F. Carballo Álvarez

Antioxidant nutrients protect against cyclosporine A nephrotoxicity.

The immunosuppressive drug cyclosporine A (CsA) has been successfully used in several diseases with immunological basis and in transplant patients. Nephrotoxicity is the main secondary effect of CsA treatment. Although the mechanisms of nephrotoxitity are not completely defined, there is evidence that suggests the role of reactive oxygen species (ROS) in its pathogenesis. It has been demonstrated in numerous in vivo and in vitro experiments that CsA induced renal failure and increased the synthesis of ROS, thromboxane (TX) and lipid peroxidation products in the kidney. Furthermore, CsA modified the expression and activity of several renal enzymes (ciclooxygenase, superoxide-dismutase, catalase and glutathione-peroxidase). Antioxidant nutrients (e.g. Vitamins E and C) can neutralize some of the effects that CsA produced in the kidney. Thus, Vit E inhibited the synthesis of ROS and TX and the lipid peroxidation process induced by CsA in kidney structures. Antioxidants can also improve renal function and histological damage produced by CsA administration. Although there are few data in humans treated with CsA, the possibility exists that antioxidants can also neutralize CsA nephrotoxicity and LDL oxidation. Thus, antioxidant nutrients could have a therapeutic role in transplant patients treated with CsA.

Pancreatitis aguda asociada a hipercalcemia. Presentación de dos casos

Hypercalcemia due to hyperparathyroidism is a rare etiology for acute pancreatitis, oscillating between 1.5 and 7% in the different series. Although the cause-effect relationship and the pathophysiology of the condition are not clear, it seems that the association among them is not incidental, and serum calcium could be a major risk factor, so that pancreatitis would come to occur during severe hypercalcemia attacks. Mutations in different genes have been proposed as well to justify why only some patients with primary hyperparathyroidism and hypercalcemia develop acute pancreatitis. References to cases like these ones are rare in the literature. We report two patients with acute pancreatitis associated with hyperparathyroidism and hypercalcemia, one of them with a fatal outcome.

Colonoscopy quality assessment

AIM Colonoscopy has become accepted as the most effective method for colon exploration. Some application problems have been detected in the setting of normal clinical care due to its wide range of uses in recent years, and therefore there is a need to measure colonoscopy quality. For that purpose valid quality indicators are necessary to be defined. The application process of some quality indicators is presented in this study. The proposed indicators in this study are: quality of bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate, and adenoma removal rate. MATERIAL AND METHOD This is a prospective 12-month study where colonoscopies performed in the VI health area of Murcia Region were evaluated. From February 2006 to February 2007 a total of 609 subjects were eligible for colonoscopy after a positive fecal blood test in the setting of a colorectal cancer screening program. A sample of thirty patients (n: 30) was considered representative to assess the reliability of quality indicators and for a preliminary analysis of results. RESULTS Indicators results are: quality of bowel preparation (87%), kappa 0.74 (95% CI: 0.48-0.99); cecal intubation rate (90%) 0.74 (95% CI: 0.49-0.99); adenoma detection and removal rate (96%), kappa: 0.78 (95% CI: 0.53-0.99); withdrawal time: 13.36 min (95% CI: 10.48-16.11). Kappa: 0.78 (95% CI: 0.49-0.99). CONCLUSIONS Quality indicators definition and application in colonoscopy performance is possible. More studies are necessary to define the role of these indicators in the setting of clinical practice.

Hepatic angiosarcoma: Presentation of two cases

Hepatic angiosarcoma is a rare primary tumor of the liver with a mesenchymal origin. Diagnosis is difficult because clinical manifestations and imaging studies are inconclusive. In many cases a diagnosis is obtained during necropsy, not being apparent during the course of disease. It is associated with several risk factors, but these contribute to explaining only a few of all reported cases. When clinical manifestations begin progression is often fast, and possibilities for curative treatment are limited.We report two cases of hepatic angiosarcoma. In the first one, our patient had an insidious initial course, and then suddenly presented with hepatic failure followed by acute respiratory distress. A diagnosis was reached during necropsy. In the second case, we initiated the study of a chronic liver disease using fine-needle aspiration biopsy, which showed findings suggestive of hepatic angiosarcoma. In the following weeks the patient started on a torpid clinic course, and died from multiple organ failure.

Enfermedad por reflujo gastroesofágico

Resumen El reflujo gastroesofagico es una entidad de alta prevalencia clinica que consiste en el paso de contenido gastrico o duodenal al esofago en ausencia de vomitos, eructos o cualquier otra situacion que lo induzca. Se produce por un desequilibrio entre factores defensivos esofagicos (barrera antirreflujo, aclaramiento esofagico y defensa tisular) y factores agresivos (el material refluido, el aumento de presion intragastrica y el retraso de vaciamiento). La pirosis y la regurgitacion son los sintomas principales, aunque tambien se pueden presentar otros como la disfagia, la tos cronica, el dolor toracico, la patologia otorrinolaringologica y el asma. La respuesta clinica al tratamiento con los inhibidores de la bomba de protones es una primera etapa en el proceso diagnostico y puede continuar con la realizacion de endoscopia alta y pHmetria en casos seleccionados. La llave del tratamiento son los inhibidores de la bomba de protones, habiendose establecido actualmente que las pautas descendentes (dosis altas iniciales) son las mas coste-efectivas. Solo un pequeno porcentaje de pacientes con enfermedad por reflujo gastroesofagico necesita cirugia y se suele limitar a la aparicion de complicaciones como el esofago de Barrett, las estenosis y el adenocarcinoma esofagico o al fracaso del tratamiento medico.

