Manuel Alvarez L

Historia natural de la colelitiasis: incidencia de colecistectomía en un área urbana y una rural mapuche, en la última década

BACKGROUND Cholelithiasis is the second cause of hospital admissions in Chile. AIM To study the prevalence of symptomatic gallstone disease and opportunity of cholecystectomy in La Florida, Santiago and among Mapuche Indians in Huapi Island. PATIENTS AND METHODS In the period 2000-2001, we contacted to 71% (1127 subjects) and to 61% (145 subjects) patients of La Florida and Huapi Island, respectively, that had previously participated in an epidemiological study on cholelithiasis in 1993. We defined symptomatic gallstone patients as those with a history of biliary colic. Each patient was subjected to gallbladder ultrasound. RESULTS In 1993, 30-35% of gallstone patients were symptomatic (approximately 70% women). During the lapse 1993-2001, only 50% of subjects from La Florida and 25% of patients from Huapi Island were cholecystectomized (p < 0.05). Fifty percent of cholecystectomies were emergency operations. In 38 symptomatic Mapuche Indians from Huapi, cholecystectomy was indicated in 2001. After five months of the indication, only one of these subjects had been operated. Laparoscopic cholecystectomy represented 40% of all cholecystectomies performed in the National Health Service Hospitals. CONCLUSIONS This study demonstrates an unacceptable high prevalence of symptomatic gallstone patients remaining non-operated in both the urban and rural communities. This reciprocally correlates with the high frequency of emergency cholecystectomies and the high incidence of gallbladder cancer among Chileans. This study contrasts negatively with the situation of Scotland, where 73.5% of cholecystectomies were laparoscopic in 1998-1999. To reach Scotland standards, the Chilean Public Health System should increase the number of cholecystectomies from 27,000 in 2001 to 57,510

Hepatotoxicidad por amoxicilina/ácido clavulánico: caso clínico

We report a 72 years old diabetic male that, after the use of combined amoxicillin-clavulanic acid, developed pruritus and jaundice. Liver function tests showed serum total bilirubin of 4.3 mg/dL aspartate aminotransferase 140 U/l (normal < 35 U/L), alanine aminotransferase 470 U/L (normal < 40) and alkaline phosphatases of 400 U/L (normal < 100). Serology for hepatitis A, B and C viruses was negative, ERCP showed a normal biliary tree and liver biopsy disclosed a cholestatic hepatitis. Ursodeoxycholic was started to relieve pruritus. Liver function tests improved shortly thereafter, suggesting that this drug may be useful in the treatment of drug induced cholestasis.

Diagnóstico de diarrea por Clostridium difficile: en busca de un enfoque clínico más eficiente

Background: The clinical parameters for the suspicion of Clostridium difficile infections, namely the use of antimicrobials and diarrhea, have a low predictive value for the diagnosis. Aim: To search other clinical variables and determine a clinical prediction model for (Clostridium difficile diarrhea. Patients and methods: All patients to whom a Clostridium difficile study was requested, were prospectively studied during 5 months. Clinical variables of these patients were registered. The diagnosis of Clostridium difficile was done using the cytotoxicity test in fibroblast cultures. Results: Ninety two patients were analyzed and in 26, the diagnosis of Clostridium difficile was confirmed. A logistic regression model disclosed an age over 60 years old, the presence of mucus in the stools and a temperature over 37.8 °C in the previous 24 h, as significant predictors of the infection. The correlation of the model, between the predicted probability and the observed condition, was 81.5%. Conclusions: The presence of the clinical variables identified in this study are associated with a high probability of an infection by Clostridium difficile in patients with diarrhea and the recent use of antimicrobials (Rev Med Chile 2001; 129: 620-625)

Diarrea asociada a Clostridium difficile: Evaluación de varios métodos de diagnóstico

