[Carcinoma of the gastroesophageal junction following variceal sclerosis: more than a coincidence?]
Larrubia JR. Mendoza JL. Ciguenza R. Lana R. Gonzalez JF. Espinos D.
Servicio de Aparato Digestivo, Hospital Universitario San Carlos, Madrid.
In the last decade, several cases of patients with esophageal varices treated with endoscopic sclerotherapy who posteriorly developed carcinoma of the gastroesophageal junction have been reported in the literature. This may only be a coincidence, although the existence of an undemonstrated relationship direct cannot be discarded. The case of a patient diagnosed with alcoholic liver cirrhosis with portal hypertension and esophageal varices who underwent several sessions of endoscopic sclerotherapy with ethanolamine oleate is presented. During follow-up dysphagia was observed due to adenocarcinoma of the lower third of the esophagus. Carcinoma of the esophagus should be taken into account as a rare diagnostic possibility in a patient with dysphagia of recent appearance with a history of esophageal varix sclerotherapy.
[Idiopathic ductopenia in adults as a cause of cryptogenic cirrhosis and complications of portal hypertension]
Rodriguez Martinez D. Fernandez Rodriguez CM. Rodriguez Prada I. Pereira Bueno S. Butron M. Colina F.
Servicio de Gastroenterologia, Hospital Xeral de Vigo.
We describe a 56 years old male patient with long-term chronic liver disease of unknown etiology presenting with esophageal varices rupture. Prophylaxis of re-bleeding with propranolol and endoscopic sclerotherapy failed to prevent further haemorrhagic events and the placement of a transjugular intrahepatic portosystemic shunt (TIPS) was needed. The portal hemodynamic data revealed sinusoidal portal hypertension and the liver biopsy displayed ductopenic cholestasis. The patient met all criteria of idiopathic ductopenia. Subsequently, the jaundice worsened and the patient required liver transplantation.
[Malignant digestive tumor mortality in Castilla-La Mancha (1975-1990)]
Criado Alvarez JJ. Martinez Hernandez J. Gonzalez Solana I. Romo Barrientos C.
Seccion de Investigacion y Docencia, Centro Regional de Salud Publica, Talavera de la Reina y Servicio de Asistencia Sanitaria, Toledo.
BACKGROUND: The study investigates the temporary trend of the mortality by digestive malignant tumours in Castilla-La Mancha from 1975 to 1990. MATERIAL AND METHODS: Standardized rates were calculated by direct method, using world and european population as standard, truncated rates (35-64 years old) and cumulative rates (0-74 years old) according to tumoral location and sex. RESULTS: In both sexes the mortality by colon cancer has increased whereas the mortality by stomach cancer has decreased. These changes observed are similar with those observed in other epidemiologic studies. CONCLUSION: Driving a 15 year period a significant change in mortality due to colonic and gastric cancer has occurred in Castilla-La Mancha.
[Mesenteric lymph node cavitation: a rare complication of celiac disease in the adult]
Susano R. de Quiros JF. Caminal L. Marroquin AG. Trapiella L. Astudillo A.
Servicio de Medicina Interna II, Hospital Central de Asturias (Centro Universitario), Oviedo.
A case of coeliac disease (CD) and mesenteric lymph node cavitation (MLNC) in a 42-years-old female is presented. The other cases reported in the literature are also reviewed. The most important ganglionar histological features are described and a pathogenic explanation is suggested.
[Arterioportal fistula and hemobilia in a patient with hepatic transplant]
Vivas S. Palacio MA. Lomo J. Cadenas F. Linares A. Rodriguez M. Rodrigo L.
Servicio de Aparato Digestivo, Hospital Central de Asturias, Oviedo.
The case of a 36-year old male liver transplant recipient hospitalized for upper digestive hemorrhage, jaundice and pain in the right hypochondrium is herein reported. Two hepatic biopsies had been performed 60 and 7 days prior to admission. Bleeding was observed to be from the biliary tract by endoscopy and an arterioportal fistula in the right hepatic lobe by echo-doppler and arteriography was seen. Treatment with selective embolization by arteriography was satisfactory with biliary tract drainage not being required. Doppler echography was used to control the evolution of the patient.
[Malignant lymphoproliferative neoplasms and chronic hepatitis C virus infection]
Perez Alvarez JC. Saez-Royuela F. Martin Lorente JL. Yuguero del Moral L. Ojeda Gimenez C. Lopez Morante A.
