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Background: Non-alcoholic fatty liver disease (NAFLD), the most common chronic liver disease in adolescents, is a feature of metabolic syndrome (MetS). Obesity and insulin resistance (IR) are risk factors for NAFLD, as well as inflammation-related genetic markers. The relationship between metabolic or inflammation-related genetic markers and alanine aminotransferase (ALT) is not fully understood. We examined the relationship of MetS, metabolic and inflammation-related genetic markers with elevated ALT in adolescents. Methods: A total of 674 adolescents participated in a cross-sectional study in Guadalajara, Mexico. Elevated ALT (>40 IU/L), a surrogate marker of NAFLD, and MetS (International Diabetes Federation definition) were evaluated. Obesity, IR, lipids, C-reactive protein (CRP) and genetic markers (TNFA-308G>A, CRP+1444C>T, IL1RN and IL6-597/-572/-174 haplotype) were evaluated. Multivariate logistic regression was performed. Results: Elevated ALT was observed in 3% and 14.1% (total and obese, respectively) of the adolescents. Obesity (odds ratio [OR], 5.86; 95% confidence interval [95% CI], 1.16–25.89), insulin (OR, 8.51; 95% CI, 2.61–27.71), IR (OR, 9.10; 95% CI, 2.82–29.38), total cholesterol (TC) (OR, 3.67; 95% CI, 1.25–10.72), low-density lipoprotein-cholesterol (LDL-C) (OR, 3.06; 95% CI, 1.06–8.33), non-high-density lipoprotein-cholesterol (HDL-C) (OR, 3.88; 95% CI, 1.27–11.90) and IL1RN (OR, 4.64; 95% CI, 1.10–19.53) were associated with elevated ALT. Among males, ≥2 MetS criteria were associated with elevated ALT (OR, 4.22; 95% CI, 1.14–15.71). Conclusions: Obesity, insulin, IR, high TC, high LDL-C, high non-HDL-C and IL1RN polymorphism were associated with elevated ALT. Among males, ≥2 MetS criteria were associated with elevated ALT. There is an urgent need to reduce obesity and IR in adolescents to prevent NAFLD.

Hepatic encephalopathy is a cerebral alteration mainly caused by hepatic insufficiency or portosystemic shunt. It ranges from minimal neurologic manifestations to coma in its overt stage. The multifactorial pathophysiology of hepatic encephalopathy has rendered numerous treatment alternatives, among which the modification of dysbiosis and hyperammonemia are currently considered to be effective, not only clinically, but also regarding cost. Recent work has developed knowledge of probiotics in different clinical settings including the relationship of the gut microenvironment to liver cirrhosis. The aim of this review was to analyze the results of clinical trials on the effect of different probiotics on hepatic encephalopathy.

Primary Immune Thrombocytopenia (TIP) is an autoimmune disease that accelerates the peripheral destruction of platelets and alters megakaryocytopoiesis. Helicobacter pylori infection and eradication has been associated with an increase in the platelet count in patients with IPT. The aim of this article is to evaluate the platelet response after H. pylori eradication in patients with chronic splenectomized IPTBetween 2008 and 2009, adult patients with a diagnosis of chronic IPT, splenectomized; They were given breath test with carbon 13-labeled urea (PAU13C). Patients who tested positive received eradication treatment with amoxicillin, omeprazole and clarithromycin for 14 days. After 6 weeks of treatment, a second PAU13C was performed. Baseline platelet counts were performed and every six months until the completion of two years.40 patients, 34 women and 6 men were included, PAU13C was positive in 17 patients (42.5%). H. pylori eradication was obtained in 16 patients (94%) confirmed by post-treatment PAU13C. In the follow-up of the patients it was observed that there was increase of platelets in 7 of the patients with eradication of H. pylori, while of the patients not infected in 9 also an increase of platelets was observed.There were no differences in the increase in platelet count among patients positive or negative to the H. pylori breath test at followup at 24 months.La trombocitopenia inmune primaria (TIP) es una enfermedad autoinmune que acelera la destrucción periférica de las plaquetas y altera la megacariocitopoyesis. La erradicación de la infección por Helicobacter pylori se ha asociado al incremento en la cuenta de plaquetas en los pacientes con TIP. El objetivo de este trabajo fue evaluar la respuesta de plaquetas después de la erradicación del H. pylori en pacientes con TIP crónica esplenectomizados.Entre 2008-2009 fueron incluidos pacientes adultos con diagnóstico de TIP crónica, esplenectomizados; se les realizó prueba de aliento con urea marcada con carbono 13 (PAU13C). Los pacientes que resultaron positivos a la prueba recibieron tratamiento de erradicación con amoxicilina, omeprazol y claritromicina por 14 días. Después de 6 semanas de tratamiento, se realizó una segunda PAU13C. Se realizaron cuenta de Plaquetas basal y cada seis meses hasta completar dos años.Se incluyeron 40 pacientes, 34 mujeres y 6 hombres, la PAU13C resultó positiva en 17 pacientes (42.5%). La erradicación del H. pylori se obtuvo en 16 pacientes (94%) confirmado por PAU13C postratamiento. En el seguimiento de los pacientes se observó que hubo incremento de las plaquetas en 7 de los pacientes con erradicación del H. pylori, mientras que de los pacientes no infectados en 9 también se observó aumento de plaquetas.No hubo diferencias en el incremento en la cuenta de plaquetas entre los pacientes positivos o negativos a la prueba de aliento para H. pylori en el seguimiento a 24 meses.

