F. Fernández Pérez

Granulocitoaféresis en la enfermedad inflamatoria intestinal: Eficacia a 32 semanas con protocolo de inducción y sesiones de mantenimiento

INTRODUCTION: Granulocytapheresis (GCAP) eliminates activated granulocytes-monocytes from peripheral blood, thus modifying the circulating pool of leukocytes and reducing intestinal inflammation. OBJECTIVE: To evaluate the efficacy of GCAP in inflammatory bowel disease (IBD) using an induction and maintenance protocol. MATERIAL AND METHOD: A retrospective study including patients with active corticosteroid-dependent or refractory IBD. Induction included 5 sessions in ulcerative colitis (UC) and 7 sessions in Crohns disease (CD); one monthly session was used thereafter until week 32. Clinical activity indices and use of corticosteroids were monitored. RESULTS: Eighteen patients were included (10 with UC, 8 with CD), 10 of them dependent on and 8 refractory to corticosteroids. Fourteen of them were refractory and a further 4 were intolerant to immunosuppressants (IS). Induction was not completed in 2 UC (severe relapses) and 1 CD (side-effects) patients. One UC and 3 CD patients withdrew during maintenance. Among patients who completed induction, response or remission was achieved in 87.5% of UC cases (2 and 5 patients) and 71.4% of CD cases (1 and 4 patients), respectively. At week 32 response-remission rates reached 75% in CU (3 and 3 patients) and 42.8% in CD (1 and 2 patients) cases, respectively. Corticosteroid withdrawal was possible in 14.2% of CD and in 62.5% of UC patients (25% in remission and 37.5% with response). There were two major side effects (thrombophlebitis and syncope). No colectomies were performed for UC patients who completed GCAP induction after a mean follow-up of 97.6 weeks (range: 72-128). CONCLUSIONS: both UC and CD respond well to GCAP induction. At 32 weeks UC patients maintain similar response-remission rates (87.5 vs. 75%), whereas almost one-third of CD patients lose response. Granolocytapheresis is an alternative, steroid-sparing treatment modality to induce and maintain remission in UC, while good patient selection and a maintenance protocol not well defined yet are needed for CD.

Abdomen agudo en la enfermedad celiaca: yeyunoileítis ulcerativa

La yeyunoileítis ulcerativa es una entidad muy infrecuente caracterizada por ulceraciones en el intestino delgado que suele afectar al yeyuno e Íleon (1). Presentamos el caso de un paciente diagnosticado de enfermedad celiaca, sin adherencia a dieta exenta en gluten, que presentó abdomen agudo secundario a perforación de una yeyunoileítis ulcerativa. Se trata de un varón de 49 años, alérgico a betalactámicos, diagnosticado de enfermedad celiaca a los 8 años de edad y desde hace 20 años sin adherencia a la dieta exenta en gluten, sin antecedentes quirúrgicos, exfumador desde hace 5 años y bebedor social. Acude al servicio de urgencias por presentar dolor abdominal agudo, difuso, de horas de evolución, acompañado de vómitos y sensación febril no termometrada. Así mismo, desde hace un año presentaba sensación de distensión abdominal y en relación a la toma “de ciertos alimentos”, aumento del número de deposiciones, pastosas, voluminosas y malolientes. No refería pérdida de peso. A su llegada a urgencias el paciente estaba hipotenso (tensión arterial 80/60), taquicárdico (130 lpm), taquipneico, con mal estado general, sensación de enfermedad y con discreta palidez cutáneo mucosa. La auscultación cardiopulmonar era normal. El abdomen era doloroso a la palpación difusa con semiología de irritación peritoneal. La analítica extraída de urgencias únicamente denotaba una anemia microcítica hipocrómica (Hb 10,7 g/dl, VCM 80 fl) siendo el resto de parámetros (bioquímica esencial con ionograCartas al Director 1130-0108/2007/99/6/359-367 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS Copyright

Biopsia hepática en pacientes con infección crónica por el VHC: experiencia de un hospital comarcal