Seccion de Aparato Digestivo, Hospital General Yague, Burgos.
It has been suggested that chronic hepatitis C virus (HCV) infection predisposes to the development of benign and malignant lymphoproliferative disorders. We present 2 cases of malignant lymphoproliferative neoplasias (a non-Hodgkin lymphoma [NHL] and a chronic lymphoid leukemia [CLL]) associated to chronic hepatitis C virus (HCV). The possible etiological role of HCV in the development of these tumors is discussed.
[Acute hepatocellular lesion induced by amoxicillin-clavulanic acid]
Julve R. Garcia A. Gomez A. Primo J. Moles JR. Hinojosa J.
Servicio de Medicina Interna, Hospital de Sagunto, Valencia.
Since first description in 1988, numerous cases of amoxycillin-clavulanic acid hepatotoxicity have been reported. Most of them are cholestatic hepatitis. A case of acute hepatocellular injury by amoxycillin-clavulanic acid is reported in a 23-years-old male, with a favourable outcome after 18 weeks.
[Endoscopic ultrasonography in the staging of esophageal cancer. Therapeutic implications]
Gines A. Bordas JM. Llach J. Mondelo F. Fernandez J. Castells A. Pera M. Grande L. Pique JM.
Seccion de Endoscopia Digestiva, Hospital Clinic i Provincial, Barcelona.
Endoscopic ultrasonography (EUS) provides accurate visualization of the different layers of the gastrointestinal wall and surrounding structures, allowing TN staging of tumors prior surgery. The aim of this study was to evaluate the sensitivity, specificity and accuracy of EUS in the staging of esophageal carcinoma as well as its applicability and usefulness in tumors with nontraversable stenoses. EUS was performed in 43 patients with esophageal carcinoma. The technique was carried out with a radial echoendoscope under sedation with i.v. midazolam. Both, the infiltration of the tumor through the layers of the esophageal wall (T staging) and the presence of lymph nodes in different areas (N and M staging) were determined. In cases with nontraversable stenoses, only the proximal tumor margin was assessed by means of EUS. EUS showed T1 stage in only one case and more advanced stages in the remaining patients: T2 (n = 12), T3 (n = 22) and T4 (n = 4). We know the outcome of 28 patients, 14 of whom underwent surgery. In these patients, the sensitivity for T and N staging was 86% and 92% respectively, and the accuracy 86% in both. Both, T and N, were overstaged in one case (7%) and understaged in another (7%). The tumor caused nontraversable stenoses in 59% of patients (n = 26). In 4 patients the staging could not be assessed with sufficient reliability. In the subgroup of patients with nontraversable stenoses who underwent surgery, the accuracy of EUS when comparing with histopathology was 80%. Endoscopic ultrasonography has a high sensitivity and accuracy in the staging of esophageal tumors even in cases with nontraversable stenoses.
[The value of endoscopic ultrasonography in the study of submucosal tumors of the digestive tract]
Varas Lorenzo MJ. Maluenda MD. Pou JM. Abad R. Turro J. Espinos JC.
Servicio de Endoscopia Digestiva, Hospital General de Cataluna, Centro Medico Teknon, Barcelona.
Twenty-one consecutive patients with 24 possible submucosal lesions of the digestive tract were studied. Endoscopic ultrasonography (EUS) differentiated between 17 true positive submucosal tumors and 3 true negative extrinsic compressions. False positives were interpreted in 3 cases and in one patient no lesion was echoendoscopically observed (false negative). The sensitivity was 94%, the specificity 50% and the positive and negative predictive values were 82% and 75%, respectively. In conclusion, EUS may be the method of choice for the study of submucosal tumors since it allows visualization of the five layers of the wall of the digestive tract in which a tumor may originate, determination of its sonographic features, depth and exact size, in addition to the invasion of neighboring organs. Moreover, EUS may aid in collecting material for cytology and microscopy by fine needle aspiration puncture (FNAP) by EUS.
[Celiac disease of the adult following orthotopic liver transplantation. Description of a case]
Garrido C. Vaquer P. Gaya J. Llompart A. Riera J. Ginard D. Bonet L. Obrador A.
Servicio de Digestivo, Hospital Son Dureta, Palma de Mallorca.
