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During the COVID-19 pandemic, endoscopic procedures are associated with a high risk of SARS-CoV-2 infection. However, in cases of upper gastrointestinal bleeding (UGIB), priority should be given to an early endoscopy.The main objective was to compare the time since arrival at the hospital and the performance of the endoscopy between both groups.We performed a retrospective study. Data contains information of patients who attended to the hospital with UGIB and underwent an endoscopy between October 19th, 2019 and June 6th, 2020. Patients were divided into 2 phases: pre-pandemic and pandemic. The time between arrival at the hospital and the performance of the endoscopy in both phases were compared as well as other indicators such hospital stay and in-hospital mortality.With information from 219 patients, the median age was 69 years. 154 and 65 endoscopies were performed in pre-pandemic and pandemic phase, respectively. The time between arrival at the hospital and the performance of the endoscopy was significantly longer during the pandemic (10.00 vs. 13.08 hours, p-value = 0.019). Nevertheless, there were no significant differences in hospital stay or mortality.The management of patients with UGIB during the COVID-19 pandemic is complex and requires the application of clinical judgment to decide the best timing to perform an endoscopy without affecting patient care.

El presente estudio tuvo por objetivo describir las características clínicas, manejo y mortalidad de pacientes adultos hospitalizados por COVID-19 durante la primera quincena de mayo del 2020 en el Hospital Nacional Edgardo Rebagliati Martins (Lima, Perú). Se realizó una cohorte retrospectiva revisando historias clínicas electrónicas. Se recolectaron datos de 152 pacientes (68,4% varones, edad promedio: 58,7 años). Se encontró que 27,0% tuvo contacto cercano con una persona con COVID-19, 64.2% llegó al hospital con una enfermedad crítica, 91,4% recibió hidroxicloroquina y 96,1% recibió azitromicina, 23,7% ingresó a la unidad de cuidados intensivos, y la mortalidad fue de 18,8%. En conclusión, más de la mitad de los pacientes acudieron a este hospital con una enfermedad crítica, casi todos recibieron fármacos que inicialmente fueron vistos como potencialmente útiles pero que actualmente no son recomendados para el manejo de COVID-19 en hospitalizados, y la mortalidad fue similar a lo reportado en otros países.

Introducción: El año 2018 se publicó la Guía de práctica clínica (GPC) para la evaluación y el manejo de la hemorragia digestiva alta (HDA) del Seguro Social de Salud del Perú (EsSalud). Esta emite enunciados basados en evidencias, que buscan optimizar el manejo de estos pacientes. Objetivo: Evaluar la adherencia a los enunciados de dicha GPC en el Hospital Nacional Edgardo Rebagliati Martins (HNERM) de EsSalud (Lima, Perú). Materiales y métodos: Estudio retrospectivo, que analizó la base de datos de todos los pacientes que acudieron al servicio de emergencia del HNERM con sospecha de HDA y fueron programados para endoscopía entre el 19 de octubre del 2019 y el 15 de abril del 2020. Se incluyó a aquellos con ≥ 18 años de edad. Esta base contiene las principales características de la historia clínica estandarizada para pacientes con HDA. Se evaluó el cumplimiento de 13 de los 34 enunciados de la GPC de EsSalud. Los resultados se presentaron descriptivamente, y se evaluaron los factores asociados al cumplimiento de los enunciados con inadecuada adherencia (< 80%) y con más de 100 participantes evaluados. Resultados: Se obtuvieron datos de 184 pacientes que cumplieron con los criterios de inclusión (varones: 59,8%, mediana de edad: 70 años). El rango de adherencia a los 13 enunciados fue de 63,2% a 99,5%. Sólo dos enunciados tuvieron adherencia inadecuada ( 60, y menor hemoglobina al ingreso. Conclusión: De los 13 enunciados evaluados, 11 tuvieron una adherencia adecuada. Resulta importante profundizar en los motiv s cuales laadherencia no es adecuada para algunos enunciados, y valorar estrategias para aumentar esta adherencia.

