E. Otero Antón

Epidemiología del síndrome de abstinencia alcohólica: Mortalidad y factores de mal pronóstico

INTRODUCTION: Patients with alcoholism and alcohol withdrawal syndrome (AWS) have a worse prognostic. METHODS: We have performed a retrospective analysis of the hospital discharges in with diagnosis include AWS from 1 of January of 1997 to the 31 of December of 2002. RESULTS: We identified 924 hospital stays with 2.4% of mortality (1.6% in Internal Medicine). Mortality is associated with greater age (57 years +/-15 vs. 49+/- 13, p < 0.005), with the diagnostic of hepatic cirrhosis (6.2 vs. 1.8%, p < 0.005), bacteraemia (10 vs. 1.8%, p < 0.001) and respiratory infection (9.6 vs. 1.8%, p < 0,001), with a lower mortality when AWS was secondary diagnosis (1.2 vs. 4.2%, p < 0.005). In multivariant analysis were associated with more mortality age (OR 1.03), hepatic cirrhosis (OR 3.4), bacteriemia (OR 4.5) and respiratory infection (OR 3.6). CONCLUSION: Alcohol withdrawal syndrome mortality could to benefit from treatment in an Internal Medicine Service.

Valganciclovir-Induced Leukopenia in Liver Transplant Recipients: Influence of Concomitant Use of Mycophenolate Mofetil

INTRODUCTION An increased incidence and magnitude of leukopenia during concomitant treatment with valganciclovir (VGC) and mycophenolate mofetil (MMF) has been reported. OBJECTIVE To evalute the incidence and severity of leukopenia and neutropenia among liver recipients treated with VGC and related factors. PATIENTS AND METHODS Retrospective analysis of clinical and analytical data related to leukopenia (<3000 leukocytes/mm(3)) and neutropenia (<900 neutrophils/mm(3)) in liver transplant patients who were treated with VGC from 2003 to 2007. We examined the influence of concomitant administration of MMF and development of subsequent infections. RESULTS Among 209 liver transplants, 40 treatments with VGC were prescribed in 37 patients (17.7%), 12 of which (30%) were associated with MMF. The patients has an average age of 49.7 +/- 12.7, body mass index (BMI) of 27.28 +/- 5.17, and Model for End-stage Liver Disease Score (MELD) 12.45 +/- 7.5. The daily average dose of VGC was 1440 +/- 446.5 mg and MMF, 1454.5 +/- 350.3 mg. We observed a decrease of 30% in initial leukocyte count (5353.7 +/- 2706.6) and 40% in neutrophil count (3600 +/- 2182.1). With no relationship to total dose or BMI-adjusted dose of VGC nor concomitant administration of MMF. The initial leukocyte count was significantly lower (4411 +/- 1930 vs 6206 +/- 3053; P = .03) and underwent a main drop (2344.7 +/- 1974.3 vs 898.1 +/- 2435.6; P = .04) when leukopenia developed. In the induced neutropenia group, previous leukocyte count (3797.1 +/- 1223.9 vs 5683.9 +/- 2829.3; P = .01), MELD (18.7 +/- 8.8 vs 11.1 +/- 6.6; P = .01), and the creatinine pretreatment (1.44 +/- 0.4 vs 1.09 +/- 0.3; P = .01) were significantly different. Subsequent infections induced by the leukopenia were not observed. CONCLUSIONS In our series, the concomitant use of VGC and MMF was not associated with a greater incidence of leukopenia and/or neutropenia than VGC administration alone. Previous leukocyte count was associated with them. MELD and renal dysfunction are factors related to severe neutropenia. Leukopenia was not associated with a greater incidence of infections.

Complicaciones y rendimiento de la biopsia hepática percutánea con marcado ecográfico

OBJECTIVES: To describe the complications and the diagnostic yield of percutaneous liver biopsies performed under ultrasonographic control in an Internal Medicine department. PATIENTS AND METHODS: A total of 750 percutaneous liver biopsies were performed at the Internal Medicine department of our institution during the 1995-2001 time period. The Menghini technique was employed previous ultrasonographic marking of the puncture site was performed by the same physicians who performed the biopsy. Major and minor complications as well as the diagnostic yield (obtention of diagnostic hepatic tissue) of the technique were recorded. RESULTS: No deaths occurred in our series. Two patients (0.3%) had major complications presenting as liver subcapsular hematoma with hemoperitoneum which resolved with conservative measures. One of them was a male patient with acute leukemia and the other was a woman on antiaggregant therapy. Eight patients (1.1%) had minor complications (vasovagal syncope), all of them young males. In three cases no adequate material for diagnosis was obtained (technique yield 99.6%). CONCLUSIONS: In our series, percutaneous liver biopsy with ultrasonographic marking is a diagnostic technique associated with a low rate of severe complications and with a high diagnostic yield. The use of ultrasonographic marking by the same physicians performed the biopsy does not involve a longer time or increased cost of the technique, provides more safety in the procedure and has a low morbidity rate. This procedure could be used on a routine basis for all percutaneous liver biopsies.

