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Resumen Introduccion En la endoscopia digestiva alta de pacientes con cirrosis hepatica a menudo se observan lesiones inespecificas, que se suelen orientar como gastropatia por hipertension portal (GHP). Sin embargo, el diagnostico de GHP puede ser dificil, tanto endoscopica como histologicamente. El estudio de expresion de CD34, que realza las celulas endoteliales de la microvasculatura podria ayudar al diagnostico diferencial. Los objetivos del estudio fueron evaluar la correlacion entre la endoscopia y la histologia en el diagnostico de la GHP y valorar la utilidad del CD34 en el diagnostico de la misma. Material y metodos Se analizaron biopsias fundicas de 100 pacientes cirroticos y 20 controles, y se realizo inmunotincion para CD34. Se compararon con las imagenes endoscopicas. Resultados Se observo una correlacion muy baja entre la histologia con el diagnostico endoscopico de GHP (kappa = 0,15). Ademas, la medicion del diametro de los vasos gastricos realzados mediante el uso de la tincion inmunohistoquimica (CD34) no mostro buena correlacion con el diagnostico endoscopico (p = 0,26) y tampoco parece aportar informacion relevante para el diagnostico histologico de GHP. Discusion Existe una baja correlacion entre la histologia y la endoscopia para el diagnostico de GHP. El uso de la inmunotincion para CD34 no mejora la rentabilidad diagnostica del estudio histologico.

Background Universal vaccination for hepatitis B virus (HBV) and migratory movements have changed the demographic characteristics of this disease in Spain and in Europe. Therefore, we evaluated the characteristics of the disease and the possible differences according to origin (immigrants vs non-immigrants) and access to treatment. Methods This is a multicenter cross-sectional study (June 2014 to May 2015) in which outpatients with a positive HBsAg were seen and followed in four Hepatology units. Demographic and clinical data and indication and access to treatment were collected in two different regions of Catalonia (Spain) where there are no barriers to treatment due to a comprehensive coverage under the National Health System. Results A total of 951 patients were evaluated (48.1% men). Of these, 46.6% were immigrants (58.7% of them were born in Africa) and were significantly younger compared to non-immigrants. The proportions of patients with alcohol consumption, being overweight, and other indicators of metabolic co-morbidities were significantly higher in non-immigrants. Among the 937 patients receiving HBeAg examination, 91.7% were HBeAg-negative. Chronic HBeAg-positive infection was significantly higher in immigrants (3.9% vs 0.6%, P = 0.001) and chronic HBeAg-negative hepatitis was higher non-immigrants (31.7% vs 21.4%, P Conclusions The immigrant population with HBV is younger and has a lower prevalence of metabolic co-morbidities and a higher frequency of chronic HBeAg infection. Despite having access to care and an indication for treatment, some do not get adequately treated due to several factors including local adaptation that precludes access to treatment.

Drug-eluting bead transarterial chemoembolization (DEB-TACE) improves the survival of patients with hepatocellular carcinoma (HCC), intermediate stage [i.e. Barcelona Clinic Liver Cancer-B (BCLC-B)]. The aim of our study was to analyse the overall survival (OS) and prognostic factors of patients with HCC treated with DEB-TACE.Patients' clinical course was recorded from January 2005 to July 2014. The median OS was obtained by the Kaplan-Meier method and compared using the log-rank test. The prognosis factors associated with OS were determined by a multivariate Cox regression analysis and the accuracy of the OS prediction was determined by calculation of the assessment for retreatment with TACE score (ART score).A cohort of 147 consecutive patients treated with DEB-TACE was included. Median age of the patients was 73.4 years. Overall, 68.7% were men, and all had cirrhosis, with 68.8% being hepatisis C virus positive. Moreover, 35.2% were staged as BCLC-A and 60.2% as BCLC-B. After a median follow-up of 19.2 months, 29.3% were alive, 4.3% needed treatment with sorafenib and 56.1% underwent DEB-TACE retreatment. Median OS was 22.8 [95% confidence interval (CI)=19.6-25.9]. After censoring for ascites and more than one nodule, OS was 23.87 (95% CI =20.72-27.01) and 26.89 (95% CI =21.00-32.78), respectively. The risk of death decreased by 22.3% with the number of DEB-TACE sessions (hazard ratio=0.777) and increased by 25.9% with higher Child-Pugh score (hazard ratio=1.259). Overall, 61.2% of the cohort had an ART score between 0 and 1.5. There were no statistical differences in OS between cohort groups with ART of 0-1.5 and at least 2.5.The results validate the efficacy and safety of DEB-TACE in patients with HCC and the importance of some prognostic factors for patient survival.

