Thyroid function in acute pancreatitis.
De Sola C. Redondo M. Pallares F. Redondo E. Hortas ML. Morell M.
Department of Digestive Medicine, Costa del Sol Hospital, Marbella, Malaga, Spain.
OBJECTIVES: To analyze changes in the thyroid function in patients with acute pancreatitis. METHODS: Admission serum levels of triiodothyronine (T3), reverse triiodothyronine (rT3), thyroxine (T4) and thyrotropin (TSH) were determined in 20 patients with pancreatitis and 20 healthy control patients. Another group of 20 patients with upper digestive haemorrhage was included to study possible changes in the pattern of thyroid function in hemodynamic alterations. In addition, laboratory indicators of liver, renal and pancreatic functions were measured in all groups. RESULTS: Our results demonstrated low levels of T3 in 20% of patients with pancreatitis and increased rT3 levels in 75% of them. Thyrotropin was always among reference ranges and only one case presented a low level of T4. No significant alterations were detected in patients with upper digestive haemorrhage. CONCLUSIONS: These results suggest that pancreatitis may play a role in the genesis of these changes, since other factors such as diet and cellular hepatic alteration appear to have had no effect on the levels of thyroid hormones in these patients. In other studies those changes in the thyroid function can be relationed with the prognosis in acute pancreatitis.
Endoscopic pancreatic stent drainage improves pain in chronic pancreatitis.
Pellicer Bautista F. Fernandez Perez FJ. Martin Guerrero JM. Pallares Manrique H. Hassan Asad M. Romero Castro R. Hergueta Delgado P. Herrerias Gutierrez JM.
Service of Digestive Diseases, Virgen Macarena Universitary Hospital, Sevilla, Spain.
Pain in chronic pancreatitis is due to intraglandular neural affection and to pancreatic duct drainage obstruction with an increased intraductal pressure. To achieve pain relief, medical, surgical and endoscopic procedures have been developed. AIM: To evaluate the efficacy of pancreatic duct stenting in patients with narcotic-dependent pain due to chronic pancreatitis. PATIENTS AND METHOD: From May-1994 to May-1996, ten patients (medium age: 47.5 yr) with alcoholic chronic pancreatitis were selected for this procedure. Pancreatography showed single or multiple Wirsung strictures in all cases. Papillotomy and pancreatic duct sphincterotomy were performed before stenting. Strictures were negotiated with a 7F dilating catheter over a guide wire, and intraductal calculi were removed as well. We used 7F plastic stents with variable lengths (5-10 cm), that were exchanged when the patient presented pain recurrence. Stent survival time was defined as the patient's pain-free time. RESULTS: In 6 of the 10 patients stent placement was carried out successfully. A single distal Wirsung stricture was diagnosed in 3 patients while in the remaining 3 there were several strictures associated to ductal lithiasis in two of them. Mean time to achieve pain relief was 3 days and mean stent survival time was 166.5 days. There were no complications due to the procedure. CONCLUSIONS: When placed through the stricture, endoscopic pancreatic stent drainage is effective in achieving pain relief. It is a safe procedure with no complications in our short series.
Acute biliary pancreatitis: sphincter of Oddi and choledochal pressure.
Ayuso Osuna V. Diez Cascon A. Valverde Sistes J.
Department of Surgery, General Hospital of Ciudad Sanitaria Valle de Hebron, Barcelona, Spain.