, but the confirmation is based on thecytotoxicity test. Recently vartious immunoassays have been introduced that allowa rapid diagnosis of this disease, but they have different sensibility and specificityand that is why the need to be evaluated with respect to the reference method. Theobjective of this study was to evaluate correlation between 5 immunoassays andthis confirmatory cytotoxicicty method. The stool samples of 60 patients withclinical suspicion of

Sarcoidosis pulmonar y gástrica. Caso clínico

We report a 66 year-old woman with a history of pulmonary sarcoidosis, diagnosed with a lung biopsy in 1993 and treated with prednisone for 2 years. She presented at our institution in 1999 with a stage IV disease and important functional and clinical impairment. A bronchial biopsy disclosed non caseating granulomas. Tuberculosis was intensively studied and persistently negative. Due to frequent nausea and vomiting an endoscopic gastric biopsy was performed which revealed non caseating granulomas involving the gastric mucosa. There was no evidence of Helicobacter pylori and stains for fungi and acid-fast bacilli were negative. Treatment with prednisone relieved digestive symptoms, although a control biopsy of the gastric mucosa revealed persistence of non caseating granulomas. Both lung stage IV and gastric sarcoidosis are uncommon forms of the disease.

Evolución de los pacientes con enfermedad de Crohn de colon operados con el diagnóstico de colitis ulcerosa

Introduccion: La proctocolectomia con reservorio ileal y anastomosis reservorio anal, (RIARA) es actualmente el procedimiento de eleccion en el tratamiento quirurgico electivo de la colitis ulcerosa (CU). La colectomia total y anastomosis ileorrectal (AIR), esta indicada en un seleccionado grupo de pacientes. Algunos pacientes sometidos a estas operaciones por aparente CU pueden evolucionar como una enfermedad de Crohn (EC). Objetivo: Comunicar el curso y pronostico de pacientes que evolucionaron como EC luego de un tratamiento quirurgico por una aparente CU. Materiales y metodos: Se identificaron a los pacientes que tuviesen tratamiento quirurgico por CU, en el periodo 1978 al 2003. Se seleccionaron a los pacientes en los cuales en su evolucion se cambio el diagnostico a EC. En ellos se analizaron las variables quirurgicas y su evolucion posterior. Resultados: En el periodo mencionado se operaron 114 pacientes por CU. En 9 pacientes (8%) el diagnostico cambio a EC, basado principalmente en la evolucion clinica alejada y/o por estudio histologico: 3 de 20 (15%) despues de una colectomia total con AIR y 6 de 84 (7%) despues de una proctocolectomia con RIARA. Las localizaciones mas frecuentes de las manifestaciones de la EC fueron el canal anal y perine. El tratamiento incluyo procedimientos quirurgicos y tratamiento medico con antiinflamatorios y/o inmunomoduladores. Dos pacientes con una colectomia con AIR necesitaron una proctectomia e ileostomia. Se extirpo el reservorio en 1 de 6 pacientes con RIARA. En resumen, una minoria de pacientes sometidos a tratamiento quirurgico con el diagnostico de CU evoluciona posteriormente como una EC. El tratamiento combinado medico quirurgico contribuye a una baja incidencia de perdida del reservorio ileal

Proctitis ulcerosa activa y refractaria: Una puesta al día

Ulcerative colitis (UC) is a chronic inflammatory disease of unknown etiology that affects a variable length of the colon, starting from the rectum. When the disease is confined to the rectum is called ulcerative proctitis (UP). Several studies have unsuccessfully attempted to determine the factors that determine the extent of involvement. The goals of therapy in UP are to induce and maintain remission of symptoms and disease. Topical treatment with 5-aminosalicylates (5-ASA) is the treatment of choice to induce remission. In the maintenance phase, long-term follow up studies suggest that treatment with 5-ASA is better than placebo, to maintain the disease inactive. For those patients that do not respond to treatment with topical 5-ASA or have a moderate to severe disease, there are additional therapies such as oral 5-ASA, topical or systemic corticosteroids, immunomodulators, biological therapies (Infliximab) and cyclosporine. Surgery is seldom needed.