A case of celiac disease of the adult is herein described in a patient with a history of orthotopic liver transplantation because of cirrhosis due to hepatitis C virus. The patient presented with a decrease in the levels of cyclosporinemia, diarrhea and an increase in transaminases. This is an infrequent form of presentation leading to differential diagnosis with a complication related to the liver disease.
[Hepatitis associated with treatment with lovastatin. Presentation of 2 cases]
Bruguera M. Joya P. Rodes J.
Servicio de Hepatologia, Hospital Clinic i Provincial de Barcelona.
Two women of 57 and 59 years of age, presented anicteric hepatitis at 9 months and 3 years, respectively, of the initiation of treatment with lovastatin (20 mg/day) for hypercholesterolemia. In both cases other causes of liver damage were excluded and the analytical alterations normalized within a few weeks following discontinuation of the medication.
[Free bowel perforation as the onset and as a complication in the evolution of crohns disease]
Nos P. Pastor M. Hoyos M. Ponce J. Berenguer J.
Servicio de Medicina Digestiva, Hospital La Fe, Valencia.
Free bowel perforation is a relatively infrequent complication of Crohn's disease. It may present during the evolution of the disease or, occasionally, in the onset of the same and may involve the small intestine or colon. We herein present 4 cases, three of ileal localization and one of colonic localization. In one of the 3 former cases and the latter case perforation took place prior to diagnosis of the disease. Review of the literature was performed with respect to the frequency, pathogenesis and characteristics of this complication and the importance of determined diagnostic techniques such as echography and CAT in addition to the most adequate treatment are commented upon.
[Volvulus of the gallbladder. Description of a case]
Sancha Perez AM. Martinez-Conde Lopez AE. Romeo Ramirez JA. Olivares Galdeano U. Gomez de Carrero Foncea JC. Echavarri Inigo J.
Cirugia General y del Aparato Digestivo, Hospital Santiago Apostol, Vitoria.
Volvulus of the gallbladder is infrequent and is predominantly observed in elderly women, being related to anatomical abnormalities of the gallbladder which, associated with other factors, favor twisting. This is commonly diagnosed as acute cholecystitis, causing severe, acute abdominal pain with a rapid evolution which may lead to the death of the patient if emergency surgery is not performed. A case of gallbladder volvulus diagnosed as acute appendicitis is presented as is a review of the literature.
[Cost effectiveness of the treatment of chronic hepatitis C with interferon-alpha]
Buti M. Casado MA. Fosbrook L. Esteban R.
Servicio de Hepatologia, Hospital General Universitario de la Vall d'Hebron, Barcelona.
The purpose of this study was to assess the cost-effectiveness of the treatment of chronic hepatitis C with interferon in Spain. Disease progression was studied using a Markov model through which an untreated cohort of 1000 patients was compared with cohorts treated with interferon 3 MU three times per week for 6, 12 or 18 months. Treatment cost, patients quality of life, and survival were the parameters evaluated. Using the perspective of the National Health System, an 18 month treatment with alfa interferon offers a better cost-effectiveness ratio than a treatment of 6 or 12 months duration. The age of the patient at the start of treatment is one of the most influential factors on the cost-effectiveness of treatment. In patients under 45 years of age, a net cost saving is observed with all treatment schedules, especially with 18 months treatment, due to significant reductions in severe complications of disease progression. In patients aged 45-60, 18 months treatment incurs a net cost, although important gains are made in survival and quality of life. In patients over 65 years of age, the economic benefits of prolonged treatment do not compensate the extra cost. In conclusion, treatment of chronic hepatitis C with alfa interferon should begin as early as possible, especially in young patients. In cases of favourable response, treatment should be extended to 18 months, in order to obtain a higher rate of sustained response, avoid progression of hepatic disease and achieve a more favourable cost-effectiveness ratio.
[Significance of the determination of antineutrophil cytoplasmic antibodies (ANCA) in ulcerative colitis and Crohns disease]
Garcia-Herola A. Nos P. Hoyos M. Hinojosa J. Moles JR. Pascual S. Bustamante M. Sanchez Cuenca JM. Carmona E. Ponce J. Berenguer J.
Servicio de Medicina Digestiva, Hospital La Fe, Valencia.