Introduction Non-cardiac chest pain (NCCP) is mainly related to oesophageal disease, and in spite of being a common condition in Mexico, information regarding it is scarce. Aim To assess the clinical characteristics and health-related quality of life of patients with NCCP of presumed oesophageal origin. Material and methods Patients with NCCP of presumed oesophageal origin with no previous treatment were included in the study. Associated symptoms were assessed and upper gastrointestinal endoscopy and 24-hour oesophageal pH monitoring were performed to diagnose gastroesophageal reflux disease, while oesophageal manometry was used to determine oesophageal motility disorders. The SF-36 Health-Related Quality of Life (HR-QoL) questionnaire was completed and its results compared to a control group without oesophageal symptoms. Results The study included 33 patients, of which 61% were women, and the mean age was 46.1 (± 11.6) years. Causes of NCCP were gastroesophageal reflux disease in 48%, achalasia in 34%, and functional chest pain in 18%. The average progression time for chest pain was 24 (2-240) months, with ≤3 events/week in 52% of the patients. The most frequent accompanying symptoms were: regurgitation (81%), dysphagia (72%) and heartburn (66%). Patients with NCCP show deterioration in HR-QoL compared to the control group ( P = .01), regardless of chest pain aetiology. The most affected areas were general perception of health, emotional issues, and mental health sub-scale ( P > 0 .05). Conclusions In our population, patients with NCCP show deterioration in HR-QoL regardless of the aetiology, frequency, and accompanying symptoms.

ResumenIntroducciónEl dolor torácico no cardiaco (DTNC) se relaciona principalmente con enfermedades del esófago, y aunque se considera una condición común, en México la información aún es escasa.ObjetivoEvaluar las características clínicas y la calidad de vida relacionada con salud en pacientes con DTNC de presunto origen esofágico.Material y métodosSe incluyeron en el estudio pacientes con DTNC de presunto origen esofágico, sin tratamiento previo. Se evaluaron los síntomas asociados, se realizó endoscopia alta y monitorización de pH esofágico de 24h para establecer el diagnóstico de enfermedad por reflujo gastroesofágico, y para descartar trastornos en la motilidad esofágica se llevó a cabo manometría esofágica. Se aplicó el cuestionario de calidad de vida SF-36, y los resultados se compararon con un grupo control de sanos.ResultadosSe incluyeron 33 pacientes, el 61% mujeres, y la edad promedio fue 46.1 (±11.6) años. Las causas de DTNC fueron: enfermedad por reflujo gastroesofágico 48%, acalasia 34% y dolor torácico funcional 18%. El tiempo promedio de progresión del dolor torácico fue 24 (2-240) meses, con≤3 eventos/semana en el 52%. Los síntomas acompañantes más frecuentes fueron: regurgitaciones (81%), disfagia (72%) y pirosis (66%). Los pacientes con DTNC muestran deterioro en su calidad de vida comparado con el grupo control, independientemente de la etiología del dolor torácico. Los dominios más afectados son la percepción general de salud, problemas emocionales y la subescala de salud mental, sin diferencia estadística significativa (P > 0.05).ConclusionesEn nuestra población, los pacientes con DTNC muestran deterioro en su calidad de vida independientemente de la etiología, frecuencia y síntomas que acompañan al dolor torácico.AbstractIntroductionNon-cardiac chest pain (NCCP) is mainly related to oesophageal disease, and in spite of being a common condition in Mexico, information regarding it is scarce.AimTo assess the clinical characteristics and health-related quality of life of patients with NCCP of presumed oesophageal origin.Material and methodsPatients with NCCP of presumed oesophageal origin with no previous treatment were included in the study. Associated symptoms were assessed and upper gastrointestinal endoscopy and 24-hour oesophageal pH monitoring were performed to diagnose gastroesophageal reflux disease, whereas oesophageal manometry was used to determine oesophageal motility disorders. The SF-36 Health-Related Quality of Life (HR-QoL) questionnaire was completed and its results compared with a control group without oesophageal symptoms.ResultsThe study included 33 patients, of which 61% were women, and the mean age was 46.1 (±11.6) years. Causes of NCCP were gastroesophageal reflux disease in 48%, achalasia in 34%, and functional chest pain in 18%. The mean progression time for chest pain was 24 (2-240) months, with≤3events/week in 52% of the patients. The most frequent accompanying symptoms were: regurgitation (81%), dysphagia (72%) and heartburn (66%). Patients with NCCP showed deterioration in HR-QoL compared with the control group (P=0.01), regardless of chest pain aetiology. The most affected areas were general perception of health, emotional issues, and the mental health sub-scale (P>0.05).ConclusionsIn our population, patients with NCCP showed deterioration in HR-QoL regardless of the aetiology, frequency, and accompanying symptoms.

