Palazón Jm

Serum and ascitic fluid bacterial DNA: A new independent prognostic factor in noninfected patients with cirrhosis

We tested the hypothesis that the presence of bacterial DNA (bactDNA) in ascitic fluid and serum is associated with decreased survival in patients with cirrhosis. In a prospective, multicenter study, we analyzed the clinical evolution of 156 patients with cirrhosis and ascites (first or recurrence) with lower than 250 polymorphonuclear cells (PMN)/μL, negative ascites bacteriological culture, and absence of other bacterial infections being admitted for evaluation of large‐volume paracentesis, according to the presence of bactDNA at admission. Survival, causes of death, and successive hospital admissions were determined during a 12‐month follow‐up period. BactDNA was detected in 48 patients. The most prevalent identified bactDNA corresponded to Escherichia coli (n = 32/48 patients, 66.6%). Patients were followed for 12 months after inclusion and in this period 34 patients died: 16 of 108 (15%) bactDNA negative versus 18 of 48 (38%) bactDNA positive (P = 0.003). The most frequent cause of death was acute‐on‐chronic liver failure in both groups (7/16 and 9/18 in patients without or with bactDNA, respectively), although more prevalent in the first month of follow‐up in patients with presence of bactDNA (0 versus 4/7). When considering patients with model for end‐stage liver disease (MELD) score less than 15, mortality was significantly higher in those with presence of bactDNA. Spontaneous bacterial peritonitis developed similarly in patients with or without bactDNA at admission. Conclusion: The presence of bactDNA in a patient with cirrhosis during an ascitic episode is an indicator of poor prognosis. This fact may be related to the development of acute‐on‐chronic liver failure at short term and does not predict the development of spontaneous bacterial peritonitis. (HEPATOLOGY 2008;48:1924‐1931.)

Obesity : A prognostic factor of severity in acute pancreatitis

This study was conducted to assess the prognostic value of obesity in acute pancreatitis and to determine the role played by obesity-associated diseases in the course of the disease. We prospectively studied 49 patients with acute pancreatitis who were divided into three groups according to their body mass index (BMI). There were 22 patients in group I (BMI < or = 25 kg/m2, normal or low weight); 15 in group II (BMI >25 and < or = 29 kg/m2, overweight); and 12 in group III (BMI >29 kg/m2, obese). Other anthropometric parameters also were measured. The severity of pancreatitis was assessed according to the Atlanta classification system. Systemic complications were significantly more common among obese than nonobese patients (p < 0.05). Patients with severe pancreatitis had a higher body-fat percentage, measured by the subscapular skin-fold thickness, and a larger abdominal circumference than patients with mild pancreatitis. Although hypertensive or diabetic patients developed more systemic complications, the multivariate analysis demonstrated that the presence of these underlying diseases did not modify the prognostic role of obesity in acute pancreatitis. We conclude that obesity is a prognostic factor of outcome in acute pancreatitis. Obesity-associated diseases do not vary the prognostic value of obesity. It seems that truncal adiposity is the kind of obesity related to worse outcome of acute pancreatitis.

Development of quinolone-resistant strains of Escherichia coli in stools of patients with cirrhosis undergoing norfloxacin prophylaxis: clinical consequences.

BACKGROUND/AIM Norfloxacin prophylaxis decreases the incidence of bacterial infections in high-risk cirrhotic patients, but may promote the development of quinolone-resistant gram-negative bacteria in stools, and eventually lead to infections due to these bacteria. The aim of the study was to evaluate the prevalence of quinolone-resistant strains of E. coli in stools on admission, and the characteristics of any nosocomial infections. METHODS Eighty-three consecutively hospitalized cirrhotic patients were included in this prospective study. The presence of quinolone-resistant strains of E. coli in stools on admission, and the characteristics of any nosocomial infections were recorded. RESULTS Fourteen out of 83 patients (16.8%) showed quinolone-resistant E. coli in stools (Group I), and 69 did not (Group II). Thirteen out of 14 from Group I (92.8%) and 17/69 (24.6) from Group II had received primary or secondary prophylaxis with norfloxacin (p<0.001). During hospitalization, 12/12 (100%) of patients from Group I and 25/66 (37.8%) of patients from Group II underwent norfloxacin prophylaxis. Three bacterial infections in patients from Group I, 3 from Group II patients receiving norfloxacin and 16 from Group II patients not receiving norfloxacin were recorded (p<0.05). No infections due to quinolone-resistant E. coli were observed in patients colonized with these bacteria. Treatment with norfloxacin induced the development of quinolone-resistant E. coli in 6/14 (42.8%) patients in a mean time of 18.5+/-9.8 days. CONCLUSIONS The development of quinolone-resistant strains of E. coli is significantly associated with previous administration of norfloxacin prophylaxis. However, in our series this fact is not associated with an increased incidence of quinolone-resistant E. coli or other gram-negative infections.