We have studied prospectively 126 consecutive patients recruited with a known diagnosis of ulcerative colitis (UC; n = 78) and Crohn's disease (CD; n = 48) for anti-neutrophil cytoplasmatic antibodies (ANCA) by indirect immunofluorescence (IFI). Forty-six percent of UC and 18% of CD patients were found positive. The sensitivity and specificity for UC diagnosis were 0.46 and 0.81, respectively. We evaluated the pattern of IFI exhibited (perinuclear: pANCA and cytoplasmatic: cANCA). cANCA was found in 77% of CD and in only 30% of UC patients (p = 0.01). Sera from all CD patients were positive at a 1:20 dilution (and not at higher dilution) and it occurred in only in 14 UC patients (30%). Positive sera were also tested to characterize the antigen specificity by enzyme-linked immunosorbent assay (ELISA) but the antigenic nature of ANCA could not be identified in most cases. No differences were found between ANCA positive and ANCA negative patients regarding colonic extension (UC) or colonic involvement (CD), activity and colectomy. We conclude that ANCA may be a helpful diagnostic test in UC patients but it not seems to be important as a marker of activity. ANCA positivity can reflect disease heterogeneity in UC patients, perhaps discriminating those with immunologic disturbances.
[Magnetic resonance cholangiopancreatography (MRCP) versus endoscopic retrograde cholangiopancreatography (ERCP): diagnostic usefulness]
Pamos S. Rivera P. Canelles P. Quiles F. Orti E. Cuquerella J. Martinez V. Medina E.
Unidad de Endoscopia Digestiva, Hospital General Universitario de Valencia.
Magnetic resonance cholangiopancreatography (MRCP) is a new noninvasive technique to examine the biliopancreatic tract that have a high diagnostic accuracy. Thus it becomes an appealing modality that can avoid invasive approaches. The purpose of this study was to evaluate the sensitivity and specificity of MRCP in comparison to endoscopic retrograde cholangiopancreatography (ERCP). We studied 41 patients (24 male, 17 female), median age 64.2 years (range 20 to 86 years), in which MRCP and later ERCP were performed; results of both techniques were compared. In the assessment of biliary tract (n = 39), sensitivity/specificity was 100/94.4% in normal bile ducts (n = 18); 100/100% in choledocholithiasis (n = 13); 100/100% in sphincter of Oddi dysfunction (n = 2), and 100/83.3% in neoplasm (3 ampullary tumors, 2 cholangiocarcinomas). In the evaluation of pancreatic duct (n = 32), sensitivity/specificity was 100/95.8% in normal pancreatic duct (n = 23); 80/100% in chronic pancreatitis (n = 5), and 100/75% in pancreatic carcinoma (n = 3). MRCP has very high sensitivity and specificity in the evaluation of the biliary and pancreatic ducts, and can avoid to perform purely diagnostic ERCP, although further studies are required to better assess the effectiveness of the technique.
[Duodenal Crohns disease: diagnostic and therapeutic complexity]
Sanjuan Portugal F. Cabrera Chaves T. Yus Gotor C. Gomollon Garcia F.
Servicio de Medicina Interna, Hospital Miguel Servet, Zaragoza.
Crohn's disease may involve any area of the digestive tract, but its localization in the duodenum is rare. The clinical, radiological or endoscopic findings may simulate those of peptic ulcer and histologic examination is not diagnostic. In contrast with Crohn's disease of any other localization, the formation of fistulas is exceptional. The authors present one case of duodenal Crohn's disease the unspecific symptomatology of which deviated the original orientation towards the more common diseases. Steroid treatment was not sufficient to control the disease which led to complications with the formation of an enterocutaneous fistula. The association of azathioprine was very effective not only in achieving remission of the process, but also in resolving the complications.
[Pancreatic abscess caused by Candida following wide-spectrum antibiotic treatment]
de Vera F. Martinez JF. Clara Verdu R. Lopez MM. Gomez A.
Seccion de Aparato Digestivo, Hospital General Universitari d'Alacant.