Twenty four patients with biliary pancreatitis were divided into three groups: A (18 subjects underwent surgery on the biliary tract seven days after admission to hospital when acute signs disappeared); B (3 cases were operated two months later), and C (3 patients underwent emergency surgery for acute cholescistitis with simultaneous acute pancreatitis). A cholecistectomy-choledochostomy through a Kehr tube was performed in all patients. Pressure in the main biliary duct (MBD) was measured. Only group A was significant (18 cases). As a control, another group, group D was considered (52 biliary cholecysto-choledochal lithiasis patients without pancreatitis and without transduodenal sphincterotomy). Group A: 1) The mean pressure in MBD on the fourth postoperative day (11 days after onset of pancreatitis) was low (p < 0.0001) in relation to that of group D with Oddi's sphincter (SO) normal; 2) in group A, no significant differences (p-NS) were found in relation to positions: during fasting, 4.4 +/- 4 cm H2O in the upright position, and 5.3 +/- 2 when lying (in group D, 9.9 +/- 4.1 cm H2O upright, and 7.76 +/- 3.6 lying with p = 0.0001), and 3) a slow improvement of pressure was observed and, on the 25th day after operation, it was nearly normal (9 cm H2O upright and 7 cm lying with p < 0.001). Group B: biliary surgery at 2 months; mean pressure in MBD meartly normal. Group C: 1) 4 days after emergency surgery, the pressure in MBF (15 cm H2O upright and 11.7 lying) was higher than in subjects with normal SO, probably due to compression of the distal part of MBD by the inflamed pancreas, and 2) from the 11th day the pressure followed the same evolution as that of group A. In conclusion, in patients with acute biliary pancreatitis, operated on the biliary tract when acute signs disappeared, MBD pressure is low (p < 0.0001) in reference to normal on the fourth post-operatory day (11 days after onset of pancreatitis) and no significant differences were found in relation to positions (upright and lying). The pressure changes are transient (4-5 weeks) and most probably due to the lesions and malfunction of the SO related to pancreatitis.
[Hepatocellular carcinoma associated to porphyria cutanea tarda and hepatitis C virus infection without cirrhosis]
Moreno FJ. Santoyo J. Bondia JA. Suarez MA. Jimenez M. Fernandez JL. Conde M. Marin R. Ribeiro M. Pelaez JM. de la Fuente A.
Servicio de Cirugia General y Digestiva, Hospital Regional Carlos Haya, Malaga.
The molecular basis of porphyria cutanea tarda is defective activity of hepatic uroporphyrinogen decarboxylase. A common characteristic is liver dysfunction than goes from cirrhosis to hepatocellular carcinoma. A high prevalence of hepatitis C virus markers has been demonstrated. We study a patient with PCT and hepatitis C virus markers that finally develops to hepatocellular carcinoma without previous cirrhosis. Previous studies with association of PCT and hepatitis C virus markers, have found liver diseases ranging from cirrhosis to hepatocellular carcinoma. The importance of this study is the absence of cirrhosis.
Endoscopic stenting in the management of malignant biliary obstruction.
Pellicer Bautista F. Martin Guerrero JM. Fernandez Perez FJ. Hassan Asad M. Pallares Manrique H. Romero Castro R. Hergueta Delgado P. Herrerias Gutierrez JM.
Service of Digestive Diseases, Virgen Macarena Universitary Hospital, Sevilla, Spain.
A relevant percentage of patients with malignant biliary obstruction are not candidates for surgery when the diagnosis is made. Endoscopically placed biliary stents have shown their efficacy in the palliative management of these patients although they do not seem to increase their survival. We report on a retrospective analysis of 37 patients with malignant biliary obstruction treated with endoscopic biliary stents. The distal third (62%) of the main life duct was the most frequent common location for the obstruction, and pancreatic cancer was the most frequent cause of obstruction (64%). Twenty three plastic (13-7F and 10-10F) and 14 metallic stents were placed initially. Forty four percent of the plastic stents (all of them 7F, none 10F) were removed after 39 days against 30% of the metallic stents after a mean period of 60 days. Global survival was 153 days (110 in the plastic stents' group versus 195 in the metallic one, p: NS). We could only make a complete follow up in 52% of the patients. Conclusions: endoprotheses are a good palliative treatment for malignant biliary obstruction. When plastic stents are used they should have a wide calibre (10F or greater). Metallic stents result in an increase of survival time without statistical significance.
Manometry and 24-hour ambulatory pH monitoring at two levels of the esophagus in patients with and without esophagitis.
Sevilla Mantilla MC. Ruiz de Leon A. Perez de la Serna J. Taxonera C. Garcia Paredes J. Diaz Rubio M.
Service of Digestive Diseases, San Carlos University Hospital, Madrid, Spain.
