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Resumen Objetivo Evaluar la influencia de una intervencion formativa en las derivaciones a consultas hospitalarias, su adecuacion y motivos de derivacion, y analizar diferencias entre medio urbano y rural. Material y metodos Estudio prospectivo de una intervencion fundamentalmente de tipo formativo (consultas compartidas y sesiones clinicas) entre Gastroenterologia y atencion primaria, realizada mensualmente en un centro de salud urbano y otro rural, comparandolos con 2 correspondientes centros control. El periodo de estudio fue de noviembre de 2004 a junio de 2008, con un periodo de referencia de 12 meses y uno de intervencion de 30 meses, dividido en 2 subperiodos (1 y 2). Los parametros (cambios en las derivaciones, y sus motivos y pertinencia) se evaluaron en 1.449 derivaciones realizadas desde atencion primaria a las consultas externas de aparato digestivo. Resultados En relacion con el periodo de referencia, descendio significativamente el porcentaje de derivaciones en los centros de intervencion: 51 y 57 % en los subperiodos 1 y 2, respectivamente. Analizando las diferencias entre los centros de intervencion y los centros control, el descenso en la proporcion de derivaciones fue de aproximadamente un 30 % en ambos periodos, que fue solo significativo en el medio rural. No se encontraron cambios significativos en la pertinencia ni en los motivos de las derivaciones. Conclusiones La intervencion resulto en conjunto eficaz en disminuir derivaciones a las consultas hospitalarias de gastroenterologia, aunque sugerimos medidas que mejoren su pertinencia.

Survival after orthotopic liver transplantation (OLT) has increased over the last decades, focusing on the metabolic complications that contribute to patient morbidity and mortality. The aim of our study was to describe the prevalence of metabolic syndrome (MS), its components, and its associated factors in patients who underwent OLT in a hospital in Spain. From November 2001 to January 2014, we performed 415 transplantations in 386 patients. We analyzed 204 patients with a minimum follow-up of 1 year (77.6% were male and the mean age was 54.2+/-9.5 years). The most frequent etiology was alcohol (41%), followed by hepatitis C virus (29.1%). The indication was decompensated cirrhosis in 51.8% and hepatocellular carcinoma in 34%. According to modified National Cholesterol Education Program-Adult Treatment Panel-III (NCEP-ATP III) criteria, 5 years post-transplantation MS was diagnosed in 38.2% of patients. Significant independent predictors of post-transplantation MS on logistic regression analysis were as follows: pretransplantation obesity (odds ratio [OR], 3.09; P = .056), 1-year post-transplantation obesity (OR, 3.95; P = .009), pretransplantation diabetes (OR, 4.63; P = .001), 1-year post-transplantation diabetes (OR, 3.01; P = .015), 1-year post-transplantation hypertension (OR, 1.85; P = .176), and hypertriglyceridemia at the first year after transplantation (OR, 2.32; P = .063). In our center the prevalence of MS at 5 years after OLT is slightly lower than published. The most important risk factors were obesity and diabetes (both pretransplantation and the first year post-transplantation).

Resumen: La trombocitosis es un hallazgo casual frecuente en pediatría. En niños, predominan las formas secundarias, siendo las infecciones su causa más prevalente. Se distinguen 4 grados de trombocitosis en función del número de plaquetas; en la forma extrema, se supera el 1.000.000/mm3. Se presenta un caso de trombocitosis extrema reactiva en un niño sano de 6 años, que requirió ingreso en cuidados intensivos para tratamiento y diagnóstico (cifra máxima de plaquetas de 7.283.000/mm3). Se revisan las diferentes causas de trombocitosis en la infancia, se describe el diagnóstico diferencial y se discute sobre los diferentes tratamientos disponibles ante un caso como el descrito. Abstract: Thrombocytosis is usually a casual finding in children. Reactive or secondary thrombocytosis is the more common form, being the infections diseases the most prevalent cause of it. Regarding the number of platelets there are four degrees of thrombocytosis; in its extreme degree the number of platelets exceeds 1,000,000/mm3. We describe a case of extreme reactive thrombocytosis in a healthy 6-year-old child. He required critical care admission for diagnosis and treatment (maximum number of platelets 7,283,000/mm3). We review the different causes of thrombocytosis in childhood, the differential diagnosis, and the available treatments in case of extreme thrombocytosis.