Resumen Introduccion La biopsia hepatica es una herramienta muy importante en la evaluacion de los pacientes con hepatitis cronica C. Es una tecnica no exenta de complicaciones, y que presenta una serie de limitaciones (falta de representatividad del organo y variablidad interobservador en la interpretacion de la muestra). Por tanto, debido a sus limitaciones y al desarrollo de nuevas tecnicas no invasivas, en la actualidad el papel de la biopsia hepatica esta siendo revaluado. Material y metodo Estudio descriptivo y retrospectivo de las biopsias hepaticas realizadas en pacientes con infeccion cronica por el virus de la hepatitis C, durante enero de 2002 a enero de 2005. Se analizaron los siguientes aspectos: a) edad, sexo, genotipo, histologia del cilindro hepatico y porcentaje de pacientes que recibieron tratamiento tras la realizacion de la biopsia hepatica; b) descripcion de las indicaciones de la biopsia en nuestros pacientes, asi como las causas de la ausencia de tratamiento despues de realizada la biopsia; c) si la decision de iniciar tratamiento se encontro influida por el grado de lesion histologica, y d) si existia correlacion entre el grado de lesion histologica y los valores de transaminasas. Resultados Se incluyo a 156 pacientes, de los que el 72% recibio tratamiento tras la realizacion de la biopsia. Las transaminasas se encontraban elevadas en el 86%. En el grupo de pacientes tratados, la alanina aminotransferasa (ALT) se encontraba elevada en el 92,30%, y en el grupo de pacientes no tratado, lo estaba en el 66%. La causa mas frecuente de no tratamiento tras la realizacion de la biopsia fue la presencia de lesiones histologicas minimas. El resultado histologico fue el siguiente: G0 en el 2%, G1 en el 26,8%, G2 en el 47,7%, G3 en el 22,2% y G4 en el 1,3%; con respecto al estadio de la fibrosis fue: F0 en el 7,2%, F1 en el 30,1%, F2 en el 37,9%, F3 en el 19,6% y F4 en el 5,2%. Los pacientes con ALT normal presentaban, en el 41%, lesiones ≥ F2, mientras que los del grupo de ALT elevada mostraban lesiones Conclusion La biopsia hepatica seria util en los pacientes con indicacion de tratamiento, pero con una elevada posibilidad de presentar efectos secundarios durante su duracion, asi como en los pacientes con transaminasas normales, donde el grado de fibrosis observado podria influir en la actitud terapeutica.

Enfermedad poliquística hepática

A 54-year-old man had an asymptomatic elevation of cytolysis-related enzymes, GGT, and alkaline phosphatase, detected at a routine laboratory study. The patient reported no alcohol abuse, no history of liver disease, and no constitutional syndrome. Physical examination showed a good general status, normal colored skin and mucosas, and no stigmata of chronic liver disease. The abdomen was soft, depressible, and slightly tender in the right hypochondrium with hepatomegaly of three finger-widths. There were no signs or symptoms of ascites. A laboratory study for liver disease was also negative. An initial ultrasound study showed the presence of multiple, well-defined anechoic lesions with posterior acoustic enhancement, distributed across the hepatic parenchyma; the kidneys were free of lesions. The study was completed with a liver MRI, which showed hypointense lesions resembling cerebrospinal fluid (CSF) on T1-weighted images, whereas in T2-weighted images with fat saturation lesions were hyperintense (Figs. 1 and 2).Paciente femenino de 40 años de edad con diagnóstico de enfermedad poliquística hepática y renal, presentándose con datos de hiporexia, intolerancia a la vía oral, así como pérdida de peso de aproximadamente 10 kg en dos meses. A la exploración presenta palidez de tegumentos, con múltiples tumores palpables sobre epigastrio e hipocondrio derecho. Se realiza ultrasonografía (USG) (Figura 1) abdominal con reporte de múltiples imágenes hipoecoicas sin sombra acústica posterior y una tomografía computada (TC) (Figuras 2 y 3) abdominal donde se observan múltiples imágenes de características quísticas en hígado y riñones. Se decide su ingreso a quirófano para destechamiento de los quistes hepáticos de mayor tamaño (Figuras 4 a 7).

Efecto hemodinámico esplácnico de somatostatina y octreótido en cirróticos: Estudio con ultrasonografía Doppler

