Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel.

BACKGROUND: Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release. PURPOSE: To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI. METHODS: For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors? FINDINGS: The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist. CONCLUSIONS: In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.

The impact of delayed biliary decompression and anti-microbial therapy in 260 patients with cholangitis-associated septic shock.

BACKGROUND: Cholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression. AIM: To determine whether the timing of biliary decompression and anti-microbial therapy affect the survival in cholangitis patients with septic shock. METHODS: Nested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multi-centre database between 1996 and 2011. RESULTS: Among 260 patients (mean age 69 years, 57% male), overall mortality was 37%. Compared to nonsurvivors (n = 96), survivors (n = 164) had lower mean admission Acute Physiology And Chronic Health Evaluation (APACHE) II (22 vs. 28, P < 0.001) and lower median serum lactate on admission (3.4 vs. 4.6 mmol/L, P < 0.001). Survivors were more likely to receive appropriate anti-microbial therapy earlier (median 2.6 vs. 6.8 h from shock, P < 0.001). Survivors were also more likely to undergo successful biliary decompression earlier (median 8.8 vs. 22 h, P < 0.001). After adjusting for co-variates, APACHE II (odds ratio, OR 1.21 per increment (1.11-1.32), time delay to appropriate anti-microbial therapy [OR 1.15 per hour (1.07-1.25)] and delayed biliary decompression >12 h [OR 3.40 (1.12-10.31)] were all significantly associated with increased mortality (P < 0.04 for all; c-statistic 0.896). CONCLUSIONS: Patients with septic shock secondary to acute cholangitis have significant mortality. Endoscopic biliary decompression >12 h after the onset of shock and delayed receipt of appropriate anti-microbial therapy were both significantly associated with adverse hospital outcome. This might suggest that early initiation of anti-microbial therapy and urgent biliary decompression (within 12 h) could potentially improve outcomes in this high-risk patient population.

Risk of hyperamylasemia and acute pancreatitis after double-balloon enteroscopy: a prospective study.

BACKGROUND AND STUDY AIMS: There have been reports, mainly retrospective, of pancreatitis and hyperamylasemia after anterograde double-balloon enteroscopy (DBE). Our aim was to report the incidence of pancreatitis and hyperamylasemia after DBE and investigate possible risk factors associated with its occurrence. PATIENTS AND METHODS: In this single-center prospective cohort study, serum samples were taken for amylase and lipase before and 3 hours after anterograde DBE in consecutive patients. Multiple variables were recorded, including total procedure time, insertion depth, and number of passes. Patients were evaluated to 24 hours later for signs of pancreatitis. The main outcome measures were the occurrence of hyperamylasemia and pancreatitis. RESULTS: 92 patients were included in the analysis (58 women, 34 men; mean age 54 years, range 18-89). The mean total procedure time was 62 minutes (range 30-120). The mean post-procedure amylase and lipase levels were significantly higher in comparison with the baseline levels (165 U/L vs. 69 U/L and 144 U/L vs. 28 U/L respectively, P<.05); 36 patients (39%) showed hyperamylasemia after the procedure and three patients developed acute mild pancreatitis. Hyperamylasemia was associated more frequently with procedure duration greater than 60 minutes ( P<.001) and insertion depth greater than 25 cm ( P<.013). CONCLUSIONS: The incidence of hyperamylasemia after anterograde DBE is common and particularly associated with longer procedure time and insertion depth. The cumulative incidence of pancreatitis was 3%. We recommend the avoidance of both unnecessarily lengthy procedures and deep insertion distances in patients who undergo anterograde DBE.

Liver transplantation for neurologic Wilson's disease: reflections on two cases within a mexican cohort.

BACKGROUND: Liver transplantation (LT) in Wilson s disease (WD) is mostly indicated when progressing liver disease or acute liver failure occurs. In patients with neurological manifestations, this procedure has not gained wide acceptance based on previous reports of dismal prognosis. OBJECTIVE: To describe a Mexican cohort of pa- tients with WD with special focus on LT in patients with deteriorating neurological manifestations. MATERIAL AND METHODS: Patients with confirmed WD and their first-degree relatives were evaluated at the hepatology clinic of a tertiary referral hospital. Attention was placed on therapy and outcome. RESULTS: Eleven patients were followed for a period of up to 80 months (7 probands and 4 affected family members), 10 patients having hepatic manifestations and 4 having neuro psychia- tric phenomena. Pharmacologic treatment was uniform in most patients, and LT was indicated in 2 cases because of deteriorating neurological status. These patients had total remission of their neurological manifestations with marked improvement on imaging studies. CONCLUSIONS: Follow-up and pharmacologic treatment was flawed by several adverse conditions present in our population. Patients with progressing neurological disease had a favorable outcome after LT, a similar response to the one reported by several authors. In conclusion, LT should be strongly considered for the treatment of these patients.