L-asparaginase (L-asp) is used as part of the initial treatment in children with acute lymphoblastic leukemia (ALL), inducing remission in 83% to 95% of the treated patients. Major toxicity effects reported are hypersensitivity reactions and dysfunctions of the liver and pancreas. Acute pancreatitis (AP) induced by L-asp has been noted in 2.5% to 16% of the treated patients. The purpose of this study was to determine the frequency and outcome of AP in children with ALL treated with L-asp in a tertiary care pediatric hospital.From January 1999 to June 2005, the charts of children with ALL admitted for L-asp treatment were reviewed. Data from children who developed AP were analyzed retrospectively. AP was defined as the presence of clinical data (nausea, vomiting, and abdominal pain), elevated pancreatic enzymes, and changes in the abdominal ultrasound and/or computed tomography (CT) scan. Clinical and biochemical data, abdominal ultrasound, and CT scan findings, complications, treatment, and outcome were analyzed retrospectively.During the last 6 years, 266 ALL new cases were started on chemotherapy including L-asp, of which 18 of 266 (6.7%) developed AP. Pancreatic necrosis by CT scan was found in 10 patients, peripancreatic collections and pseudocyst formation were detected in 5 and 3 cases, respectively, and resolved by cystogastrostomy or drainage. Two patients developed chronic pancreatitis and 3 diabetes. There was no relationship between number of doses and pancreatic toxicity. None of the patient died due to pancreatic toxicity.L-asp is an effective drug to treat ALL, the administration of L-asp requires the monitoring of pancreatic toxicity to detect AP and have treatment initiated as early as possible. Chronic complications after AP occur in almost one third of cases.

Parenteral nutrition (PN) is a mixture that covers the nutritional needs when enteral nutrition is not an option; however, PN is not free of complications. The aim of our study was to determine the indication and frequency of NP complications in pediatric patients treated at a tertiary center.Children receiving PN at the Hospital de Pediatría del Centro Médico Nacional Siglo XXI were included. Demographic and anthropometric characteristics were recorded, as well as the reason of indicating PN, the time of administration, and the complications associated to this type of nutrition.Sixty-nine pediatric patients with PN were included: 33 neonates, 18 infants (between one and 11 months of age), nine preschoolers (from 1 to 5 years of age), and nine children over five years of age. Instructions for initiating the PN were given for the treatment of 71 % of the patients with diseases of the digestive tract who were treated surgically. Complications of PN occurred in 87 % of the children and 76.7 % had more than one complication. Metabolic complications occurred in 98 % of the children while mechanical and infectious complications only in 1 %, respectively.Parenteral nutrition was indicated more frequently in pediatric patients with digestive diseases treated surgically. Metabolic complications were the main concern in pediatric patients with PN.Introducción: la nutrición parenteral (NP) es una mezcla que cubre las necesidades nutricionales cuando no es posible lograr esta tarea por la vía enteral en el paciente; sin embargo, no está exenta de complicaciones. El objetivo del estudio fue conocer la indicación y la frecuencia de complicaciones de la NP en pacientes pediátricos atendidos en un centro de tercer nivel. Métodos: se incluyeron niños que recibieron NP en el Hospital de Pediatría del Centro Médico Nacional Siglo XXI del Instituto Mexicano del Seguro Social. Se registraron las características demográficas, antropométricas, la causa de la indicación de la NP, su tiempo de administración y las complicaciones asociadas a este tipo de nutrición. Resultados: se incluyeron 69 pacientes pediátricos: 33 recién nacidos (RN) y 18 lactantes entre uno y 11 meses de edad; nueve preescolares entre uno y cinco años, y nueve niños mayores de cinco años. Las enfermedades del tracto digestivo tratadas quirúrgicamente constituyeron el 71 % de las indicaciones para el inicio de NP. Se presentaron complicaciones en el 87 % de los pacientes y 76.7% tuvieron más de una complicación. Las complicaciones metabólicas representaron 98 %, las mecánicas 1 % y las infecciosas 1 %. Conclusión: la NP en este centro de tercer nivel se indicó principalmente a pacientes sometidos a cirugía del tracto digestivo.