Thrombocytosis is usually found by chance in children. Reactive or secondary thrombocytosis is the more common form, with infectious diseases being the most prevalent cause of it. Regarding the number of platelets there are four degrees of thrombocytosis; in its extreme degree the number of platelets exceeds 1,000,000/mm3. We describe a case of extreme reactive thrombocytosis in a healthy 6-year-old child. He required critical care admission for diagnosis and treatment (maximum number of platelets 7,283,000/mm3). We review the different causes of thrombocytosis in childhood, the differential diagnosis, and the available treatments in case of extreme thrombocytosis. Resumen: La trombocitosis es un hallazgo casual frecuente en pediatría. En niños, predominan las formas secundarias, siendo las infecciones su causa más prevalente. Se distinguen 4 grados de trombocitosis en función del número de plaquetas; en la forma extrema, se supera el 1.000.000/mm3. Se presenta un caso de trombocitosis extrema reactiva en un niño sano de 6 años, que requirió ingreso en cuidados intensivos para tratamiento y diagnóstico (cifra máxima de plaquetas de 7.283.000/mm3). Se revisan las diferentes causas de trombocitosis en la infancia, se describe el diagnóstico diferencial y se discute sobre los diferentes tratamientos disponibles ante un caso como el descrito.

Resumen Introduccion Los perfiles de expresion genica (PEG) en las primeras semanas de tratamiento de pacientes con hepatitis C cronica pueden servir para evaluar la eficacia de la terapia basada en interferon. El objetivo de este trabajo fue estudiar los PEG de pacientes respondedores y no respondedores precoces antes y tras 12 semanas de tratamiento con peginterferon alfa y ribavirina. Metodos Estudio observacional donde se analizaron los PEG de 12 pacientes con hepatitis C cronica candidatos a recibir tratamiento con peginterferon alfa y ribavirina. Resultados De los 12 pacientes estudiados, seis mostraron una respuesta virologica precoz completa, mientras que seis no lograron controlar la viremia. En respondedores precoces, el tratamiento con peginterferon y ribavirina indujo un aumento de la expresion de un mayor numero de genes de respuesta al interferon (ISG15, IFI6, IFI44L, IFI27, MX1, OASL, IRF7, IFIT3, IFITM1, EIF2AK2, HERC5 y APOBEC3A) que en no respondedores (ISG15, IFI44L, IFI27, IRF7, USP18) (p Conclusiones Los PEG descritos en este trabajo pueden ayudar a comprender mejor la patogenesis de la infeccion, asi como las bases fisiologicas de la respuesta al tratamiento. Asi, el mayor efecto del tratamiento sobre la expresion de genes de respuesta al interferon observado en respondedores podria explicar su mejor control de la carga viral.

Background The diagnostic efficacy of current tissue sampling techniques for upper GI subepithelial tumors (SETs) appears to be limited. Better tissue acquisition techniques are needed to improve the diagnostic yield in this setting. Objective Our purpose was to determine the safety and diagnostic yield of EUS-guided needle-knife incision and forceps biopsy (SINK biopsy) of upper GI SETs. Design Retrospective database review. Setting Academic tertiary-care referral center. Patients This study involved 14 consecutive patients referred for EUS evaluation of upper GI SETs with previous unsuccessful attempts at tissue diagnosis by conventional forceps biopsy. Intervention EUS-guided needle-knife incision and forceps biopsy. Main Outcome Measurements The safety and diagnostic yield of this method, compared with EUS-guided fine-needle aspiration (EUS-FNA), when possible. Results SINK biopsy provided tissue samples that were sufficient for definite histologic diagnosis in 13 of 14 cases (diagnostic yield 92.8%). There were 8 gastric GI stromal tumors. In 7 of 8, the size of SINK specimens allowed immunohistochemical analysis, and the evaluation of malignant potential was carried out by means of mitotic index determination in 5 cases (71.42%). SINK biopsies determined the pathological diagnosis of all (4 of 4) nonmesenchymal lesions. Eight patients underwent both EUS-FNA and SINK, with final histologic diagnosis determined in 6 of 8 cases (75%) by SINK versus 1 of 8 cases (12.5%) by EUS-FNA (Fisher exact test, P = .023). There were no procedure-related complications. Limitations A single-center, retrospective analysis with small sample size. Conclusion SINK biopsy appears to be an easy, safe, and effective technique for determining the definitive pathological diagnosis, evaluation of the malignant potential, and planning management of SETs. It could be a reliable alternative to conventional FNA, providing larger samples that improve the histologic yield.

Gastrointestinal amyloidosis may occur as part of the systemic manifestations of primary amyloidosis or in a localized form. The symptoms and signs that may occur are numerous and nonspecific, hampering clinical suspicion when this disease has not already been diagnosed. Gastric ulcers presenting as massive bleeding are an uncommon manifestation of this disease. We report the case of a patient with primary amyloidosis who developed massive gastrointestinal bleeding complicated by an amyloid gastric ulcer. Emergency surgery was required to control the bleeding.