OBJECTIVE: To define the relationship between esophageal dysmotility and severity of gastroesophageal reflux (GER) at the distal and proximal levels. METHODS: Two-level, 24-hour ambulatory pH monitoring and manometry of the esophagus were performed in 40 patients with abnormal distal acid exposure and in 20 healthy controls. Twenty patients with normal endoscopy or endoscopic evidence of grade I esophagitis were assigned to group 1 and 20 with grade II-III esophagitis were assigned to group 2. We used a dual-site pH probe with antimony electrodes spaced 15 cm apart. RESULTS: Patients had greater acid exposure than controls at both levels. The percentage of distal reflux episodes reaching proximal esophagus was significantly greater in group 1 than in the control group. The most marked reductions in the percentage of time of the pH remaining under 4 were detected in the patients with the most severe distal acid reflux and esophagitis (group 2). The mean lower esophageal sphincter pressure was significantly lower in group 2 than in group 1. The percentage of tertiary waves or nonperistaltic contractions was significantly higher in group 2 than in group 1 and the control group. Patients with milder distal reflux had significantly lower distal and middle esophageal wave amplitudes than controls. There were no significant differences between controls and patients with severe esophagitis in terms of the esophageal peristaltic wave amplitude in the middle third of the esophagus. CONCLUSIONS: No correlation was observed between episodes of distal reflux and proximal reflux in GER patients. Esophageal motor activity appears to be an important determinant of the severity and extension of GER in the proximal esophagus.
[Primary intestinal T lymphoma]
Remacha B. Palau A. Velicia R. Caro-Paton A. Ripolles V.
Seccion de Aparato Digestivo, Hospital General de Castello.
Primary gastrointestinal lymphoma comprises a group of distinctive clinicopathological entities. They may be of B or T-cell type. Intestinal T-cell lymphomas are much less common and include the entity: lymphomas T enteropathy-associated T-cell lymphoma, the most common, and T-cell lymphoma without features of enteropathy. The morphologic and immunologic findings suggest that derived from mucosal T lymphocytes population. Clinically, the patients were usually males with constitutional symptoms and acute perforation and/or obstruction of the small bowel. Their prognosis are very poor and tumor are very aggressive.
[Acute abdomen as a complication of a duodenal duplication cyst]
Louredo Mendez A. Alonso Poza A. De Tomas Palacios J. Trinchet Hernandez M. Munoz-Calero A.
Servicio de Cirugia General I, Hospital General Universitario Gregorio Maranon, Madrid.
The authors report an exceptional case of acute abdomen caused by the necrosis and perforation of a duodenal duplication cyst in a 23 year-old-patient. The cyst was located at the anterior and lateral surface of the duodenum, between its first and second portion. The patient underwent a cephalic duodenopancreatectomy (Whipple's procedure) because of the intimate adherence of the necrotic and inflammatory mass to duodenum and head of the pancreas. The histological examination of surgical specimen confirmed the diagnosis, showing a cystic structure lined with an epithelium and a common muscle wall shared by the cyst and the duodenum. There was no communication between the cyst and duodenal lumen.
HLA-DR2 gene and Spanish patients with ulcerative colitis.
Fernandez Arquero M. Lopez Nava G. De la Concha EG. Figueredo MA. Santa Cruz S. Dumitru CG. Diaz Rubio M. Garcia Paredes J.
Department of Immunology, Hospital Clinico San Carlos, Madrid, Spain.
BACKGROUND: An association with class II MHC genes has been described in ulcerative colitis, as in other diseases with immunological pathogenesis. Heterogeneous results have been reported, depending on the studied population. OBJECTIVE: To study the importance of these genes in our population, mainly the alleles of group HLA DR2 (gene HLA-DRB1). PATIENTS AND METHODS: We studied a total of 107 patients diagnosed of ulcerative colitis and 200 unaffected controls. Complete information about sex, age, family antecedent, age of onset, localization, complications, surgery and treatment was obtained from these patients. DNA was extracted from peripheral blood leukocytes and all the individuals were HLA-DRB1 genotyping. RESULTS AND CONCLUSIONS: We conclude that a positive association exists between DR15 and ulcerative colitis (p < 0.05). This positive association was characterized and various clinical parameters were analyzed, being concluded that DR1501 is more frequent in this disease (p < 0.05) and in benign manifestations; the frequency of the allele DR1502 was also found to be elevated in severe manifestations.