Pancreatic infection by Candida is an infrequent entity. We report two cases and review literature. A 67 year-old woman who was admitted for severe acute pancreatitis of biliary origin developed high fever during fourth week of stay; it was secondary to a pancreatic abscess due to Candida. On the other hand, a 67 year-old man with severe acute biliary pancreatitis and renal insufficiency showed an abscess of similar characteristics that was identified during fourth week of evolution. Both of them recovered completely after surgical drainage and antifungical parenteral treatment. The use of broad spectrum antibiotics recently recommended for prophylaxis of pancreatic infection in patients with necrotizing acute pancreatitis, can favour opportunistic infection by several agents. Pancreatic abscesses by Candida often occurs in patients receiving broad spectrum antibiotics, although it isn't an essential condition. The fact that Candida could be only a contaminant may delay diagnosis and early treatment, and then it can determine a poor outcome. Adequate treatment is urgent surgical drainage associated with antifungical parenteral therapy. Usefulness of antifungic drugs in patients undergoing long term antibiotic prophylaxis for secondary infection must be evaluated.
[Chronic cholestasis as a presentation form of portal cavernoma]
Garcia Escano MD. Andrade RJ. Alcantara R. Melgarejo F. Camargo R. Moreno P. Alcain G. Fraile JM. Franquelo E.
Servicio de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Malaga.
A 37 year-old-woman was evaluated in 1993 for a chronic asymptomatic cholestasis. An endoscopic retrograde cholangiopancreatography showed the biliary tract compressed, and a mesenteric angiogram disclosed that the cause of biliary obstruction was a portal cavernoma. In addition, large esophageal varices with "red spots" were observed at endoscopy. Propranolol and ursodeoxicolic acid were started and the patient has remained asymptomatic to date. The biliary features of portal cavernoma are reviewed, as well as its pathogenesis, diagnosis and management. Portal cavernoma should be considered in the differential diagnosis of chronic cholestasis.
[Evaluation of body fluid compartments and their relationship with water-electrolyte changes in obstructive jaundice]
Gallardo Valverde JM. Padillo Ruiz FJ. Rodriguez Quiros M. Gomez Alvarez M. Naranjo Rodriguez A. Martin Malo A. Puente Gutierrez J. Mino Fugarolas G. Sitges-Serra A. Pera Madrazo C.
Departamento de Cirugia, Hospital Universitario Reina Sofia, Cordoba.
BACKGROUND: The alteration of the mechanisms of water and sodium preservation may be an important factor in the development of acute postoperative renal failure in obstructive jaundice (OJ). Experimental OJ has been associated with a depletion of the extracellular volume and alteration of the mechanisms of regulation of hydrosaline metabolism. The aim of this study was to evaluate the distribution of the body volumes and the regulating hormones of hydrosaline metabolism in human OJ. PATIENTS AND METHOD: A prospective, clinical study evaluating 18 patients with OJ (9 females and 9 males) with a mean age of 69 +/- 8.9 years was performed. The plasma levels of antinatriuretic peptide (ANP), aldosterone and renin were determined. The body volumes were evaluated by tetrapolar bioimpedanciometry. The results of the patients with OJ were compared with a control group (CG) of 12 healthy subjects, matched for age and sex (6 females and 6 males with a mean age of 64.5 +/- 14 years). RESULTS: High ANP values were observed in 87.5% of the patients. The results of the hormonal studies compared with the CG were: ANP (117.33 +/- 37.7 vs 41.31 +/- 16.8 pg/ml; p < 0.001), aldosterone (185.68 +/- 82.1 vs 44.3 +/- 21.6 pg/ml; p < 0.001) and renine (57.18 +/- 69.9 vs 16.08 +/- 9.7 microU/ml; p < 0.05). Depletion of extracellular volume was found in 75% of the patients. CONCLUSIONS: Human obstructive jaundice is associated with an important alteration in the hormonal mechanisms of water and sodium regulation. This alteration is accompanied by a marked depletion of extracellular volume.
[Intestinal obstruction and necrotizing thyroiditis secondary to Pneumocystis carinii infection in a seropositive hemophiliac patient seropositive for human immunodeficiency virus]
Olcoz Gonni JL. Moran Blanco A. Bahamonde Carrasco A. Alonso A. Suarez D. Gundin MJ. Munoz M.
Servicio de Digestivo, Hospital de Leon.
We report a case of bowel infection by Pneumocystis carinii (PC) that presented as an acute obstruction accompanied by intestinal hemorrhage (melena) in a HIV seropositive hemophilic patient. Laparotomy followed by resection of two plaque-like jejunal tumors was performed, and intravenous therapy with pentamidine was initiated. No other organ was found to be affected by PC (not even the lung), with the exception of the thyroid gland. To our knowledge, this is the first reported case in which acute intestinal obstruction was the presenting symptom of extrapulmonary pneumocystosis.