Introduccion . La neoplasia mucinosa papilar intraductal (IPMN) se diagnostica ahora con mayor frecuencia debido al mayor uso de los metodos de imagenes, y conlleva un desafio clinico su manejo y seguimiento por su probable transformacion maligna. Objetivos . Conocer las caracteristicas por ecoendoscopia (USE), evolucion clinica y sobrevida de los pacientes diagnosticados de IPMN por USE. Materiales y metodos. Estudio de cohorte retrospectivo con analisis de sobrevida en pacientes diagnosticados de IPMN por USE entre 2013 y 2018 en el Hospital Nacional Edgardo Rebagliati Martins (HNERM). Se analizaron variables demograficas y ecoendoscopicas, ademas de seguimiento hasta el fallecimiento o 6 meses despues del termino del estudio. Se realizo el analisis de sobrevida con los metodos de Kaplan-Meyer y de regresion de Cox. Resultados . Se incluyeron 133 pacientes con IPMN. Edad media fue 68,6 anos, 80 (60,2%) fueron mujeres. Segun subtipos, 89 (66,9%) fueron de rama secundaria, 23 (17,3%) de ducto principal y 21 (15,8%) de tipo mixto. La principal localizacion fue cabeza de pancreas (41,4%). En el seguimiento, 22 (16,5%) fueron a cirugia, 22 (16,5%) fallecieron despues de una mediana de seguimiento de 522 dias. En 8 pacientes (6%) se detecto neoplasia maligna. La tasa de sobrevida global fue 86.8% (IC 95%, 79,6-91,6) al ano y de 81.9% (IC95%, 73,3-88,0) a los 3 anos. En analisis univariado los factores asociados a la sobrevida fueron los subtipos de IPMN-DP ( p =0,02) y mixto ( p =0,005), sexo masculino ( p =0,004), tamano de lesion ≥30 mm ( p =0,000), nodulos ( p =0,014) y Wirsung ≥10 mm ( p =0,01). En el analisis multivariado, los factores predictores asociados con la sobrevida fueron: IPMN-DP (HR=6,3, p =0,005), IPMN mixto (HR=4,9, p =0,008) y tamano de lesion ≥30 mm (HR=7,1, p =0,000). Conclusiones. El diagnostico de IPMN de ducto principal y mixto se asocian como factores predictores de sobrevida, al igual que el tamano de la lesion ≥30 mm.

Introduction colorectal perforations are one of the most feared complications after performing an endoscopic resection. The use of endoclips is considered for the management of these complications. Objectives to evaluate the efficacy and safety of the use of endoclips in the management of perforations and deep mural injuries that occur after an endoscopic colorectal resection. Methods a prospective cohort of consecutively included patients was used with a diagnosis of perforation or deep mural injury after an endoscopic colorectal resection treated with endoclips in our institution. The rates of perforation and deep mural injury were obtained. The factors associated with an unfavorable evolution after the placement of the endoclips were analyzed. Results after 342 endoscopic mucosal resections (EMR) and 42 endoscopic submucosal dissections (ESD), there were 25 cases with perforation or deep mural injury. The deep mural injury rate was 3.22 % and 7.14 % in the case of EMR and ESD, respectively. The perforation rate was 1.46 % and 14.29 % in the case of EMR and ESD, respectively. Successful closure with endoclips was achieved in 24 cases (96 %). Only one patient presented an unfavorable evolution (10 %) after successful closure. The factors associated with an unfavorable evolution were the presence of diffuse peritoneal symptoms and a perforation size greater than or equal to 10 mm. Conclusion endoscopic closure with endoclips is effective to avoid surgery in cases of deep mural injury or perforation after an endoscopic resection.

In recent years there has been an increase in the use of self-expanding metallic stents (SEMS) in patients with unresectable malignant stenosis of the bile duct. However, in Peru there are no reports on the safety and efficacy of this procedure.To evaluate the safety and efficacy of the use of SEMS in the palliative management of malignant stenosis of the bile duct.Retrospective cohort. All patients referred for placement of biliary SEMS as part of a palliative treatment between January 2016 and August 2018 were included. Rates of successful placement of SEMS, adequate palliation of the obstruction, and complications associated with the procedure were obtained. The patency of the prosthesis was evaluated during follow-up. Survival was determined after placement of the prosthesis.We included 32 patients with indication of palliative management due to an unresectable malignant stenosis of the bile duct. Pancreatic cancer (56.25%) followed by cholangiocarcinoma (31.25%) were the most frequent etiologies. A successful first-time placement rate of 96.97% was achieved. Adequate palliation of biliary obstruction was achieved in 100% of patients (p0.05). Two SEMStc migrated during follow-up (6.25%) being managed with the placement of a new SEMSuc.The placement of SEMS is a safe and effective therapeutic strategy in the palliative management of patients with malignant obstruction of the biliary tract.