Establishment of an experimental model of colon cancer which replicates the regional extension pattern of human colorectal adenocarcinoma.
Garcia Olmo D. Garcia Rivas M. Garcia Olmo DC. Atienzar M.
Research Unit, Albacete General Hospital.
OBJECTIVE: The aim of this study was to develop an experimental model of colon adenocarcinoma based on the orthotopic implantation of tumor cells in syngenic rats, which reproduces the regional extension pattern of human colorectal adenocarcinoma. EXPERIMENTAL DESIGN: Cell cultures: cell line DHD/K12-PROb. Animals: BD-IX rats. Tumour implantation: intra-caecal injection containing 1 x 10(6) cells in 0.25 ml of PBS. Design: randomized observation study of three groups until five rats were shown to have cancer implantations in each group: GROUP I: sacrificed one week after the injection (n = 6), GROUP II: sacrificed two weeks after the injection (n = 9), GROUP III: sacrificed four weeks after the injection (n = 10). Measurements: macroscopic and histological examination, with particular emphasis on caecal lesions. Tumours were classified according to the TNM system (UICC, 1987). RESULTS: GROUP I: tumors were found in 83% of cases (5/6), 4 of which were classified as T1N0M0 and 1 as T2N0M0. GROUP II: tumour in 55.5% of cases (5/9). One was classified as T1N0M0, 3 as T2N0M0 and 1 as T3N0MPER. GROUP III: tumors were found in 50% of cases (5/10). Two were classified as T4N0M0, 2 as T4N1MPER, and 1 as T3N1MPER. The degree of wall infiltration of the tumor showed statistical differences between groups I and III and groups II and III (p < 0.05). CONCLUSIONS: Our model offers a step by step reproduction of events described for human colorectal adenocarcinoma. It was therefore easy to predict how long it would take to achieve a degree of local extension, which is essential in the design of cancer experiments. Moreover, this model has the advantage that it uses immunocompetent rats, which facilitates the methodology.
ABO blood groups, rhesus factor and Helicobacter pylori.
Martin de Argila C. Boixeda D. Valdezate S. Mir N. Barcena R. Gisbert JP. Garcia Plaza A. Canton R.
Gastroenterology Department, Ramon y Cajal Hospital, Universidad de Alcala de Henares, Madrid, Spain.
BACKGROUND: The aim of this study was to demonstrate an association between Helicobacter pylori infection, ABO blood groups and Rhesus factor; providing the association between duodenal ulcer and O group blood as well as the former and H. pylori infection. METHODS: Three-hundred and one healthy subjects were prospectively studied. In all of them ABO blood groups and Rhesus factor were determined by standard techniques. Systemic IgG antibodies against H. pylori were assayed using a quantitative enzyme-linked immunosorbent assay technique (Helico-G, Porton, Cambridge, UK). RESULTS: The overall seroprevalence was 52.2%. H. pylori infection distribution was similar among ABO blood groups and Rhesus factor. No statistically significant differences were observed in mean values of IgG antibodies among different blood groups. CONCLUSIONS: Distribution of H. pylori seroprevalence does not differ between different ABO or Rhesus factor blood groups. This excludes a possible link between this microorganism and the high ulcer prevalence in O blood group.
Preoperative chemotherapy followed by esophagectomy compared with surgery alone in the treatment of squamous cell carcinoma of the esophagus.
Hernandez Lizoain JL. Cienfuegos JA. Pardo F. Martinez Regueira F. Sola I. Aristu J. Azinovic I.
Department of General Surgery, Clinica Universitaria, School of Medicine, University of Navarra, Pamplona, Spain.