The life expectancy of patients with hepatocellular carcinoma (HCC) has increased in the last few years due to recent treatment advances. However, extrahepatic metastases from tumors, previously described only occasionally, are becoming more frequent in clinical practice. The choice between an active or passive approach to these metastatic lesions can sometimes present clinicians with a difficult dilemma. We discuss the case of a male patient with multifocal HCC and cranial metastasis from a primary liver tumor and who, after surgery and radiotherapy over the metastatic lesion, has survived for more than 3 years.

El colapso actual de los servicios de urgencias ha originado el desarrollo de otros ambitos de atencion como los hospitales de dia. La cirrosis hepatica (CH) es una enfermedad cronica que presenta descompensaciones que requieren atencion. El objetivo es comparar las diferencias entre las visitas urgentes de los pacientes con CH al hospital de dia de hepatologia (HDH) o al servicio de urgencias (URG). Material y metodos: Estudio prospectivo observacional, mediante la complementacion de un cuestionario de los pacientes que acudieron al HDH y a URG entre 9/2007 y 8/2008. Se recogieron variables demograficas, clinicas y exploraciones complementarias realizadas. Resultados: Hubo 743 consultas, 62% al HDH. La edad media fue de 65 ± 12 anos, ratio hombre/mujer 2,3. El diagnostico mas frecuente en URG fue la encefalopatia (26,2% URG versus 6% HDH, p < 0,001) seguido de la hemorragia digestiva alta (17,7% URG versus 0,6% HDH, p < 0,001). La ascitis fue el mas frecuente en HDH (66,2% HDH versus 22,7% URG, p < 0,001). Las exploraciones realizadas fueron, analisis: 95% URG versus 60% HDH (p < 0,01); radiologia: 71% URG versus 11% HDH (p < 0,01), y paracentesis: 51% URG versus 74% HDH (p < 0,01). El tiempo de estancia en URG fue de 21,3 ± 121,5 h respecto a 3,3 ± 2,4 h en HDH (p < 0,001). Se hospitalizaron el 53% de los visitados en URG y el 12% de los visitados en HDH (p < 0,05). Conclusion: los pacientes acuden mayoritariamente al HDH, realizandose menos pruebas y presentando un tiempo de estancia menor. La atencion continuada de pacientes con CH en el HDH es adecuada y eficiente.

We report the case of a young man with chronic hepatitis B infection of probable perinatal acquisition who was diagnosed with hepatocellular carcinoma at a very early stage (BCLC 0) with a highly favorable prognosis. However, the tumor progressed rapidly and the patient died within months. Currently, there are few data that could help to identify cases likely to show rapid progression and which could prompt initiation of aggressive therapies that might prevent or control such progression.