Introducción: Durante la pandemia de COVID-19, los procedimientos endoscópicos se asocian con un alto riesgo de infección por SARS-CoV-2. Sin embargo, en casos de hemorragia digestiva alta (HDA), se debe dar prioridad a una endoscopia precoz. Objetivo: El objetivo principal fue comparar el tiempo transcurrido desde la llegada al hospital y la realización de la endoscopia entre ambos grupos. Materiales y métodos: Realizamos un estudio retrospectivo. Los datos contienen informaciónde pacientes que acudieron al hospital con HDA y fueron sometidos a endoscopia entre el 19 de octubre de 2019 y el 6 de junio de 2020. Los pacientes se dividieron en 2 fases: prepandémica y pandémica. Se comparó el tiempo transcurrido entre la llegada al hospital y la realización de la endoscopia en ambas fases, así como otros indicadores como la estancia hospitalaria y la mortalidad intrahospitalaria. Resultados: Con información de 219 pacientes, la mediana de edad fue de 69 años. Se realizaron 154 y 65 endoscopias en fase prepandémica y pandémica, respectivamente. El tiempo entre la llegada al hospitaly la realización de la endoscopia fue significativamente mayor durante la pandemia (10,00 frente a 13,08 horas, valor de p = 0,019). Sin embargo, no hubo diferencias significativas en la estancia hospitalaria ni en la mortalidad. Conclusión: El manejo de pacientes con HDA durante la pandemia de COVID-19 es complejo y requiere la aplicación del juicio clínico para decidir el mejor momento para realizar una endoscopia sin afectar la atención del paciente. Introduction: During the COVID-19 pandemic, endoscopic procedures are associated with a high risk of SARS-CoV-2 infection. However, in cases of upper gastrointestinal bleeding (UGIB), priority should be given to an early endoscopy. Objective: The main objective was to compare the time since arrival at the hospital and the performance of the endoscopy between both groups. Materials and methods: We performed a retrospective study. Data contains information of patients who attended to the hospital with UGIB and underwent an endoscopy between October 19th, 2019 and June 6th, 2020. Patients were divided into 2 phases: pre-pandemic and pandemic. The time between arrival at the hospital and the performance of the endoscopy in both phases were compared as well as other indicators such hospital stay and in-hospital mortality. Results: With information from 219 patients, the median age was 69 years. 154 and 65 endoscopies were performed in pre-pandemic and pandemic phase, respectively. The time between arrival at the hospital and the performance of the endoscopy was significantly longer duringthe pandemic (10.00 vs. 13.08 hours, p-value = 0.019). Nevertheless, there were no significant differences in hospital stay or mortality. Conclusion: The management of patients with UGIB during the COVID-19 pandemic is complex and requires the application of clinical judgment to decide the best timing to perform an endoscopy without affecting patient care.

RESUMEN Antecedentes: las dilataciones endoscópicas se consideran el tratamiento de elección para las estenosis esofágicas, sin embargo, no se cuenta en nuestra región con estudios en los que se evalúe la seguridad de este procedimiento. Objetivo: evaluar la seguridad de las dilataciones esofágicas y los factores asociados a las complicaciones. Material y métodos: cohorte retrospectiva. Se incluyeron todos los pacientes referidos para dilatación esofágica entre enero de 2015 y junio de 2017. Se obtuvo la tasa de complicaciones y se determinó la asociación entre la no adherencia a la "regla de los tres" y el desarrollo de complicaciones. Se analizaron otros factores predictivos asociados al desarrollo de complicaciones. Resultados: se incluyeron 164 pacientes en los que se realizaron 474 dilataciones. La etiología más prevalente fue la estenosis de anastomosis quirúrgica. Se presentaron seis complicaciones: tres perforaciones (0,63%), dos sangrados (0,42%) y un episodio de dolor significativo que requirió observación posprocedimiento (0,21%). La dilatación endoscópica esofágica fuera de la "regla de los tres" no se encontró asociada a un mayor riesgo de complicaciones. La dilatación con balón fue el único factor predictivo para el desarrollo de complicaciones. Conclusiones: la dilatación esofágica es un procedimiento seguro. La no adherencia a la "regla de los tres" no parece estar asociada a un mayor riesgo de complicaciones, incluyendo la perforación esofágica. ABSTRACT Background: endoscopic dilation is considered as the treatment of choice for esophageal strictures. However, there are no studies in our region that have assessed the safety of the procedure. Objective: to assess the safety of esophageal dilation and the factors associated with the development of complications. Materials and methods: a retrospective cohort was studied. All patients referred for esophageal dilation between January 2015 and June 2017 were included in the study. A complication rate was obtained and the association between nonadherence to the "rule of 3" and the development of complications was determined. Other predictive factors associated with complication development were also analyzed. Results: a total of 164 patients that underwent 474 dilations were included in the study. Surgical anastomosis stricture was the most prevalent etiology. A total of six complications occurred, including three perforations (0.63%), two bleeding events (0.42%) and one episode of significant pain that required post-procedure observation (0.21%). Endoscopic esophageal dilation without adherence to the "rule of 3" was not associated with a higher risk of complications. Balloon dilation was the only predictive factor for complications. Conclusions: esophageal dilation is a safe procedure. Nonadherence to the "rule of 3" does not appear to be associated with a higher risk of complications, including esophageal perforation.

