as age, anthropometric indexes, stage of cirrhosis development using the Child-Pugh index, serum ferritin and treatment with insulin resistance inducing drugs were compared in both groups. RESULTS: Average baseline insulinemia in group I was 21.5 mU/ml (18.6-24.4), vs 14 mU/ml (10-18) in group II (p < 0.001), and the percentage of hyperinsulinemia was 87.5% (72.5-95.9) vs 56.1% (40.8-70.6), respectively (p < 0.01). No differences were observed between the two groups when comparing the following variables: age [54.4 (48.3-60.6) vs 59.9 (56.3-62.7) years of age, NS], weight [72.9 (69.5-76.3) vs 74.2 (70.8-77.7) kg, NS], height [163.6 (160.5-166.7) vs 161.3 (159.4-163.2)] cm, NS], body mass index [27.6 (26.1-29.1) vs 28.4 (27.3-29.5) kg/m2 of height, NS]; and Child-Pugh staging score (A: 31 vs 27; B: 0 vs 7; C: 1 vs 7, NS). However, serum ferritin levels in group I patients were higher than those in Group II [123.3 (12.4-289.3) vs 65.5 (2.4-306) ng/ml, p < 0.05]. It must be considered that at the recruitment 3 patients in Group I were taking either diuretics or non-selective beta-adrenergic blockers, compared to 14 patients in Group II, p < 0.01. Finally, the multivariate logistic regression analysis showed that insulinemia values (OR = 1.21; CI 95% 1.09-1.34, p < 0.001) and ferritin levels (OR = 1.21; CI 95% 1.02-2.69, p < 0.04) were independent variables associated to HCV infection. CONCLUSIONS: HCV-positive non-diabetic cirrhotic patients have higher baseline insulinemia levels and increased prevalence of hyperinsulinemia than cirrhosis due to other etiologies. This could be explained by an increase of peripheral insulin resistance, mediated by the increase of iron deposits in these patients, and could be responsible for the increased risk of developing diabetes mellitus.

Tumor neuroendocrino no funcionante de localización hepática / Not functioning neuroendocrine tumor of the liver

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[Fatal infectious mononucleosis during azathioprine treatment in Crohn's disease]. / Mononucleosis infecciosa mortal durante el tratamiento con azatioprina en la enfermedad de Crohn.

The benefits of immunosuppressive agents in inflammatory bowel disease have been the subject of controversy. However, extensive clinical data have conclusively proved their efficacy with respect to potential toxicity. Azathioprine is one of the most widely used immunosuppressive agents in the treatment of Crohn's disease and its effectiveness has been proved in corticosteroid dependent, corticosteroid-refractory and fistulizing Crohn's disease. We present a 24-year-old male, treated with azathioprine for corticosteroid dependent Crohn's disease who was admitted to hospital with constant fever, lymphadenopathy and liver function abnormalities secondary to infectious mononucleosis after a primary infection with Epstein-Barr virus. The patient developed constitutional symptoms and progressive jaundice and 14 days after hospital admission died because of massive upper gastrointestinal bleeding due to hemorrhagic erosive gastropathy.

[Factors associated with an atherogenic lipid profile in premenopausal women without clinical cardiovascular disease]. / Factores asociados a un perfil lipídico aterógeno en mujeres premenopáusicas sin enfermedad cardiovascular clínica.

BACKGROUND: To investigate different factors associated to a non desirable lipid profile in premenopausal women without cardiovascular disease. To determine the independent factors of lipid profile as a whole of the sample, for planning preventive studies. PATIENTS AND METHODS: We study (March 1994 to June 1996) premenopausal women with alcohol consumption less than 14 g/day and normal serum level of glucose. Group I: women with a non desirable lipid profile (total cholesterol [TCH, mg/dl]/high density lipoprotein cholesterol [HDL-C, mg/dl] > or = 5). Group II: with a desirable lipid profile (TCH/HDL-C < 5). The following factors were analyzed: age, body mass index (BMI), waist/hip ratio (W/H), systolic blood pressure (SBP, mmHg), fasting plasma insulin (fpI, microU/ml), cigarette smoke (CS) and presence of parents with history of non insulin dependent diabetes mellitus (NIDDM) or hypertension. STATISTICAL METHODS: Mann-Whitney and Student statistics. Contingency-table analysis (chi 2 statistic). Pearson correlation and multiple linear regression. RESULTS: We analyzed 126 women (age = 30 +/- 8.2; 95% CI, 29-32; TCH = 197 +/- 36; 95% CI, 190-203 mg/dl), with 20 women (group I) and 106 (group II). Women from group I had higher values of W/H (0.83 +/- 0.04 vs 0.78 +/- 0.06; p < 0.001), BMI (29.9 +/- 9 vs 24.6 +/- 4.9; p < 0.03), fpI (12.9 +/- 10.4 vs 7.8 +/- 3.5; p < 0.05), SBP (125.9 vs 117; p < 0.02), as well as higher percentage of smokers (75 vs 40%; p < 0.01) and parents with NIDDM (60 vs 26%; p < 0.01) or hypertension (60 vs 49%; NS). No differences of age were detected (32 +/- 7.3 vs 30 +/- 8.3; NS). BMI (0.32; p < 0.01), W/H (0.50; p < 0.01), SBP (0.27; p < 0.01) and fpI (0.33; p < 0.01) were positively correlated with TCH/HDL-C ratio (n = 126). In multiple regression analysis (n = 126), W/H (regression coefficient = 6.1; 95% CI, 3.1-9.1), fpI (regression coefficient = 0.045; 95% CI, 0.018-0.072) and CS (regression coefficient = 0.5; 95% CI, 0.336-0.667) were the only independent predictors (p < 0.01) of the TCH/HDL-C ratio, controlling a 46% of the variance (R2 = 0.46). CONCLUSIONS: Our data indicates that central obesity, hyperinsulinemia and cigarette smoke are independently associated to a high risk cardiovascular lipid profile in premenopausal women without cardiovascular disease. This study suggests the importance of these factors in the management of early lipid control in these women.

[Lymphoblastic stimulation in cirrhotic and non-cirrhotic chronic alcoholics]. / Estimulación linfoblástica en alcohólicos crónicos con o sin cirrosis hepática.

OBJECTIVE: To study whether there exists a functional change in lymphocytes in chronic alcoholic patients compared with chronic alcoholic cirrhotic patients. An open, prospective study was performed of the in vitro proliferative response (lymphoblastic transformation) of lymphocytes to phytohemagglutinin, mitogen pokeweed, and concanavalin A. PATIENTS: 73 males (51.4 +/- 12 years) divided on the basis of alcoholic intake and/or chronic liver disease in: social drinkers (< 80 g ethanol/day), 23; excessive drinkers (80-160 g ethanol/day), 14; chronic alcoholics (> 160 g ethanol/day), 21; and cirrhotic patients with no current alcohol consume, 15 cases. RESULTS: In social drinkers, excessive drinkers and cirrhotic patients similar proliferative responses to mitogens were observed, with no significant differences between groups. CONCLUSIONS: Our findings support the concept that chronic alcoholism has immunosuppressive effects which precede the emergence of liver cirrhosis.