The aim of this study is to assess the effect of concomitant preoperative radio-chemotherapy in the treatment of epidermoid esophageal cancer. We studied a total of 45 patients, divided into two groups. Group I consisted of 20 patients diagnosed with epidermoid esophageal cancer who had been treated initially with esophagectomy. Group II consisted of 25 patients treated with preoperative radiotherapy and two cycles of chemotherapy (cisplatin and 5-fluorouracil), one at the beginning and the other at the end of the radiation treatment, on whom an esophagectomy was subsequently performed. The clinical characteristics were similar in both groups. In group II, there were 12 cases (48%) with absence of tumor in the esophageal wall, three of which had node involvement. The operative mortality was similar in both groups (10% and 8% respectively). The only significant difference found in the postoperative complications was the incidence of anastomotic leak; but this was related to the different esophagectomy techniques used rather than the type of therapy. A decrease in the number of patients with tumor recurrence was observed in Group II, especially where the local component was concerned. The best actuarial survival rate at five years was in patients with no presence of tumor after neoadjuvant treatment (44.4%). However, the radio-chemotherapy seems not to have had any benefit in cases with node involvement.
[New antiviral agents in the treatment of chronic hepatitis B and C]
Olaso Peiro V. Lopez Viedma B. Cordoba Cortijo J.
Servicio de Medicina Digestiva, Hospital La Fe, Valencia.
Interferon (IFN) is the drug universally used in the treatment of B and C chronic hepatitis. Due to its low efficacy, 40% in the treatment of chronic hepatitis B and 10-20% in the treatment of chronic hepatitis C, and to its adverse events, in some cases severe, new antiviric molecules are being investigated. Lamivudin, famciclovir and the association of ribavirin and IFN are the more relevant and will be clinically accepted in an immediate future. It is also probable that rigid indications for hepatic transplantation in patients with liver cirrhosis by B virus change in the next years due to the use of these new antiviric drugs before and after transplantation. In this revision we analyze the current situation of these new therapies. However, most information come from pilot studies, and multicentric randomized studies are needed to establish firm conclusions about the role that these new therapies are going to play in the treatment of viral chronic hepatitis.
[Endoscopic diagnosis of an ileocolic intussusception in an adult]
Gonzalez Rodriguez JF. Baki W. Nisa Gutierrez E. Cantero Cid R. Velasco Suarez M. Ramirez Armengol JA.
Servicio Central de Endoscopia, Hospital Universitario San Carlos Madrid.
Although intussusception is the most frequent cause of intestinal obstruction in children, it only represents 5-10% of all adults. The preoperative diagnosis is difficult and it is rarely done by endoscopy. We present a case of adult ileocolic intussusception caused by an ileon terminal hamartoma. The diagnosis was done by colonoscopy.
Liver cirrhosis and mortality by abdominal surgery. A study of risk factors.
Carbo J. Garcia-Samaniego J. Castellano G. Iniguez A. Solis-Herruzo JA.
Center of Clinical Research, Institute of Health Carlos III, Madrid, Spain.
AIM: To determine the mortality-related factors in cirrhotic patients who underwent nonderivative abdominal surgery. PATIENTS AND METHODS: We retrospectively reviewed the clinical charts of 63 patients (38 men, 25 women) with liver cirrhosis and abdominal surgery. Patients who underwent surgical derivative procedures for portal hypertension and/or hepatic resection for hepatic tumor were excluded. The study population was divided in patients who died (Group 1) and alive patients (Group 2). Thirteen (21%) patients died and the other 50 (79%) had an uneventful course. We compared the clinical and analytical parameters between both groups. Multivariate analysis was performed for the variables with predictive value. RESULTS: Prothrombin time and the presence of hepatic encefalopathy showed statistical significance in the univariate analysis (p < 0.05 and p < 0.01, respectively). However, in multiple logistic regression analysis serum bilirrubine value was associated with mortality rate (Odds ratio 1.65, 95% CI, 0.97-1.14; p = 0.064). Emergency surgery was required more frequently in patients of group 1 than in those of group 2, but the difference did not achieve statistical significance. CONCLUSIONS: In the present study, the serum bilirrubine value, the prothrombin time and the presence of hepatic encefalopathy were associated with mortality of cirrhotic patients who underwent non-derivative abdominal surgery. The lack of significance of other factors (albumin, nutrition, infections and urgent surgery) could be due to the small number of patients in our series.
[NF-kappa B and inflammatory intestinal diseases]
Nosti-Escanilla MP. Pena AS.