Usefulness of surveillance programmes for early diagnosis of hepatocellular carcinoma in clinical practice.

Background/Aims: Surveillance programmes (SPs) for hepatocellular carcinoma (HCC) in patients with cirrhosis intend to diagnose the tumour in its early stages when an effective therapy can be applied. The aims of this study have been to compare the survival of patients with HCC being diagnosed or not in SPs, and to establish a more accurate profile of the best target population.

Comparison of staging systems to predict survival in hepatocellular carcinoma

Abstract: Purpose: Some new staging systems in hepatocellular carcinoma (HCC) have been described in the last years. The aim of this study was to compare the survival‐predicting capacity of some variables and the prognostic classifications.

The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: Part 1 (diagnosis)

Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.

Infección crónica por el virus de la hepatitis C y enfermedad hepática asociada en una prisión española

OBJECTIVE The objective of this study was to determine the prevalence and genotype distribution of chronic hepatitis C virus (HCV) infection in a penitentiary population. The secondary objective was to describe histological findings in liver of the biopsied population, and identify risk factors associated with liver fibrosis and inflammatory activity. METHODS Among 800 inmates, 730 accepted HCV antibody screening and PCR confirmation. Sociodemographic, behavioral, and incarceration-related variables were analyzed. Liver biopsy was offered to individuals with chronic HCV infection. Advanced liver disease was defined as fibrosis 3 and/or an inflammatory activity index score 8). RESULTS HCV antibodies were found in 279 inmates. PCR confirmed HCV infection in 250 inmates, yielding a prevalence of 34.2% (95% confidence interval [CI]: 30.8-37.8). Intravenous drug use was independently associated with HCV infection, odds ratio (OR) 51.7 (95% CI: 31-86). Genotypes were 1a 32.9%, 3 29.7%, 1b 18.4% and 4 17.1%. Fifty-one liver biopsies were performed; advanced liver disease was found in 7 patients (13.7%) based on fibrosis and in 31 patients (60.7%) based on the inflammatory activity index. High AST and ALT levels were associated with advanced liver disease established on both fibrosis and inflammatory activity (P<.05). Lengthy intravenous drug use was associated with inflammatory activity (P=.02; OR 1.2; 95% CI: 1.03-1.7). CONCLUSIONS Persistent HCV infection is highly prevalent among prison inmates and is associated with intravenous drug abuse. HCV genotype diversity is higher in prison inmates than in the general population. Higher transaminase levels are associated with advanced liver disease.

Acute and chronic hemodynamic changes after propranolol in patients with cirrhosis under primary and secondary prophylaxis of variceal bleeding: a pilot study.

Background and aim Prophylactic treatment of variceal bleeding in cirrhotic patients with &bgr;-blockers is effective in only some patients. Our aim was to determine whether the response of the hepatic venous pressure gradient (HVPG) to the intravenous administration of propranolol predicts the response after chronic oral propranolol treatment. Patients and methods We included prospectively cirrhotic patients with esophageal varices under primary prophylaxis (PP) and secondary prophylaxis (SP). The HVPG was measured at baseline and after a propranolol bolus (0.15 mg/kg intravenous). A patient was considered a good-responder if HVPG decreased to 12 mmHg or 20% from baseline. Patients then received oral propranolol (heart rate titrated). Poor-responders under SP were also included in a variceal band ligation program. After at least 3 months, a second hemodynamic study was conducted. Results Fifty-six patients were included (36 SP and 20 PP). Response rate was similar (32.1 and 41.9%, P=0.7) and the Pearsons correlation coefficient was 0.61 (P=0.001). In 81.4% patients, the first study predicted the response status of the second. Six patients rebled on follow-up between the studies, all of them were poor responders to intravenous propranolol. Conclusion A single hemodynamic study using intravenous propranolol seems to predict chronic response to propranolol.