OBJECTIVE—The aim of this study was to describe the agreement between impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) in children with excess body weight using the original and the revised definitions of IFG. RESEARCH DESIGN AND METHODS—Obese and overweight children aged 4–17 years were included (n = 533). Anthropometric parameters and biochemical tests (fasting and 2-h glucose tests after an oral glucose load [1.75 g/kg]) were performed. Case subjects with a fasting plasma glucose ≥126 mg/dl were excluded. The diagnostic parameters of the original and the revised definitions of IFG for detecting IGT were estimated. The analysis of agreement between these categories was made using the κ test. RESULTS—The prevalence of IFG increased from 6.2 to 13.3% using the new criteria. The prevalence of IFG became closer to the prevalence of IGT (14.8%). The revised criteria increased the sensitivity from 26.6 to 36.7%. However, the new IFG definition was not useful for identifying IGT cases. Of the 71 case subjects with IFG, only 29 (40.8%) had IGT. In addition, 50 case subjects with IGT (9.4%) and 13 with diabetes (2.4%) had a fasting glycemia CONCLUSIONS—The new definition modestly increases the sensitivity of IFG for detecting IGT in children with excess body weight. Despite this, more than one-half of these cases are not detected. In addition, the false-positive rate was increased by 61%.

We undertook this study to compare the clinical outcome of stapled rectal mucosectomy (SRM) alone and in combination with sphincterotomy and cutaneous flap anoplasty and to determine the influence of factors related to complications and patient satisfaction.Patients with second- to fourth-degree hemorrhoids who underwent SRM alone or in combination with other anorectal procedures were included. Postoperative complications, symptom resolution and patient satisfaction were analyzed.Two hundred forty one patients with a minimum follow-up of 1 year were divided into three groups: SRM alone (n = 187), SRM combined with sphincterotomy (n = 31) and SRM combined with cutaneous flap anoplasty (n = 23). Patients with SRM with sphincterotomy showed a higher complication rate than the other groups (32 vs. 12.8% and 13%, respectively, p = 0.02). SRM combined with sphincterotomy was associated with a higher rate of complications (OR = 3.5; 95% CI = 1.4-8.7). SRM alone with low mucosal resection was associated with a lower complications rate (OR = 0.4, 95% CI = 0.2-0.8). Resolution of preoperative symptoms was80% among the three groups. There was no association between complications and type of procedure with satisfaction level. Resolution of symptoms80% was associated with low/intermediate level of satisfaction (p0.001).Resolution of preoperative symptoms is similar among the three groups. SRM combined with sphincterotomy has a higher risk of complications. The satisfaction level is associated with resolution of preoperative symptoms.

Steatorrhea represents the indirect sign of lipid maldigestion in chronic pancreatitis and even when the measurement of fecal fat is considered as a gold standard for the diagnosis of steatorrhea, this test is not commonly used within clinical practice because of the inconvenience related to sample collection. Although the use of breath test using mixted tryglicerides was initally validated as an indirect alternative for the assessment of exocrine pancreas reserve, only recently has used this method as a surrogate for the measurement of fat in feces.To evaluate fat digestion by means of the breath test with 13C labelled mixed triglycerides in patients with chronic pancreatitis.Patients with chronic pancreatitis underwent clinical and biochemical evaluation. The latter included serum amylase, lipase, betacarotenes; fecal fat analysis and breath test using 13C-mixed tryglicerides. Breath test results are expressed as the percentage of 13C recovered in the breath sample.Seventeen patients (age: 45 +/- 5 years) were included, of which 7 had steatorrhea (fecal fat greater than 7 g/day). In patients with steatorrhea, the percentage of recovered 13C from breath was significantly lower (6 +/- 4%) than in patients without it (25 +/- 5%).Results suggest the uselfuness of breath test with 13C-mixed tryglicerides as an alternative for the assessment of lipid digestion in patients with chronic pancreatitis.