Departamento de Gastroenterologia, Universidad Libre de Amsterdam, Paises Bajos.
The chronic inflammatory bowel diseases (IBD), such as Crohn's disease (CD) and ulcerative colitis (UC), are multifactorial pathologies. There is overwhelming evidence that genetic factors play a pivotal role in the predisposition to suffer from IBD. The severity of the inflammatory response depends on genes coding for proteins which regulate the cytokine production. Among them, NF kappa B stands out as the most important regulator of the gene expression of several pro- and anti-inflammatory genes. We present hereby its structure, function, regulation and the role played in IBD. Different theories relating the mechanism of action of glucocorticosteroids to NF kappa B are described in this review as well. The more accurate knowledge of the NF kappa B physiology has allowed new therapeutical approaches to inflammatory diseases to appear, namely the transfer to primary intestinal epithelial cells by an adenoviral vector of a mutant I kappa B (the inhibitory protein of NF kappa B) and the local use of p65 antisense phosphorothioate oligonucleotides.
[Anisakiasis at the ileal level]
del Olmo Escribano M. Cozar Ibanez A. Martinez de Victoria JM. Urena Tirao C.
Servicio de Anatomia Patologica, Hospital General de Especialidades Ciudad de Jaen.
Two cases of ileal anisakiasis are presented here. Symptoms were compatible with appendicitis. Either of them were operated on, the both were found and ileal tumour. Damage zone was removed. Pathological examination of piece showed us anisakis simplex larva set in the mucosa. The evolution of patients had no complications, currently they are asymptomatic. Both of them had eaten uncooked anchovy some days before. Anisakiasis cases are quite strange in Spain. There was only seven cases of anisakiasis in Spanish literature previously.
Liver transplantation in cirrhotic patients over 60 years of age.
de la Pena A. Herrero JI. Sangro B. Pardo F. Hernandez JL. Alvarez-Cienfuegos J. Quiroga J. Prieto J.
Liver Unit (Department of Internal Medicine), Clinica Universitaria de Navarra, Pamplona, Spain.
Although life expectancy in Spain is above seventy years, age over sixty is considered a relative contraindication for liver transplantation (LT) in most centers. The aim of this study was to assess the outcome of LT in patients over sixty years of age comparing them to patients under that age. From January 1992 to August 1995, 61 cirrhotic patients underwent LT at our institution; of them, 43 (group I) were younger than 60 years (mean +/- SEM: 51.9 +/- 0.9 years, range: 37-59) and 18 patients (group II) were 60 years or older (64.1 +/- 0.7, range: 60-71). Main pre-transplant variables (sex, etiology of liver disease, presence of hepatocarcinoma, Child-Pugh's score and renal function) were similar in both groups. The follow-up (median and range) for group I was 28 and 3-47 months, and for group II 16.5 and 3-48 months. Actuarial survival rates at one and four years post-LT were respectively 88.3% and 85.6% for group I, and 87.8% and 87.8% for the group II (p = n.s.). There were no differences between both groups regarding the incidence of rejection, major infections, neurologic complications, renal failure, pathological bone fractures, diabetes mellitus or hypertension. Nevertheless, cardiovascular complications were significantly more frequent in group II (p = 0.002) although they were not the cause of death. In conclusion, our results show that the outcome of LT in patients over sixty years old is comparable to that observed in patients under that age. LT should not be contraindicated on the only basis of an age greater than 60 years.
[Screening for colorectal cancer predisposition]
Gonzalez Gonzalez E. Rodriguez Salas N. Doblado Cardellach B. Larranaga Barrera E. Serrano Sanchez P.
Servicio de Cirugia General y Aparato Digestivo, Hospital Universitario La Princesa, Madrid.
In the last years the advantages in molecular biology have developed a variety of useful tests in order to detect genetic mutations. These mutations are associated to a susceptibility of suffering a colo-rectal cancer. The genetic tests are designed to screen the disease although many problems can emerge when they are offered to the population. In this article, we will try to analyze the advantages, disadvantages and the present indications for genetic testing in colo-rectal cancer, particularity in cases of familial adenomatous polyposis and nonpolyposis inherited colon cancer.