Diagnostic yield, therapeutic impact, and complications of double-balloon enteroscopy in patients with small-bowel pathology.

BACKGROUND AND AIMS: Until recently the study of small bowel was limited to the radiographic approach. This paper describes experience with the first 86 procedures evaluated and treated with the new technique of double-balloon enteroscopy (DBE). PATIENTS AND METHODS: Between August 2005 and September 2006, DBE was conducted in consecutive patients. The characteristics of the patients, indications for the procedures, procedural parameters, and diagnostic yield are described here. All conventional treatment options were available. All the patients had previously undergone esophagogastroduodenoscopy and colonoscopy. RESULTS: Eighty-six procedures in sixty-eight patients were carried out (41 women, 27 men; mean age 48.5 years, range 20-82). The most common indications were gastrointestinal bleeding (n = 40) and iron deficiency anemia (n = 7). The mean duration of the procedure was 63 (range 20-194) mins and 80 (range 20-150) minutes for the oral and anal routes, respectively. The mean depth of small-bowel insertion was 250 and 200 cm for the oral and anal routes, respectively. Impact in diagnosis and/or treatment was obtained in 50 patients (73.5%). The commonest findings in the 68 patients were angiodysplasia (n = 11), polyps (n = 8), nodular lymphoid hyperplasia (n = 5) and normal (n = 20). No major complications were observed. CONCLUSION: DBE is a useful tool for the diagnosis and treatment of patients with small-bowel pathology in whom traditional methods have not been effective. In almost two-thirds of patients DBE was clinically useful for diagnosis and treatment. The complication rate with the procedure was very low.

[Predictive factors for portal hypertension in patients with primary sclerosing cholangitis]. / Factores predictores de hipertensión portal en los enfermos con colangitis esclerosante primaria.

BACKGROUND: Primary sclerosing cholangitis (PSC) is characterized by progressive destruction of bile ducts, which may lead to cirrhosis and portal hypertension. The factors associated with the presence of esophageal varices (EV) and the risk of bleeding have not been well defined. AIM: To determine the factors associated with the presence of EV and risk of bleeding in a cohort of patients with PSC. MATERIAL AND METHODS: We analyzed the demographic, biochemical and endoscopic characteristics, and follow-up of 32 patients with a diagnosis of PSC. All patients underwent endoscopic evaluation to determine the presence of EV at diagnosis and annually during follow-up. RESULTS: There were 24 men (75%) and 8 women (25%). The mean age was 40.2 years (range, 19-66). At diagnosis, none of the patients had a previous history of variceal bleeding and 4 (13%) had EV on endoscopic examination. In bivariate analysis, the factors associated with the presence of EV were: splenomegaly (4/6 vs 0/26; p < 0.001), ascites (2/4 vs 0/24; p < 0.001), thrombocytopenia (96 +/- 27 vs 299 +/- 135 x 10(3), p < 0.001), and hypoalbuminemia (2.4 +/- 0.6 vs 3.5 +/- 0.6 g/dl; p = 0.005). During a mean follow-up period of 7 years (range, 2-15 years), 6 patients developed EV and 7 patients had at least one episode of variceal bleeding. In logistic regression analysis, the factors independently associated with the presence of EV at diagnosis were thrombocytopenia (p = 0.001) and splenomegaly (p = 0.01). The factors associated with variceal bleeding were worsening of liver function (p = 0.01) and splenomegaly (p = 0.02). CONCLUSIONS: There are noninvasive indicators of portal hypertension that could predict the presence of EV and risk of bleeding in patients with PSC. The presence of thrombocytopenia, splenomegaly or worsening of liver function should be detected in these patients, as they could benefit from endoscopic surveillance.