Resumen Introduccion Numerosos ensayos clinicos demuestran una alta eficacia en el tratamiento con interferon pegilado y ribavirina; sin embargo, se conoce poco sobre los resultados obtenidos en la practica clinica. Objetivo Evaluar en la practica clinica la respuesta y los factores que influyen en el tratamiento de la hepatitis cronica por el virus C. Material y metodos Entre agosto de 2001 y diciembre de 2005, se trato a 219 pacientes con interferon pegilado (alfa-2a en dosis fijas o alfa-2b segun el peso) y ribavirina. Los pacientes que presentaban un genotipo 1 o 4 recibieron tratamiento con interferon pegilado alfa-2a (180 |xg/semana) y ribavirina (1.000 mg/dia si 75 kg) o interferon alfa-2b (1,5 μg/kg/semana) y ribavirina (10,6 mg/kg/dia) durante 48 semanas. Los pacientes con genotipo 2 y 3 fueron tratados durante 24 semanas con la misma pauta de interferon pegilado alfa-2a o alfa-2b, pero con 800 mg de ribavirina al dia repartida en dos dosis. La respuesta viral sostenida (RVS) se ha determinado como la negatividad del ARN del virus de la hepatitis C a los 6 meses despues de finalizar el tratamiento. Resultados Se incluyeron 219 pacientes (un 69% varones, con una edad de 44 ± 10 anos). Como antecedentes epidemiologicos, un 22,4% habia consumido drogas por via parenteral y un 22,4% habia sido transfundido antes del ano 1992. Un 47% de los pacientes con biopsia hepatica tenia puentes de fibrosis o cirrosis hepatica establecida. Los genotipos se distribuyeron de la siguiente forma: 69,8% genotipo 1; 4,1% genotipo 2; 17,8% genotipo 3; 8,2% genotipo 4. Del total de 219 pacientes, 76 (35%) fueron tratados con interferon pegilado alfa-2a y 143 (65%) con interferon alfa-2b. Segun el genotipo, la RVS se obtuvo en un 46% genotipo 1, un 88,9% genotipo 2, un 78,9% genotipo 3 y un 33,3% genotipo 4. El analisis univariado mostro que el genotipo es la unica variable que influyo en la RVS. Conclusion El tratamiento con interferon pegilado y ribavirina en la practica clinica diaria presenta una RVS similar a la obtenida en los ensayos clinicos. El genotipo viral continua siendo la principal variable correlacionada con la RVS.

Resumen La unidad de atencion continuada y hospital de dia permite el manejo ambulatorio de los pacientes con una enfermedad digestiva. Objetivo Disminuir los ingresos hospitalarios y el numero de pacientes con una enfermedad digestiva que acude a urgencias. Material y metodos Los pacientes se atienden segun dos niveles asistenciales: a) atencion continuada, en que se visitan de forma urgente los pacientes con una descompensacion aguda de su enfermedad digestiva, y b) atencion programada, en que se realizan procedimientos que por su complejidad requieren personal de enfermeria, sin ser necesario el ingreso hospitalario. Resultados En el periodo comprendido entre 1995 y 2005 se ha pasado de realizar 118 visitas en atencion continuada en 1995 a 784 en 2005. En atencion programada las paracentesis han aumentado de 237 en 1995 a 687 en 2006 y las infusiones de hierro intravenoso de 111 en 2004 a 519 en 2006. El numero de ingresos hospitalarios paso inicialmente de 605 en 1995 a 430 en 2000, para posteriormente aumentar. El numero de pacientes con una enfermedad digestiva que acudio a urgencias disminuyo un 75% estos anos. Conclusiones La unidad de atencion continuada y hospital de dia permite una disminucion inicial del numero de ingresos en el area de hospitalizacion convencional y en el porcentaje de pacientes con patologia digestiva que acuden a urgencias.

SUMMARY Background Sustained virological response rates of up to 52% have been obtained with peginterferon α2a (40 kDa) plus ribavirin in patients suffering from chronic hepatitis C genotype 1 in randomized-controlled trials. Aim To assess early virological response and its clinical utility in predicting an sustained virological response in patients suffering from chronic hepatitis C genotype 1 in routine clinical practice in Spain. Methods Treatment-naive patients received pegylated interferon α2a (40 kDa) 180 µg/week plus ribavirin 1000/1200 mg/day for 48 weeks, and were followed for a further 24 weeks. Overall, 475 patients received at least one dose of medication and were included in the efficacy population. Results The overall sustained virological response rate was 48%. Of those with week 12 virological data, 83% had an early virological response. The negative predictive value of an early virological response was 93%. Conclusion If sustained virological response is the goal, a treatment-decision based on a 12-week evaluation during routine clinical practice is feasible.