Adenocarcinoma of the rectum and anus in a patient with Crohn's disease treated with infliximab

In the present paper, we report the case of a patient with long-standing Crohn s disease and multiple complications that, after receiving treatment with infliximab, was diagnosed with an adenocarcinoma of the rectum and anus that required radical surgery, later presenting multiple metastases. In the discussion, characteristics and major risk factors for colorectal cancer in patients with inflammatory bowel disease will be largely reviewed, and current studies will be analyzed in connection with the appearance of neoplasms in patients being treated with biologics.

Gammapatía monoclonal: un diagnóstico frecuentemente soslayado

Objetivo Conocer la frecuencia de aparicion de bandas monoclonales en un laboratorio clinico como estimacion de incidencia de gammapatia monoclonal y la proporcion de estas bandas en las que no se establece un diagnostico clinico explicito o propuesta de seguimiento. Otros objetivos son describir su distribucion y las caracteristicas de los pacientes. Pacientes y metodos Se estudiaron 200 pacientes en los que se habia detectado de novo una banda monoclonal. Resultados La incidencia fue de 6,59 ×10 −4 ano −1 . En el 59,5% no constaba una estimacion diagnostica. En el grupo de diagnosticados la mas frecuente fue gammapatia monoclonal de significado incierto. La edad media de los pacientes fue de 74,4 anos y la diferencia entre porcentajes por sexo fue estadisticamente significativa. Discusion Los datos sugieren una falta de esfuerzo clinico cuando el resultado es la aparicion de una banda monoclonal. No existe discrepancia en la distribucion de las bandas y caracteristicas de los pacientes respecto a lo descrito en otros estudios.

Hemorragia digestiva por metástasis duodenal de mesotelioma pleural maligno

A57-year-old smoker male consulted due to progressive dyspnea, with no cough or expectoration. He also referred history of diffuse abdominal pain, constipation and weight loss of 10 kilograms in the last months. At exploration it was relevant tachypnea, hypoventilation of the right lung and epigastric pain. On chest X-Ray we could observe right pleural effusion. Also a CT was made, informing thickening of right pleura and presence of multiple adenopathies in mediastinum (Fig. 1). After pleural biopsy it was all catalogued as malignant mesothelioma. Barium radiological study of the upper gastrointestinal tract was also carried out to complete the study of the anemia that was diagnosed in laboratory tests. This showed several ulcerative defects on duodenum. Because of these findings, a gastroscopy was performed, and several irregular ulcers with elevated borders were seen on the mucosa of second duodenal portion (Fig. 2). Some biopsies were taken for histological and immunohistochemical study, which informed duodenal infiltration with malignant mesothelioma. PICTURES IN DIGESTIVE PATHOLOGY

Duodenal leishmaniasis in a HIV patient

We report the case of a 31-year-old male who was diagnosed with HIV infection eleven years ago. At this moment his disease is in stage C3. He consulted because of watery diarrhea with no pathologic products for the last 5 months. He also reported continual abdominal pain unrelated to food ingestion. Over those months he lost about 7-8 kg of body weight, and some skin nodes developed in different parts of his body. Laboratory parameters were nonspecific in the first study. Antibodies against Leishmania, CMV, syphilis, HBV, and HCVwere all negative. Blood and stool cultures and parasite tests were all negative, too. A biopsy was obtained from skin nodes, which was positive for Leishmania, and a digestive endoscopy was carried out, which showed a paved, nodular mucosa all over the duodenum, from which we took several biopsies (Figs. 1 and 2). A histological study revealed a clear, severe infiltration of duodenal villi by macrophages filled with Leishmania bodies (Fig. 3). Diagnosis: malabsorption due to visceral leishmaniasis with skin and small-bowel infiltration in a HIV patient.

Úlcera rectal penetrada a espacio presacro

Una mujer de 62 anos de edad consulta en area de urgencias de nuestro hospital por cuadro de rectorragia franca. En la valoracion inicial presentaba estabilidad clinica y hemodinamica, siendo la exploracion fisica anodina salvo el tacto rectal que fue muy doloroso y con presencia de sangre en recto. La hemoglobina y el hematocrito se mantuvieron en rango de normalidad, mientras que presentaba una sobredosificacion de dicumarinicos con INR: 6.3. Como antecedente inmediato destaca que la enferma venia presentando en los dias previos un cuadro gripal que estaba tratando de modo sintomatico. El dia anterior al de su consulta refiere haberse administrado un supositorio de diclofenaco. A pesar de la correccion de las alteraciones de la coagulacion con administracion de vitamina K y plasma, persistio una rectorragia cuantiosa, que anemizo a la paciente, lo que obligo a la transfusion de 2 unidades de concentrados de hematies. Se realizo una colonoscopia, que mostro una laceracion profunda, a unos 7-8 cm del margen anal, de bordes irregulares, en los que parecen apreciarse tejido muscular y aponeurotico (Fig. 1). Con posterioridad se habria de someter a la paciente a un TAC, que confirmo la sospecha de perforacion rectal y evidencio igualmente un hematoma perirrectal de 6,5 cm de diametro con burbujas aereas en relacion con esta (Figs. 2 y 3). Diagnostico: ulcera rectal perforada a espacio presacro en relacion a tratamiento de diclofenaco en supositorio. En coordinacion con el servicio de cirugia de nuestro hospital se decidio actitud expectante, mejorando la paciente progresivamente del dolor y la sensacion de ocupacion perineal y desapareciendo la rectorragia en dias ulteriores.