Factores predictores de hipertensión portal en los enfermos con colangitis esclerosante primaria / Predictive factors for portal hypertension in patients with primary sclerosing cholangitis

Objetivo: Determinar en una cohorte de enfermos con CEP la frecuencia de VE y los factores asociados para predecir su presencia y riesgo de hemorragia. Material y métodos: Se evaluaron las características demográficas, bioquímicas, endoscópicas y la evolución clínica de 32 enfermos con CEP. En el momento del diagnóstico y con un seguimiento promedio anual a todos se les realizó estudio endoscópico para determinar la presencia de VE. Resultados: Veinticuatro pacientes eran varones (75%) y 8, mujeres (25%). El promedio de edad fue de 40,2 años (intervalo mínimo-máximo, 19-66). En su primera endoscopia ningún paciente tenía historia de hemorragia varicosa y 4 (13%) presentaron VE. En el análisis bivariado, los factores que se asociaron a la presencia de VE fueron: esplenomegalia (4/6 frente a 0/26; p < 0,001), ascitis (2/4 frente a 0/24; p < 0,001), trombocitopenia (96 ± 27 frente a 299 ± 135/103, p < 0,001) e hipoalbuminemia (2,4 ± 0,6 frente a 3,5 ± 0,6 g/dl; p = 0,005). Durante un seguimiento promedio de 7 años (intervalo mínimo-máximo, 2-15) 6 pacientes desarrollaron VE y 7 tuvieron, al menos, un episodio de hemorragia. En el análisis de regresión logística los factores que se asociaron de manera independiente a la presencia de varices fueron trombocitopenia (p = 0,001) y esplenomegalia (p = 0,01). Los factores asociados a hemorragia varicosa fueron el deterioro de la función hepática (p = 0,01) y la esplenomegalia (p = 0,02). Conclusiones: En pacientes con CEP existen marcadores no invasivos de hipertensión portal que pueden ser útiles para predecir la presencia de VE y un mayor riesgo para hemorragia varicosa. Es importante identificar la presencia de esplenomegalia, trombocitopenia y deterioro de la función hepática en estos pacientes, ya que podrían beneficiarse con la vigilancia endoscópica

Background: Primary sclerosing cholangitis (PSC) is characterized by progressive destruction of bile ducts, which may lead to cirrhosis and portal hypertension. The factors associated with the presence of esophageal varices (EV) and the risk of bleeding have not been well defined. Aim: To determine the factors associated with the presence of EV and risk of bleeding in a cohort of patients with PSC. Material and methods: We analyzed the demographic, biochemical and endoscopic characteristics, and follow-up of 32 patients with a diagnosis of PSC. All patients underwent endoscopic evaluation to determine the presence of EV at diagnosis and annually during follow-up. Results: There were 24 men (75%) and 8 women (25%). The mean age was 40.2 years (range, 19-66). At diagnosis, none of the patients had a previous history of variceal bleeding and 4 (13%) had EV on endoscopic examination. In bivariate analysis, the factors associated with the presence of EV were: splenomegaly (4/6 vs 0/26; p < 0.001), ascites (2/4 vs 0/24; p < 0.001), thrombocytopenia (96 ± 27 vs 299 ± 135 x 103, p < 0.001), and hypoalbuminemia (2.4 ± 0.6 vs 3.5 ± 0.6 g/dl; p = 0.005). During a mean follow-up period of 7 years (range, 2-15 years), 6 patients developed EV and 7 patients had at least one episode of variceal bleeding. In logistic regression analysis, the factors independently associated with the presence of EV at diagnosis were thrombocytopenia (p = 0.001) and splenomegaly (p = 0.01). The factors associated with variceal bleeding were worsening of liver function (p = 0.01) and splenomegaly (p = 0.02). Conclusions: There are noninvasive indicators of portal hypertension that could predict the presence of EV and risk of bleeding in patients with PSC. The presence of thrombocytopenia, splenomegaly or worsening of liver function should be detected in these patients, as they could benefit from endoscopic surveillance

Factores predictores de hipertensión portal en los enfermos con colangitis esclerosante primaria / Predictive factors for portal hypertension in patients with primary sclerosing cholangitis

