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Sobrecrecimiento bacteriano intestinal en pacientes con pancreatitis crónica

Small intestine bacterial overgrowth in patients with chronic pancreatitis Background: Previous reports describe 30-40% of small intestine bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP), SIBO is a cause of persistent symptoms in this group of patients even when they are treated with pancreatic enzymes. Aim: To asses the frequency of SIBO in patients with CP. Patients and methods: We studied 14 patients with CP using an hydrogen breath test with lactulose to detect SIBO, a nonabsorbable carbohydrate, whose results are not influenced by the presence of exocrine insufficiency. Main symptoms and signs were bloating in 9 (64%), recurrent abdominal pain in 8 (57%), intermittent diarrhea in 5 (36%) and steatorrhea in 5 (36%). At the same time we studied a healthy control group paired by age and sex. Results: SIBO was present in 13 of 14 patients with CP (92%) and in 1 of 14 controls (p<0.001). The only patient with CP and without SIBO was recently diagnosed and had minimal morphologic alterations in computed tomography and endoscopic pancreatography. Conclusions: SIBO is common in CP and may be responsible for persistent symptoms. Proper diagnosis and treatment could alleviate symptoms and improve quality of life (Rev Med Chile 2008; 136: 976-80). (Key words: Gastrointestinal contents; Malabsorption syndrome; Pancreatitis, chronic)

Obesidad: factor de riesgo para esteatohepatitis y fibrosis hepática

Background: Nonalcoholic fatty liver (NAFL) has been recognized as a cause of chronic liver disease. Its main risk factor is obesity. Aim: To describe the clinical and liver pathological findings in a group of patients who underwent surgery as obesity treatment. Patients and Methods: Sixty eight patients with severe or morbid obesity were subjected to surgery as obesity treatment. Each patient was evaluated with a complete clinical and laboratory medical assessment. A wedge of liver was excised during surgery. Liver biopsies were analyzed without knowledge of clinical and laboratory findings. The presence of steatosis, inflammation (portal or lobular), fibrosis and cirrhosis were recorded in the pathological analysis. Age and body mass index (BMI) were correlated with pathological data. Significance was set at a p value of less than 0.05. Results: Ninety one percent of patients had steatosis, 45% inflammation and 47% fibrosis. One patient had cirrhosis (1,4%). There was a statistically significant association between BMI and moderate or severe steatosis (p <0.03). There was also an association between BMI and portal (p=0.017) and lobular inflammation (p=0.034). A BMI over 40 kg/m2 (morbid obesity) was significantly associated with the presence of fibrosis (p=0.032). Moreover, the presence of moderate or severe steatosis was a risk factor for the development of hepatic fibrosis (p=0.026). Conclusions: Obesity is a major and independent risk factor for steatohepatitis and fibrosis. The degree of steatosis in the liver biopsy, is a risk factor for the development of fibrosis (Rev Med Chile 2002; 130: 731-6)

Función pancreática exocrina en diabetes mellitus: Determinación de elastasa fecal

g/g) in 10 (14%) and severely decreased in 13(19%). There was a significant association between elastase levels and time of evolution ofdiabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit(p=0.042). No significant association was found between elastase levels and other chroniccomplications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy orwith insulin requirement.

Enfermedad Celíaca del adulto: Experiencia clínica

Thirty seven patients (28 women), were studied. Median ageat diagnosis was 41 years (range 15-69). Main symptoms and signs were diarrhea (78%), weightloss (38%) and abdominal pain (38%). Anemia was found in 49%, elevation of ESR in 57%,elevation of alkaline phosphatases in 54%, elevation of aspartate aminotransferase in 38% and arise in alanine aminotransferase in 27%. Antiendomysial antibodies were positive in 17/22(77%) and antitransglutaminase in 19/22 (86%) patients. Endoscopic findings were suggestive ofCD in 47% of cases and duodenal biopsy showed intestinal villi atrophy in 34 (92%) patients.The three patients with normal histology had positive serology and a good response to gluten freediet.

Pancreatitis autoinmune: Experiencia clínica y revisión de la literatura

Background: Autoimmune pancreatitis is a special form of chronic pancreatitis, more common in men and usually presenting as obstructive jaundice or abdominal pain. It may be associated with other immunological disorders and sometimes it is possible to find positive serological markers. Typical images show pancreatic enlargement with focal or diffuse stenosis of the pancreatic duct but sometimes it presents as a focal pancreatic mass that is difficult to differentiate from pancreatic carcinoma. Aim: To report ten cases of autoimmune pancreatitis. Material and Methods: Retrospective review of clinical records of 10 patients aged 26 to 56 years (six males) with autoimmune pancreatitis. Results: The clinical presentation was obstructive jaundice in six cases, acute pancreatitis in two, persistent increase in serum amylase and Upase in one, and permanent abdominal pain and weight loss in one. On imaging studies, a circumscribed mass was founded in six patients. An endoscopic retrograde colangiopancreatography was performed in four patients showing an abnormal pancreatic duct in all. Six patients were operated and tissue for pathological study was obtained in five, showing inflammatory infiltration. Vive patients were treated with steroids with a good clinical response. Conclusions: Autoimmune pancreatitis must be borne in mind in the differential diagnosis of pancreatic lesions.