Aim: Doppler-ultrasound assessment of the splanchnic hemo dynamic effects of intravenous somatostatin and octreotide ad ministration. Material and method: forty-five cirrhotic patients with esophageal varices were randomized to receive 1-hour intra venous somatostatin (SOM, 250 g), octreotide (OCT, 50 g), or placebo (PLA). In baseline and at 15, 30, 45 and 60 minutes of infusion, mean velocity, congestion index, flow volume and diam eter of the portal vein, as well as the superior mesenteric artery resistivity index, were measured. Plasma bradykinine and vasoac tive intestinal peptide (VIP) concentrations were also measured at baseline and at 30 and 60 minutes. Results: while placebo caused no changes in any of the venous and arterial parameters, SOM and OCT caused a sustained de crease in portal vein velocity (-19.41 vs. -11.19%) and flow (-22.79 vs. -12.33%), and an increase in the congestion index (+17.5 vs. +7.5%) and resistivity index of the superior mesenteric artery (+7.18 vs. +6.16%) with respect to baseline (p < 0.05). These changes were already evident at 15 minutes and remained unchanged during the time of the study period. With respect to OCT, SOM caused a high er reduction in mean velocity and flow of the portal vein, with no sig nificant differences for congestion index and mesenteric artery resis tivity index, both increased by SOM and OCT. Plasma bradykinine and VIP concentrations remained unchanged in the three groups. Conclusions: at therapeutic doses, intravenous somatostatin and octreotide reduce portal vein velocity and flow, and increase portal vein congestion index and superior mesenteric artery resis tivity index. Somatostatin causes a higher portal flow reduction than octreotide in spite of a similar splanchnic arterial effect.

Intrahepatic arteriovenous fistula resulting from needle biopsy.

A 38-year-old male patient with HVC-related chronic liver disease refered to our Unit for percutaneous liver biopsy. Physical exam, hemogram and coagulation tests were unremarkable. Two hours after the procedure he refered an intense epigastric pain irradiated to right upper quadrant with nausea. Abdominal palpation revealed deep pain in right upper quadrant without peritoneal signs. Chest and plain abdominal X-ray did not show pneumothorax neither pneumoperitoneum, and blood tests evidenced no changes in hemoglobine concentration. Abdominal ultrasound showed an intravesicular clot without bile duct dilation or intraperitoneal free liquid. Pain killer were given to the patient with a significative improvement. Before hospital discharge the patient developed slight scleral jaundice but no other complications. On follow-up there were no new complications and jaundice solved spontaneously. Two years after the complication, an abdominal ultrasound revealed a right hepatic lobe tubular vascular image with a turbulent flow by doppler with no abnormalities in hepatic veins neither portal vein blood flow (Fig. 1). A trifasic-CT scan evidenced a prompt arterial filling of such vascular tract that depended upon the right branch of the hepatic artery with a contrast-media captation in the surrounding parenchyma (Fig. 2).

Massive hepatic amyloidosis with fatal hepatic failure

A 55-year-old woman diagnosed with high blood pressure, hypothyroidism, and various vertebral fractures attributedto severe osteopenia was admitted to the hospital with a gastrointestinal bleeding secondary to a benign gastric ulcer. Dur-ing the examination, attention was drawn to an indolent smooth-surface, hard hepatomegaly associated with severely ten-der spinous processes in lumbar vertebrae. Laboratory parameters showed normocytic anemia (Hb 8.7 g/dl, VCM 84 fl)with a prothrombin activity of 35% and changes in the liver tests (GGT 588 U/L, AP 231 U/L, normal transaminases andbilirubin). In view of these findings an abdominal ultrasound was obtained, which showed liver enlargement without signsof portal hypertension, but evidences of chronic liver disease with no definite findings. Because of the presence of severecoagulation problems, a transjugular liver biopsy was carried out, and the diagnosis of amyloidosis was reached; later, abone marrow puncture was performed before the advent of vertebral fractures in the lumbar region. After the diagnosis ofprimary amyloidosis and plasmocytoma, treatment was begun with high-dose of dexamethasone; however, liver and re-nal function impaired progressively, the patient developed jaundice and died.Liver involvement is frequent in systemic amyloidosis, and varies according to different series from 56 to 90% if weexclude familial amyloidosis (1,2). The onset of the disease usually involves a presentation with symptoms secondary toliver dysfunction, including abdominal distension and hepatomegaly. Liver function tests may be abnormal and usuallyinclude elevated alkaline phosphatase and GGT. The presence of jaundice and particularly serum bilirubin levels above5 mg/dl is exceptional and commonly associated with a poor outcome (2). The presence of severe intrahepatic cholestasisat onset is exceptional; thus, Goenka et al. (2) described the existence of only 27 cases, of which 22 died before the sixthmonth after development of jaundice. The presence of high alkaline phosphatase levels up to 4 times the normal value re-sults in poor prognosis, with a mean survival of 3.3 months since jaundice development (3). Treatment with melphalanand prednisone, together with the assessment of potential liver transplantation are the only therapeutic options.