Infections are one of the leading causes of morbidity and mortality in solid organ transplant recipients because of treatment with immunosuppressive agents. Infections due to nontuberculous mycobacteria (NTM) are infrequent but may be a major cause of morbidity. Treatment is associated with therapeutic limitations due to drug interactions with immunosuppressive agents and enhanced toxicity. Treatment of NTM infection most commonly involves surgery, reducing the doses of immunosuppressive medications and/or therapy with antimycobacterial medications The American Thoracic Society recommends isoniazid, rifampicin, and ethambutol. The current duration for treatment of pulmonary disease caused by Mycobacterium kansasii is 18 months. We describe the case of an immunosuppressed liver transplant recipient with poor outcome due to acute cholangitis who also developed concomitant infection with an uncommon organism, M. kansasii, in the late posttransplantation period.

Fundamento y objetivo Debido a la mayor morbimortalidad de la hepatitis aguda por el virus de la hepatitis A (VHA) cuando ocurre en pacientes con infeccion cronica por el virus de la hepatitis C (VHC), interesa conocer la prevalencia de inmunizacion frente al VHA en estos pacientes. Pacientes y metodo Se determinaron los anticuerpos de tipo inmunoglobulina G (IgG) frente al VHA (IgG anti-VHA) en 313 pacientes con infeccion cronica por el VHC (anti-VHC) y en 313 individuos anti-VHC negativo. Resultados La prevalencia de IgG anti-VHA encontrada fue identica en ambos grupos: un 81,2%. Sin embargo, entre los menores de 41 anos esta prevalencia era mayor en los anti-VHC positivo que en los individuos del grupo control. La adiccion a drogas por via parenteral y los tatuajes fueron mas frecuentes en el primer grupo. La presencia de IgG anti-VHA se asocio con la edad y con la procedencia del medio rural en ambos grupos. Conclusiones La prevalencia de IgG anti-VHA aumenta con la edad y es mas elevada entre los individuos de procedencia rural. Tambien podria ser mayor entre los pacientes jovenes anti-VHC positivo, en comparacion con los controles de edad similar. Este hallazgo puede deberse a las peores condiciones higienicas probablemente asociadas con ciertas practicas mas communes entre estos individuos, como la adiccion a drogas por via parenteral y los tatuajes.

Fundamento y objetivo: Es conocido el papel que desempenan los mediadores inmunologicos proinflamatorios en la patogenia de algunas alteraciones de organos distantes en la pancreatitis aguda (PA). El objetivo de este estudio ha sido evaluar la relacion entre dichos mediadores y la afectacion hepatica, renal y pulmonar en pacientes con PA. Pacientes y metodo: En 34 pacientes con PA se valoraron el dia del ingreso, parametros bioquimicos de funcion hepatica, creatinina y presion parcial de oxigeno (PO2) arterial, y se establecieron puntos de corte. Se determinaron el receptor soluble tipo I del factor de necrosis tumoral (sTNFRI), el receptor antagonista de la interleucina (IL) 1 (IL-1Ra), la IL-6, el receptor soluble de la IL-6 (sIL-6R), la IL-18 y la molecula de adherencia intercelular-1 (ICAM-1) los dias 1, 2, 3 y 7, y se compararon entre los pacientes con los parametros en el momento del ingreso (bioquimicos y PO2) superiores o inferiores a un punto de corte establecido. Resultados: Se encontraron valores significativamente mas elevados y mantenidos de sTNFRI, IL-18 e ICAM-1, y de IL-6 solo el primer dia, en los pacientes con algun parametro de funcion hepatica superior al punto de corte. sTNFRI, IL-1Ra e ICAM-1 presentaban al inicio valores significativamente superiores en los pacientes en relacion con la creatinina, y de estos e IL-6 en los que presentaban PO2 inferior a 60 mmHg. Conclusiones: sTNFRI, IL-6, IL-18 e ICAM-1 se comportaron como marcadores tempranos de lesion hepatica; sTNFRI, IL-1Ra e ICAM-1, de disfuncion renal, y estos e IL-6, de afectacion pulmonar.