Mutaciones en el gen HFE (C282Y, H63D, S65C) en pacientes alcohólicos con datos de sobrecarga de hierro

Introduccion La patogenia de la sobrecarga de hierro en alcoholicos no esta enteramente aclarada. La frecuencia de las mutaciones del gen de la hemocromatosis hereditaria (HFE) es alta en la poblacion. Los heterocigotos presentan datos de sobrecarga de hierro similares a los de los alcoholicos. Objetivo Analizar si el exceso de hierro en alcoholicos se asocia a las mutaciones C282Y, H63D o S65C del gen HFE. Pacientes y Metodos Se estudiaron 32 alcoholicos activos (29 varones y tres mujeres, de edades entre 30-67 anos) que presentaban datos de sobrecarga de hierro (ferritinemia elevada con o sin saturacion de transferrina aumentada). En todos se estudiaron las mutaciones C282Y, H63D y S65C. En 16 casos se dispuso de histologia hepatica. Se compararon los datos de sobrecarga de hierro en los pacientes con y sin mutaciones. Resultados Veintidos pacientes (68,8%) no presentaban ninguna mutacion, uno (3,1%) era heterocigoto-C282Y, tres (9,4%) eran homocigotos- H63D, 4 (12,5%) eran heterocigotos-H63D y dos pacientes (6,3%) eran heterocigotos compuestos (C282Y/H63D). Ningun paciente era homocigoto- C282Y ni presento la mutacion S65C. La saturacion de transferrina, la ferritinemia y el indice de hierro hepatico fueron similares en los pacientes con y sin alguna mutacion. Tres pacientes (9,3%) fueron etiquetados de hemocromatosis. Uno era homocigoto-H63D, otro heterocigoto compuesto (C282Y/H63D) y en la restante no se encontro ninguna de las mutaciones. Conclusion En nuestro medio la sobrecarga de hierro en alcoholicos parece independiente de la presencia de las mutaciones C282Y, H63D y S65C en el gen HFE.

Polycystic liver disease

A 57-year-old woman with a past history of serous ovarian cystadenoma was admitted to hospital complaining of progressive abdominal bloating for the last six months. Physical examination revealed an increase in abdominal perimeter. The rest of the physical examination was normal. Alkaline phosphatase and gamma-glutamyl-transpeptidase were marginally raised, while the rest of the liver function panel was normal. An abdominal contrast-enhanced computerized tomography (CT) scan (Figs. 1 and 2) demonstrated polycystic liver disease with a giant cyst (22 x 19 cm) and a right kidney that was pushed towards the pelvis. Serologic tests for echinococcal antigens were negative. The giant cyst was aspirated under laparoscopic guidance with 5 liters of clear fluid withdrawn. A laparoscopic fenestration was performed without complications. Cystic fluid cultures were negative. A histopathological analysis of wall fragments confirmed the typical findings in a simple cyst. Currently, the patient is asymptomatic.

Enfermedad de Wilson de manifestación tardía

Un varon de 58 anos con antecedente de trastornos psiquiatricos fue estudiado por elevacion persistente de transaminasas. Se establecio el diagnostico de enfermedad de Wilson en base a una ceruloplasmina serica baja (menor de 3 mg/dL), una excrecion urinaria de cobre aumentada y una concentracion hepatica de cobre aumentada (1050 mcg por gramo de tejido seco). No se observo anillo de Kayser-Fleischer en el estudio con lampara de hendidura. Fue tratado con D-penicilamina, con normalizacion progresiva de las transaminasas. Los casos similares de enfermedad de Wilson de manifestacion tardia son excepcionales, pero confirman la heterogeneidad clinica de la enfermedad.

Influencia de factores virales y del huésped en la actividad histológica en pacientes con hepatitis crónica por virus de la hepatitis B y elevación moderada o intermitente de alanina aminotransferasa

Objective: viralandhostfactorsarerelatedwithprogressionof pathologicallesioninchronichepatitisB.Weanalyzedthesefactors inpatientswithmoderateorintermittentlyelevatedALTlevels,and itsthresholdthatdeterminatesignificanthistologicalactivity. Patients and methods: retrospective analyses of viral and host parameters in 89 consecutive chronic hepatitis B patients biopsied because of moderate or intermittently elevated ALT lev els[1-2xULN(ULN=39IU/mL)]and/orDNA-HBV>2x10 3

Hepatitis B de novo con anticuerpo frente al HBcAg negativo en un trasplantado hepático

De novo hepatitis B was diagnosed in a 47-year-old man 15 months after liver transplantation for end-stage alcoholic cirrhosis. Serum antibodies to hepatitis B core antigen (anti-HBc) were negative, and remained undetectable over 20 months of follow-up. The possible causes of negative serum anti-HBc despite of active hepatitis B virus infection are reviewed. Immunosuppression may underlie this phenomenon in similar cases.: De novo hepatitis B was diagnosed in a 47-year-old man 15 months after liver transplantation for end-stage alcoholic cirrhosis. Serum antibodies to hepatitis B core antigen (anti-HBc) were negative, and remained undetectable over 20 months of follow-up. The possible causes of negative serum anti-HBc despite of active hepatitis B virus infection are reviewed. Immunosuppression may underlie this phenomenon in similar cases.