BACKGROUND AND AIMS The ability of noninvasive methods to predict the development of cirrhosis has not been established. We evaluated the ability of three noninvasive methods [the Forns index, the aspartate aminotransferase-to-platelet ratio index (APRI), and the Non-Invasive Hepatitis-C-related Cirrhosis Early Detection (NIHCED) score] to determine the risk of developing cirrhosis in chronic hepatitis C. METHODS Consecutive patients with chronic hepatitis C who had undergone liver biopsy between 1998 and 2004 were eligible. We used the three methods to evaluate patients at baseline and at follow-up (4-10 years later). When these methods yielded discordant or indeterminate results, a second liver biopsy was performed. Logistic regression models were fitted for each method to predict whether cirrhosis would appear and to predict long-term mortality from cirrhosis. RESULTS We included 289 patients in our study. The mean scores at baseline and at follow-up, respectively, were as follows: Forns, 5.47 ± 1.95 and 6.56 ± 2.02; APRI, 1.1 ± 2.33 and 1.4 ± 1.53; and NIHCED, 7.79 ± 11.45 and 15.48 ± 15.28. The area under the receiver operating characteristic curve for predicting cirrhosis was 0.83 for Forns, 0.79 for APRI, and 0.76 for NIHCED. The sensitivity and specificity for predicting cirrhosis, respectively, were 75 and 71% for Forns (cutoff 4.7), 86 and 42% for APRI (cutoff 0.48), and 41 and 82% for NIHCED (cutoff 0). The area under the receiver operating characteristic curve for predicting mortality was 0.86 for Forns, 0.79 for APRI, and 0.84 for NIHCED. CONCLUSION Indirect noninvasive markers could help identify patients with chronic hepatitis C at risk of progression to cirrhosis.

Triptans are a class of drugs with proven efficacy in the acute treatment of migraine headache. The first component of these drugs was sumatriptan, with various derivatives subsequently emerging. Until now, there has only been one reported case of liver toxicity with zolmitriptan. We now present a case of hepatotoxicity related to another drug in this group: rizatriptan.

Summary Background : Helicobacter pylori infection may lead to peptic ulcer disease, and causes significant morbidity in patients with cirrhosis. The measurement of H. pylori antigens in human stools has been proposed as a valuable, non-invasive, diagnostic tool. A number of tests have recently been commercialized. However, very few data are available on their reliability in patients with cirrhosis. Aim : To evaluate the usefulness of three new tests — HpSA (Meridian Diagnostics Inc., Cincinnati, OH, USA), Simple H. pyl (OPERON S.A., Zaragoza, Spain) and FemtoLab H. pylori (Connex, Martinsried, Germany) — in the diagnosis of H. pylori infection in cirrhotic patients. Methods : H. pylori infection was determined in 79 cirrhotic patients (48 men, 31 women; age range, 29–82 years; mean, 62 ± 11 years) by concordance of histology and urea breath test. The sensitivity, specificity and positive and negative predictive values of each stool test were calculated. Results : According to the reference method, the sensitivities of HpSA, Simple H. pyl and FemtoLab H. pylori immunoassays were 76%, 87% and 78%, respectively, and their specificities were 93%, 62% and 79%, respectively. Conclusions : Faecal tests are non-invasive and easy-to-perform tools for the diagnosis of H. pylori infection. However, their sensitivity and specificity seem to be non-optimal in patients with cirrhosis.