Objetivos Este proyecto experimental ha sido disenado para evaluar: a) la capacidad de la oxitetraciclina para inducir esteatosis en el higado de rata cuando es administrada durante un periodo prolongado; b) evaluar si las ratas hembras son mas susceptibles a este farmaco, y c) estudiar las posibles alteraciones ultraestructurales y su relacion con los mecanismos de la esteatosis. MeTodos Sesenta y dos ratas Wistar (31 machos y 31 hembras) fueron distribuidas en 6 grupos, dos grupos control y cuatro grupos experimentales. El estudio duro 3 meses. Se obtuvo sangre y tejido hepatico bajo anestesia para el estudio morfologico (microscopia optica [MO] y microscopia electronica [ME]). Resultados La esteatosis fue de tipo microvesicular con una distribucion periportal. Aparecio en los grupos tratados, con un grado significativamente mayor en las hembras (p = 0,004). No se observo ninguna relacion con la dosis. El estudio ultraestructural revelo una dilatacion de los microsomas en todos los grupos experimentales, sin diferencias en cuanto al sexo. No se constato una proliferacion de los peroxisomas ni la aparicion alteraciones mitocondriales. Conclusiones La oxitetraciclina produce predominantemente esteatosis hepatica microvesicular, apareciendo fundamentalmente en hembras. Como posible mecanismo de esta esteatosis inducida por oxitetraciclina postulamos un descenso en las funciones mitocondrial, microsomal y peroxisomal como resultado de una inhibicion en la sintesis proteica de estos compartimientos celulares.

Introduction Liver biopsy remains the gold standard to evaluate fibrosis. However, it is invasive and uncomfortable as well as associated with complications. Transient elastography (FibroScan) is a simple and noninvasive method to assess liver fibrosis by measuring liver stiffness in kilopascals. Body mass index (BMI) greater than 28 is associated with high rates of invalid tests. Liver transplant patients show increased rates of obesity. We do not yet have many data about the usefulness of FibroScan in liver transplantation. Aims To analyze the applicability of FibroScan to assess fibrosis in liver transplantation and study the association between obesity and valid tests. Material and Methods We prospectively assessed the performance of transient elastography in 29 liver transplant patients from February to May 2008. We prospectively studied the success rate, the elasticity (stiffness) in kilopascals, and the BMI. Results The BMI was greater than 30 kg/m 2 in four patients; 25 to 30 kg/m 2 in eight; and 17 had BMI 2 . The overall success of FibroScan was 24/29 (82.7%). However, among patients with BMI > 30 kg/m 2 , it was 2/4 (50%), whereas for BMI 2 it climbed to 100%. The average duration of the procedure was 211.52 seconds for BMI 2 ; 236 seconds for BMI between 25 and 30 kg/m 2 ; and 361 seconds in patients with a BMI > 30 kg/m 2 —differences that were statistically significant. Conclusions FibroScan seemed to be a promising approach to assess liver fibrosis.BMI is a limiting factor toward achieving a valid test; FibroScan had limited usefulness in obese patients.

Arterioportal shunt in the liver is a rare vascular disorder that may be due to congenital vascular malformation (hereditary hemorrhagic telangiectasia), trauma, iatrogenic causes (after a hepatic biopsy) or neoplasm. Initial treatment consists of transcatheter arterial embolization with different kinds of materials. We present the case of a 64-year-old woman with signs of portal hypertension and severe diarrhea. Doppler ultrasonography, computed tomography and angiography revealed arterioportal fistulae between the hepatic artery and right portal vein. Transcatheter arterial embolization with n-butyl-2-cyanoacrylate surgical glue (Glubran) was successfully performed. After 2 years of follow-up, the patient remains asymptomatic. Transcatheter arterial embolization with Glubran should be considered as a therapeutic option in arterioportal shunts and could be a definitive therapy.

Cavernous hemangioma is the most frequent benign hepatic tumor. These tumors are usually small, solitary or multiple, and asymptomatic but they can be large. In the majority of cases, these tumors are sporadic. We describe a family in which six members from three successive generations presented cavernous hepatic hemangiomas. One of the women, who was taking oral contraceptives, presented a giant cavernous hemangioma causing pain in the right hypochondriac region and biochemical abnormalities while the remaining cases were asymptomatic. We found only one study in the literature that reports familial cavernous hepatic hemangioma; a further two studies describe hepatic hemangiomas in members of families with angiomas in other sites. We believe that description of a new family with this disease is of interest. The findings could support autosomal dominant inheritance as the mode of transmission of these tumors, as well as the existence of proliferative factors in these tumors.

Whipple's disease is a rare systemic disease of infectious etiology. Its clinical presentation is highly variable. The most common symptoms are diarrhea, weight loss, abdominal pain and joint manifestations. Non-digestive manifestations frequently precede digestive symptoms by several years. For all these reasons, diagnosis is difficult. Definitive diagnosis is established by the finding of PAS-positive macrophages in the lamina propria of the thin intestine. It is important to start appropriate antibiotic therapy early, as this improves the prognosis. We present the case of a male patient in whom the first manifestations of the disease were constipation and upper gastrointestinal hemorrhage, two forms of clinical presentation that have rarely been described in the literature on Whipple's disease.