A wide variety of benign and malignant submucosal lesions may arise from the wall of the large intestine. They can originate in the submucosa or in the muscular propia; furthermore, they can be caused by compression of extrinsic structures.1,2 We report a case of a submucosal mass identified as a fecalith protruding into the cecum.

Hepatitis C is a common cause of end-stage liver disease, and the main indication for liver transplantation in Latin America. Treatment of hepatitis C infected patients improves important long-term outcomes as mortality. Sustained viral response is reached in near 50% of patients with the previous management based in pegylated interferon and ribavirin. Recently new drugs were available increasing sustained viral response significantly, changing the standard of care to triple therapy. This guidelines provides a framework for practitioner in Latin America, to the management of patients with hepatitis C chronic infection.

To determine the prevalence of Helicobacter pylori in symptomatic outpatients in Red Rebagliati (EsSalud) from 2010 to 2013.An observational, transversal and analytical study. Records of outpatients with diagnostic 13C-urea breath test of Helicobacter pylori in the period 2010-2013 were reviewed.Of the 1711 patients, the overall prevalence of Helicobacter pylori was 45.5% (95% CI: 43.17-47.89) being higher in women than in men (47.1% vs. 42.1%, p=0.056). There were significant differences in age between infected and uninfected (44 vs. 39, p0.05), with association between age and the presence of Helicobacter pylori (p0.001). The estimated prevalence in the pediatric population was 36.3% and was found positive in 201 (51.1%) women of childbearing age. Most (43.9%) came from the financial sector of the city.The prevalence of Helicobacter pylori in the study population was similar in both sexes and is related to age. The average socioeconomic status of Lima maintains the prevalence of Helicobacter pylori reported in the last years.

Hepatic encephalopathy (HE) is a neuropsychiatric syndrome characterized by changes in cognitive function, behavior, and personality, as well as by transient neurological symptoms and electroencephalographic changes, which occur in the context of acute or chronic liver failure. Cirrhosis is the main disease associated to HE, and it is known that its incidence is increasing worldwide. As a cause of mortality, cirrhosis is ranked 14 worldwide, but 10 in developed countries. It has been demonstrated that the incidence of liver disease is increasing, in part because of the ascending prevalence of NAFLD, HCV, HCC, as well of alcohol consumption. The real incidence of cirrhosis in Latin America is unknown, although in some Latin American countries that provided national data, cirrhosis death rates were between 5 and 17/100,000 for men and 3 and 5/100,000 for women. Disability, quality of life, and social aspects should be considered when assessing the impact of a disease. In this context, preliminary estimates of the global burden of disease attributable to chronic liver disease seem to be substantial. Hepatic encephalopathy, a main complication of liver failure, occurs in 30-45% of patients as overt encephalopathy, but when subclinical or minimal hepatic encephalopathy (MHE) is considered, estimates of the incidence of encephalopathy vary from 20 to 60%. In USA, the 2009 NIH Report on the Costs of Digestive Diseases stated that liver disease was the second most costly disease in direct and indirect costs (13.1 billion dollars). Although the economic cost of HE has not been assessed, it is obvious that the economic impact of HE on daily activities of living is extremely high, as the costs of diminished work performance and lost wages are substantial.