Objetivo: Determinar en una cohorte de enfermos con CEP la frecuencia de VE y los factores asociados para predecir su presencia y riesgo de hemorragia. Material y métodos: Se evaluaron las características demográficas, bioquímicas, endoscópicas y la evolución clínica de 32 enfermos con CEP. En el momento del diagnóstico y con un seguimiento promedio anual a todos se les realizó estudio endoscópico para determinar la presencia de VE. Resultados: Veinticuatro pacientes eran varones (75%) y 8, mujeres (25%). El promedio de edad fue de 40,2 años (intervalo mínimo-máximo, 19-66). En su primera endoscopia ningún paciente tenía historia de hemorragia varicosa y 4 (13%) presentaron VE. En el análisis bivariado, los factores que se asociaron a la presencia de VE fueron: esplenomegalia (4/6 frente a 0/26; p < 0,001), ascitis (2/4 frente a 0/24; p < 0,001), trombocitopenia (96 ± 27 frente a 299 ± 135/103, p < 0,001) e hipoalbuminemia (2,4 ± 0,6 frente a 3,5 ± 0,6 g/dl; p = 0,005). Durante un seguimiento promedio de 7 años (intervalo mínimo-máximo, 2-15) 6 pacientes desarrollaron VE y 7 tuvieron, al menos, un episodio de hemorragia. En el análisis de regresión logística los factores que se asociaron de manera independiente a la presencia de varices fueron trombocitopenia (p = 0,001) y esplenomegalia (p = 0,01). Los factores asociados a hemorragia varicosa fueron el deterioro de la función hepática (p = 0,01) y la esplenomegalia (p = 0,02). Conclusiones: En pacientes con CEP existen marcadores no invasivos de hipertensión portal que pueden ser útiles para predecir la presencia de VE y un mayor riesgo para hemorragia varicosa. Es importante identificar la presencia de esplenomegalia, trombocitopenia y deterioro de la función hepática en estos pacientes, ya que podrían beneficiarse con la vigilancia endoscópica

Background: Primary sclerosing cholangitis (PSC) is characterized by progressive destruction of bile ducts, which may lead to cirrhosis and portal hypertension. The factors associated with the presence of esophageal varices (EV) and the risk of bleeding have not been well defined. Aim: To determine the factors associated with the presence of EV and risk of bleeding in a cohort of patients with PSC. Material and methods: We analyzed the demographic, biochemical and endoscopic characteristics, and follow-up of 32 patients with a diagnosis of PSC. All patients underwent endoscopic evaluation to determine the presence of EV at diagnosis and annually during follow-up. Results: There were 24 men (75%) and 8 women (25%). The mean age was 40.2 years (range, 19-66). At diagnosis, none of the patients had a previous history of variceal bleeding and 4 (13%) had EV on endoscopic examination. In bivariate analysis, the factors associated with the presence of EV were: splenomegaly (4/6 vs 0/26; p < 0.001), ascites (2/4 vs 0/24; p < 0.001), thrombocytopenia (96 ± 27 vs 299 ± 135 x 103, p < 0.001), and hypoalbuminemia (2.4 ± 0.6 vs 3.5 ± 0.6 g/dl; p = 0.005). During a mean follow-up period of 7 years (range, 2-15 years), 6 patients developed EV and 7 patients had at least one episode of variceal bleeding. In logistic regression analysis, the factors independently associated with the presence of EV at diagnosis were thrombocytopenia (p = 0.001) and splenomegaly (p = 0.01). The factors associated with variceal bleeding were worsening of liver function (p = 0.01) and splenomegaly (p = 0.02). Conclusions: There are noninvasive indicators of portal hypertension that could predict the presence of EV and risk of bleeding in patients with PSC. The presence of thrombocytopenia, splenomegaly or worsening of liver function should be detected in these patients, as they could benefit from endoscopic surveillance

La programacion en el ambito de la rehabilitacion / Programs in rehabilitation

RESUMEN Aunque todos los programas que se deben desarrollar son importantes, existen entre ellos algunos que constituyen la parte medular de la prevención de la invalidez y la rehabilitación del inválido. La importancia de la programación estriba en que las metas que se alcanzan en un período determinado, deben estar en relación directa con sus propios recursos; tanto humanos como materiales y financieros, porque sólo a través de ellos se genera una actividad y se logra la obtención de objetivos predeterminados. Si partimos de la premisa de que para cualquier actividad se necesita el recurso financiero como condición indispensable y de que para obtener este se necesita un presupuesto. llegamos a la sencilla conclusión de que este último tampoco puede llevarse a cabo sin una previa programación, siguiendo como anteriormente señalamos una de las más importantes innovaciones de la Reforma Administrativa y que se conoce actualmente con el nombre de "Presupuesto por Programas". La programación es un acontecimiento vigente que debemos dar cumplimiento por disposiciones contempladas en la Reforma Administrativa y dictadas por la Secretaría de Programación y Presupuesto: en la inteligencia de que salvo a los programas de apoyo. no se otorgarán asignaciones presupuestales, si ésta no están correspondidas con metas. Trabajar en base a programas nos permite y nos permitirá cada vez con mayor precisión, medir la eficiencia de los resultados ya que cada uno de ellos tiene un objetivo. una meta por alcanzar, un responsable en su ejecución. un costo determinado y un momento en el tiempo para su conclusión exitosa