Summary Background : Helicobacter pylori-associated peptic ulcer is a frequent complication in cirrhotic patients and its morbidity rate is high. In spite of this, diagnostic methods for H. pylori infection have not been fully evaluated in these patients. Aim : To evaluate H. pylori diagnostic methods in patients with liver cirrhosis. Methods : One hundred and one cirrhotic patients were included in the study. Three antral and two corpus biopsies were obtained for rapid urease test of the antral mucosa, and Giemsa stain and immunohistochemistry were performed for both the corpus and antrum. Serology, 13C-urea breath test and faecal H. pylori antigen determination were also carried out. Results : Sixty-two patients were positive and 35 were negative for H. pylori infection; four were indeterminate. The sensitivity and specificity were 90.4% and 100%, respectively, for antral histology, 100% and 100% for gastric body histology, 90.4% and 100% for antral immunohistochemistry, 96.2% and 96.7% for body immunochemistry, 85.7% and 97% for rapid urease test, 83.6% and 55.9% for serology, 96.4% and 97.1% for 13C-urea breath test and 75.4% and 94.1% for faecal antigen. Conclusion : The most reliable tests for H. pylori infection in cirrhotic patients were the 13C-urea breath test and gastric body histology.

Background: Helicobacter pylori infection is the major pathogenic factor for peptic ulcer disease. Its epidemiology is not fully known; few data are available in patients with chronic liver disease. Aims: To investigate the seroprevalence and factors associated with Helicobacter pylori infection in a series of liver cirrhosis patients. Methods: Two hundred and twenty consecutive patients were prospectively included in a study aimed to evaluate the effect of dietary intervention on cirrhosis complications and survival. At inclusion, an epidemiological and clinical questionnaire was completed. Sera were obtained and stored at −70°C until analyzed. They were tested for Helicobacter pylori antibodies using a commercial ELISA kit. Results: Eleven out of 220 patients had borderline anti- Helicobacter pylori IgG titers. Of the remaining 209 patients, 105 (50.2%) showed positive titers of Helicobacter pylori IgG. Univariate analysis showed that Helicobacter pylori infection was more frequent in older patients, those born outside Catalonia, and in patients with a low educational level. Past ethanol consumption and current smoking correlated negatively with Helicobacter pylori infection. Multivariate analysis selected age (OR 3.1, 95% CI 1.46–6.45), educational level (OR 2.2. 95% CI 1.18–4.2) and alcohol consumption (OR 0.7 95% CI 0.45–0.99) as the variables independently related to Helicobacter pylori infection. Conclusions: Helicobacter pylori infection in cirrhosis has the same epidemiological pattern as in the general population. Suggestions that the etiology or the severity of the liver disease could be related to Helicobacter pylori infection were not confirmed by our study.

Primary biliary cirrhosis (PBC) is characterized by the autoimmune inflammatory response of small intrahepatic bile ducts. Prevalence in Spain is estimated as 61.9 cases per million inhabitants, whereas Northern Europe rates over 200 cases/million. Our objective was to determine the incidence and prevalence of PBC in our health area.PBC was defined by the presence of abnormal liver tests (dissociated cholestasis) with positive antimitochondrial antibodies and/or compatible liver histology. Medical records from patients diagnosed between 1990 and 2002 were reviewed retrospectively. The following data were collected: diagnostic data, demographic and analytic data, liver histology and stage and treatment and disease outcome.In a population of 389 758 inhabitants, 87 patients were diagnosed with PBC. Mean age at diagnosis was 63.9+/-12.6 years. Eighty-four (96.6%) were women. Mean annual incidence was 17.2 per 10 inhabitants and the prevalence at the end of study was 195 per 10. Biopsy was performed in 71 (81.6%) patients, 61 of whom (86%) did not have fibrosis. Time of follow-up was 63.6+/-43.2 (2.28-153.9) months.Incidence and prevalence in our reference area are higher than in some Spanish areas, as per the results previously published; however, they are comparable with those obtained in Northern Europe and the US.