¿Es la pancreatitis crónica una enfermedad rara en Chile? ¿Subdiagnóstico, baja prevalencia o ambos?

Background: Chronic pancreatitis (CP) is a rare disease in Chile, without a clear explanation for this low prevalence. Aim: To analyze the characteristics of our patients with pancreatitis. Material and methods: Retrospective analysis of a database of patients with pancreatitis of a clinical hospital. Morphological proof of diagnosis (calcifications/calculi, alterations of ducts, local complication or histology) was obtained for every patient. History of acute pancreatitis was recorded and exocrine-endocrine function was assessed. Results: We retrieved information of 121 patients with pancreatitis (86 males) in a period of 20 years. The number of cases increased markedly every five years. The calculated incidence and prevalence was 0.8/100000/year and 6/100000, respectively. Pancreatic calcifications were initially observed in 93 patients and became evident during the follow-up in another six patients. Severe pain or local complications occurred in 27 patients, requiring surgery in 10 or endoscopic treatment in 15. During the years of follow-up, 55 patients were free of symptoms. Exocrine and endocrine insufficiency was demonstrated and treated in 81 and 67 patients, respectively. Alcoholic etiology was evident 40% of patients. In 29% no etiology was identified. Mapuche origin was exceptional. Conclusions: Late diagnosis of CP is common, since most of our patients presented with advanced stages. Even though CP is increasingly diagnosed in our hospitals, the number of cases is still far fewer when compared to other countries. Underdiagnosis alone cannot explain this difference and genetic factors might be of importance.

Enfermedad relacionada a IgG4: Manifestaciones extrapancreáticas en pancreatitis autoinmune

Leimos con gran interes el articulo de Erlij et al sobre el caso de un paciente portador de enfermedad relacionada a IgG4 y su analisis (1.). Estamos muy en acuerdo con que se trata de una enfermedad que entro al grupo de “grandes simuladores” y su importancia en el diagnostico diferencial esta creciendo cada dia. La representante mas conocida de este grupo de enfermedades es la pancreatitis autoinmune, descrita por Sarles hace mas de 50 anos. Sin embargo, el termino autoinmune data solo de 1994 (2) y el concepto de enfermedad sistemica es joven, solo aproximadamente 10 anos (3). Las experiencias iniciales de nuestro grupo con pancreatitis autoinmune (PAI) fueron ya comunicadas (4), discutiendo tambien posteriormente la dificultad de diagnostico diferencial con el cancer de pancreas (5). Aprovechando la buena revision de Erlij et al (1), queremos enfatizar que la importancia de esta patologia involucra a muchos mas especialistas de lo pensado. En nuestro grupo, actualmente tenemos registrados 36 pacientes quienes tuvieron por lo menos un episodio de pancreatitis autoinmune, algunos de ellos con recaidas, otros con necesidad de tratamiento de mantencion, pero la gran mayoria con excelente respuesta al tratamiento con esteroides. Las enfermedades asociadas a la PAI en parte comprometen el tubo digestivo, higado y en particular, la via biliar, pero no exclusivamente el terreno gastroenterologico: en multiples casos son manifestaciones extradigestivas (Tabla I). Una de las principales dificultades en el diagnostico ha sido el bajo rendimiento de IgG4: aunque varios de nuestros pacientes, en particular los primeros de ellos, no tuvieron determinacion de IgG4 (n=11), el nivel de IgG4 fue normal en 16 de los 25 casos estudiados, resulto elevado solo en 8 y dudoso en 1 paciente. Cabe la posibilidad de que parte de estos casos correspondan a PAI tipo 2, lo que seria apoyado tambien por la asociacion con enfermedad inflamatoria intestinal en 5 pacientes. Sin embargo, la especificidad y sensibilidad de la determinacion de IgG4 en el suero estan muy lejos de 100%, aun en casos cuando las alteraciones histologicas son caracteristicas y la infiltracion por linfocitos IgG4 positivos es detectable en la biopsia. La alternativa podria ser la determinacion de plasmoblastos (6), normalmente ausentes en la sangre periferica, pero presentes en gran numero en enfermedad relacionada a IgG4. Leer mas...