Non-cardiac chest pain (NCCP) is defined by recurrent episodes of substernal chest pain non related to ischemic heart disease, it's origin being in many cases the gastrointestinal tract; however, it may be associated to psychosomatic disorder.To investigate the main causes of NCCP and to evaluate associated psychiatric comorbidity.Patients with NCCP referred by a cardiologist were assessed underwent an upper endoscopy, ambulatory pH monitoring and stationary esophageal manometry. NCCP was considered gastro esophageal reflux disease (GERD) positive when the endoscopy and/or ambulatory pH monitoring were abnormal. When all results were normal, the symptom was considered as a functional chest pain (FCP). Patients were assessed by the Psychiatry service and diagnosed in accordance to the Diagnostic and Statistics Manual of Mental Diseases, fourth edition (DSM-IV). Several other test were applied for the assessment of anxiety and depression.Thirty-four patients were included (25 women and nine men; average age: 46.2 +/- 11.56 years). Three patients were eliminated because of refusal of the psychiatric evaluation. In 21 (68%) patients, NCCP was GERD-positive and in 10 (32%) to FCP. The most common symptoms associated to chest pain were: heartburn in 23 (74%), regurgitation in 21 (68%) and dysphagia in 15 (48%) patients. Upper endoscopy was abnormal in four cases; ambulatory pH monitoring was abnormal in 21 (67.7%) patients. The frequency of psychiatric disorders related to NCCP was 52%, in 10 patients with GERD-positive (48%) and six patients with FCP (60%). Mayor depression was the most common diagnoses identified among both groups.The high frequency of GERD and psychiatric disorders found in NCCP supports the multidisciplinary approach to NCCP.

Cystic tumours of the spleen are generally rare, and a parasitic origin is relatively unlikely. The present case report shows, however that when a splenic cyst is found, the differential diagnosis must always consider the possibility of echinococcosis. We report the case of a patient suffering from a cystic lesion of the spleen where surgery and histopathology yielded the diagnosis of splenic echinococcosis. Abdominal pain in the left upper quadrant and splenomegaly detected by simple abdominal radiology are the most commonly found indicators for this disease. The treatment should be surgical, attempting to preserve as much splenic tissue as possible, although conservative treatment is frequently unfeasable due to massive involvement of the spleen. Although rare, splenic hydatidosis should be included in the differential diagnosis when a cystic splenic lesion is identified with sonography or CT scan.

Introduction. Extrahepatic portal vein obstruction is an important cause of portal hypertension among children. The etiology is heterogeneous and there are few evidences related to the optimal treatment. Aim and methods. To establish guidelines for the diagnosis and treatment of EHPVO in children, a group of gastroenterologists and pediatric surgery experts reviewed and analyzed data reported in the literature and issued evidence-based recommendations. Results. Pediatric EHPVO is idiopathic in most of the cases. Digestive hemorrhage and/or hypersplenism are the main symptoms. Doppler ultrasound is a non-invasive technique with a high degree of accuracy for the diagnosis. Morbidity is related to variceal bleeding, recurrent thrombosis, portal biliopathy and hypersplenism. Endoscopic therapy is effective in controlling acute variceal hemorrhage and it seems that vasoactive drug therapy can be helpful. For primary prophylaxis of variceal bleeding, there are insufficient data for the use of beta blockers or endoscopic therapy. For secondary prophylaxis, sclerotherapy or variceal band ligation is effective; there is scare evidence to recommend beta-blockers. Surgery shunt is indicated in children with variceal bleeding who fail endoscopic therapy and for symptomatic hypersplenism; spleno-renal or meso-ilio-cava shunting is the alternative when Mesorex bypass is not feasible due to anatomic problems or in centers with no experience. Conclusions. Prospective control studies are required for a better knowledge of the natural history of EHPVO, etiology identification including prothrombotic states, efficacy of beta-blockers and comparison with endoscopic therapy on primary and secondary prophylaxis.