Determinación de la elastasa-1 fecal en el diagnóstico de la pancreatitis crónica

Introduccinn El diagnostico de pancreatitis cronica se basa en datos morfologicos y funcionales. Para la evaluacion de la funcion excocrina, el test de secretina-colecistocinina constituye el patron oro, pero resulta invasivo y se encuentra poco disponible. Recientemente, se ha investigado la posibilidad de que la determinacion de la elastasa-1 fecal sea un test indirecto de la funcion pancreatica. Objetivo Evaluar el valor diagnostico de la elastasa-1 fecal en la pancreatitis cronica, comparandola con otros metodos indirectos de funcion pancreatica, como el test de pancreolauril en orina y la determinacion de quimotripsina fecal. Para ello, analizamos los 3 metodos diagnosticos en 4 grupos de pacientes: grupo I (14 enfermos con pancreatitis cronica confirmada); grupo II (5 pacientes con episodios recurrentes de pancreatitis aguda etilica); grupo III (9 casos con diarrea de origen no pancreatico); grupo IV (8 pacientes con otras enfermedades gastrointestinales). Resultados Con respecto a los grupos control (grupos III y IV), los pacientes del grupo I y II presentaron concentraciones inferiores de elastasa-1 fecal (grupos I-II: 88 µg/g; grupos III-IV: 635 µg/g; p Conclusion La determinacion de la elastasa-1 fecal es un metodo indirecto eficaz en el diagnostico de pacientes con pancreatitis cronica avanzada. Sin embargo, no mejora la sensibilidad de otros metodos indirectos en estadios iniciales de dicha enfermedad. Su mayor ventaja es su elevada especificidad.

Etiología de la hemorragia digestiva alta de origen péptico: papel de Helicobacter pylori y los antiinflamatorios no esteroideos

Introduccion La hemorragia digestiva alta sigue siendo una complicacion grave y frecuente de la enfermedad ulcerosa. Es muy importante en estos pacientes llegar a un diagnostico etiologico para instaurar un tratamiento adecuado que impida la recidiva de la hemorragia. Objetivo Por un lado, investigar la prevalencia de infeccion por Helicobacter pylori y antiinflamatoiros no esteroideos (AINE) en pacientes con hemorragia digestiva alta de origen peptico, y por otro, analizar la estrategia planteada para el diagnostico de H.pylori en nuestro trabajo previo. Pacientes Y Metodos Se incluyo en el estudio a 73 pacientes con hemorragia digestiva alta de origen peptico diagnosticada por endoscopia. Se interrogo acerca del consumo de AINE. Se diagnostico de infeccion por H.pylori si uno de los tests era positivo (test de ureasa, histologia, test de aliento). Resultados La infeccion por H.pylori se encontro en el 92% de las ulceras duodenales y en el 88% de las gastricas. El 56% de los pacientes habian tomado AINE. Si se excluye a estos pacientes, el porcentaje de infeccion por H.pylori pasa a ser del 96,7%. El diagnostico se realizo con test de ureasa en el 46% de los casos. En el resto de los pacientes fue preciso realizar test de aliento e histologia. Conclusiones La principal etiologia en pacientes con hemorragia digestiva alta de origen peptico es H.pylori , seguido del consumo de AINE, y es relativamente frecuente la coexistencia. La estrategia propuesta de realizar un test de ureasa y, cuando sea negativo, proceder al estudio histologico y el test de aliento, es valida y permite obtener un diagnostico de infeccion aun cuando los pacientes estuvieran tomando tratamientos que dificultaran el diagnostico.