Objective To develop and validate a non-invasive index to predict the presence of cirrhosis in patients with chronic hepatitis C on the basis of clinical, laboratory, and ultrasound findings. Materials and methods Data from the complete history and physical examination, serologic studies, liver ultrasound, and liver biopsy of patients with chronic hepatitis C were analyzed using multivariate regression to develop a cirrhosis predictive index. This index was then applied prospectively to another group of patients with chronic hepatitis C to determine its accuracy. Results Three hundred and thirty-two patients were included (mean age, 48.5 ± 18.7 years; male-female ratio, 1.27). Sixty-seven patients (20%) had cirrhosis at histology. Logistic regression identified seven variables that predicted cirrhosis: age ≥ 60 years, platelet count ≤ 100 (× 10 9 /L), AST/ALT ≥ 1, prothrombin time (Ratio) ≥ 1.1, caudate hypertrophy, right lobe atrophy and splenomegaly. Patients scoring ≥ 22 in total had a statistically significant probability of cirrhosis (sensitivity, 80%; specificity, 96%; and diagnostic accuracy, 94%). Conclusion Cirrhosis can be predicted in patients with chronic hepatitis C by the evaluation of seven clinical, laboratory, and sonographic variables. The index will be useful for the management and follow-up of hepatitis C patients drastically reducing the indications for biopsy in this context.

The aim of this study was to investigate the clinical and epidemiological factors associated with the appearance of peptic ulcer in patients with cirrhosis and, in particular, the role of Helicobacter pylori infection.A total of 201 of 220 consecutive patients included in a prospective study that aimed to evaluate the effect of dietary intervention on cirrhotic complications and survival underwent upper gastrointestinal endoscopy. At entry, an epidemiological and clinical questionnaire was completed and the presence of peptic ulcer disease or esophageal varices at endoscopy was prospectively collected. Sera were obtained and stored at -70 degrees C until analyzed, being tested afterward for Helicobacter pylori antibodies using a commercial ELISA kit.Eleven of 201 patients had borderline anti-Helicobacter pylori IgG titers and were excluded from further analysis. In the remaining 190 patients, point prevalence of peptic ulcer was 10.5% and lifetime prevalence 24.7%. Multivariate analysis selected male sex (OR 2.3; 95%CI 1.09-4.89) and Helicobacter pylori seropositivity (OR: 1.7, 95%CI 1.02-2.81) as the variables independently related to peptic ulcer disease.Male sex and seropositivity for Helicobacter pylori are the major risk factors for peptic ulcer in cirrhosis.

The hepatitis C virus (HCV) genotype is an important predictive outcome parameter for pegylated interferon plus ribavirin therapy. Most published therapeutic trials to date have enrolled mainly patients with HCV genotypes 1, 2 and 3. Limited studies have focused on genotype 4 patients, who have had a poor representation in pivotal trials. Our aim was to evaluate the efficacy and safety of treatment with standard dose pegylated interferon alfa-2a in combination with weight-based ribavirin in patients with chronic hepatitis C genotype 4. In this prospective observational study, 198 patients with HCV-4 were included in this study from February 2004 to August 2005,188 patients who received at least 1 dose of drugs were included in the ITT analysis and they were treated with pegylated interferon alfa-2a and ribavirin for 48 weeks. Baseline and demographic characteristics, response to treatment at weeks 12, 48 and 72, and the nature and frequency of adverse effects were analyzed. Virological response at week 12 was achieved in 144 patients (76.6%). Virological response at the end of treatment was present in 110 patients (58.5%). At week 72, 99 patients presented SVR (52.7%). The reported adverse events were similar to those found in the literature for treatments of similar dose and duration. In conclusion, combined treatment with pegylated interferon alfa-2a and ribavirin was well tolerated and effective in chronic hepatitis C genotype 4, yielding response rates between those reported for genotype 1 and those of genotypes 2-3.