Hepatitis C infection is a global burden disease. Its relationship to chronic hepatitis, cirrhosis and hepatocellular carcinoma has been demonstrated, and at the current moment in USA and Europe is one of the major causes for liver transplantation. In Latin America, seroprevalence for HCV is between 1-2%. Risk groups are well-known: persons that have received blood products, drug addicts, health-workers, sexual workers, convicts, those with tattoo or piercing, as well as newborns from women positive for HCV. Genotype 1 is the more prevalent (80%) in Latinamerica, although genotypes 2, 3 and 4 have been found. In Peru, prevalence is low, around 1%, being found more frequently in the jungle region. Risk groups demonstrated in Perú are persons that received transfusion, patients in hemodyalisis, health-workers (in special those that work with blood products), and drugaddicts especially those with cocaine aspiration. Genotype 1 is the more prevalent, although few studies have been done. It is urgent to do more epidemiological studies related to this infection to know the real situation of this disease and its consequences in order to establish better health strategies.

HCV Infection is a global burden disease and it is related to the development of progressive liver fibrosis, cirrhosis and hepatocellular carcinoma. At least 80% of the persons that have an acute infection evolve to chronicity. This event affects the patient and their contacts for the risk of acquiring the infection. Once chronic HCV is present some factors accelerate progression: older age, obesity, alcohol consumption, etc. Severity of fibrosis is one of the most important factors to be analyzed before deciding to treat a patient. Pegylated interferon and ribavirin is the .standard of care. for this disease, however, it has many side effects, some of them life threatening. That is the reason why this treatment must be indicated in the right moment in the right patient. A complete medical evaluation must be done previously to initiate treatment. Other concurrent problems must be ruled out or treated. Decompensated cirrhosis, autoimmune diseases or other uncontrolled disease are contraindication to HCV treatment. Previous failure to treatment for HCV must be analyzed to identify the reasons for that event and consider retreatment. Cryoglobulinemia and membranoproliferative glomerulonephritis are indications for treatment independent from the severity of liver disease.br /

Hepatocellular carcinoma (CHC) is one of the leading causes of worldwide cancer mortality. The aim of this study is to describe the clinical and epidemiological characteristics, as well as treatment prescribed in patients with this diagnosis.Longitudinal and prospective study that included patients with diagnosis of CHC in the Department of Digestive System at the HNERM-EsSalud between august 2007 and august 2008.We included 36 patients, median age was 60,1 years and 61,1% were male. Cirrhosis was present in 69,1% and median age in this group was 68,9 years, the median age in those without cirrhosis was 40 years (p0,001). The most frequent associated cause was hepatitis B (38,9%) and 60% had AFP higher than 200 ng/ml. In cirrhotic patients, 80% were Child-Pugh score B or C. Symptomatic treatment was prescribed in 44,4% of the patients.Epidemiological features are different between patients with or without cirrhosis. In the first case their characteristics are similar to those described in areas of low risk for CHC; in the second group the characteristics are similar to those described in areas with high risk population. CHC has frequent association with hepatitis B virus. High percentage of patients is diagnosed with an advanced stage of HCC.

Alcoholic hepatitis represents the most severe form of alcoholic liver disease Recent research points to an exaggerated inflammatory response, mediated by neutrophils,as the basic mechanism of liver damage. This entity has a distinctive clinical picture and a characteristic histopathology and a poor outcome.Recent investigation reveals a complex network of intracellular and intercellular communication signals involving hepatocytes, endothelial cells, monocytes, lymphocytes, neutrophils,Ito and Kupffer cells, leading to massive migration of neutrophils from blood to liver.When neutrophils reach the liver, multiple cytokines produced locally by endothelium, hepatocytes and Kupffer cells, up-regulate their function. Activation of neutrophils leads to increased production of oxygen radicals(mainly superoxide)and hydrogen peroxide production.To date there is general agreement that measurement of superoxide production by neutrophils is a reliable way of determining neutrophil function and its activation.Thirty one patients with acute alcoholic hepatitis, twenty with compensated alcoholic liver disease end seventeen controls were studied.Patients with alcoholic hepatitis and alcoholic liver disease were enrolled on admission to the hospital and if they had no features of infection, bleeding or renal failure.The neutrophil stimuli used were opsonized zymosan and fMLP.The production of superoxide was similar in the three groups when neutrophils were not stimulated.After stimulation with opsonized zymosan,there was an increase in the production of superoxide from patients with acute alcoholic hepatitis in comparison to those with alcoholic liver disease and controls. This increase was statistically significant when fMLP was the stimulant(p0.05). This is a reliable technique that can be use in the evaluation of different therapeutic modalities in acute alcoholic hepatitis