Glucogenosis tipo III asociada a carcinoma hepatocelular

Type III glycogen storage disease is a hereditary disorder with autosomal recessive transmission. It is characterized by accumulation of abnormal glycogen in the liver and, in 80% of patients, in muscle. The liver can also show fibrosis and sometimes cirrhosis. Until 2000, 9 cases of cirrhosis had been published, 3 of which showed associated hepatocarcinoma. We present the case of a 31-year-old woman, diagnosed in childhood with type III glycogen storage disease, who 30 years after onset developed a hepatocellular carcinoma with portal thrombosis in the context of advanced cirrhosis. This is the first case to be reported in the Spanish literature of type III glycogen storage disease associated with hepatocellular carcinoma.

Seven versus ten days of rabeprazole triple therapy for Helicobacter pylori eradication: a multicenter randomized trial

BACKGROUND

Ten-day triple therapy is somewhat more effective than 7-day treatment for curing Helicobacter pylori infection. Recent studies have suggested that rabeprazole-a proton pump inhibitor with fast onset of acid inhibition-could raise the efficacy of 7-day therapies to the levels obtained with 10-day treatment.

OBJECTIVE

To compare the efficacy of 7- and 10-day rabeprazole-based triple therapy for H. pylori eradication.

PATIENTS AND METHODS

Four hundred and fifty-eight patients were randomized to 7 or 10 days of triple therapy, including rabeprazole 20 mg, clarithromycin 500 mg, and amoxicillin 1 g, all twice a day. Cure rates were evaluated by urea breath test.

RESULTS

Two hundred and thirty-seven patients received 7-day and 221 received 10-day therapy. Groups were comparable in terms of demographic variables. Intention to treat cure rates were 73.8% (95% CI: 67-79%) for 7-day and 79.6% (95%: CI:74-85%) for 10-day therapy (p= 0.09). Per-protocol cure rates were 81.8% (95% CI:76-86%) and 89.3% (95% CI: 84-93%), p= 0.02, respectively. Cure rates were similar in peptic ulcer patients but in subjects without ulcer they were clearly lower for 7-day therapy: 66%versus 77% by intention to treat (p= 0.08) and 73%versus 91% in the per-protocol analysis (p= 0.004). Side effects and compliance in the two groups were comparable.

CONCLUSIONS

Seven- and 10-day triple therapies seem equally efficient in peptic ulcer patients. In contrast, 7-day therapy is significantly less effective in nonulcer dyspepsia patients. Ten-day therapy, therefore, seems preferable when treating nonulcer patients.

[Irritable bowel syndrome in patients under age 55 with dyspeptic syndrome]

The presence of IBS was studied in 289 patients under 55 years of age with dyspeptic syndrome. The subjects were divided into two groups: group I (240 patients with DS) and group II (49 patients with DS and IBS). The mean duration of follow%shy;up was 10.8 years (130 months). IBS was diagnosed in 49 patients (17%). Females accounted for 64% and 77% of groups I and II, respectively (p < 0.05). There were no differences in mean age or the type of FDS. The patients in group II consulted more often and earlier (92% returned for consultation, and took 27 months in doing so) than those in group I (52% and 40 months)(p < 0.05). The number of diagnostic tests requested was greater in group II. Psychiatric pathology was in turn more common in group II than in group I (20 versus 7%)(p < 0.05).

[Gastrointestinal disorders in Guatemala and their relation with parasitic infections]

BACKGROUND

To determine the frequency of symptoms sugestive of functional gastrointestinal disorders and their relation to parasite infections in a developing nation.

MATERIAL AND METHODS

174 consecutive patients was seen in a gastroenterology clinic in Solola (Guatemala).

RESULTS

Symptoms suggestive of irritable bowel syndrome was diagnosed in 37 patients (21%), irritable bowel syndrome with dyspeptic syndrome in 26 (15%) and dyspeptic syndrome in 24 (14%). Forty-two patients (24%) had been diagnosed of parasitation in the past. Such patients had a higher risk of suffering symptoms suggestives with functional gastrointestinal disorder (OR 6,335 CI 95% 2.72-14-75). Fifty-nine patients (34%) were subjected to parasite examination in stools; of these, 13 proved positive. In this same group of patients the risk of functional gastrointestinal problems was likewise higher among the subjects with parasite infection (p < 0.05). In turn, 41 patients (49%) with symptoms suggestives of gastrointestinal functional disorders were or had previously been diagnosed of parasite infection.

CONCLUSIONS

Symptoms suggestives of functional gastrointestinal disorders are frequent in developing regions and its was in relation to intestinal parasites.

Influence of Helicobacter pylori infection and eradication on blood lipids and fibrinogen

BACKGROUND

An association between Helicobacter pylori infection and heart disease has been suggested. A potential mechanism may be inflammation-induced atherogenic changes of lipoproteins, but epidemiological studies have provided conflicting results.

METHODS

In a prospective multicentre study, 830 patients submitted for endoscopy and H. pylori testing were evaluated. Of the 686 H. pylori-positive patients, 487 received and 199 did not receive eradication treatment. Serum lipids and plasma fibrinogen were measured at baseline in all patients and 3 months later in those initially positive for H. pylori.

RESULTS

H. pylori had no influence on baseline lipid or fibrinogen levels. Increases in high-density lipoprotein cholesterol were observed in 368 patients who received eradication treatment and in 193 untreated patients: 0.06 mmol/L (P=0.000) and 0.07 mmol/L (P=0.009), respectively. Similar minor increases in total cholesterol and triglycerides occurred in both groups. Lipid changes were related to symptom relief and a reduction in smoking. Eradication therapy was associated with a minor decrease in plasma fibrinogen irrespective of the resolution of infection.

CONCLUSIONS

H. pylori has no influence on blood lipids or fibrinogen. Both the eradication of infection and symptomatic treatment without eradication are associated with minor lipid changes related to symptom relief and lifestyle modifications. Thus, the inflammatory changes associated with H. pylori are unlikely to affect lipoprotein or fibrinogen metabolism.

[Gastrointestinal disorders in Guatemala and their relationship with parasitic infections]

BACKGROUND

To determine the frequency of symptoms suggestive of functional gastrointestinal disorders and their relation to parasite infections in a developing nation.

MATERIAL AND METHODS

174 consecutive patients was seen in a gastroenterology clinic in Solola (Guatemala).

RESULTS

Symptoms suggestive of irritable bowel syndrome was diagnosed in 37 patients (21%), irritable bowel syndrome with dyspeptic syndrome in 26 (15%) and dyspeptic syndrome in 24 (14%). Forty-two patients (24%) had been diagnosed of parasitation in the past. Such patients had a higher risk of suffering symptoms suggestives with functional gastrointestinal disorder (OR 6,335 CI 95% 2.72-14-75). Fifty-nine patients (34%) were subjected to parasite examination in stools; of these, 13 proved positive. In this same group of patients the risk of functional gastrointestinal problems was likewise higher among the subjects with parasite infection (p < 0.05). In turn, 41 patients (49%) with symptoms suggestives of gastrointestinal functional disorders were or had previously been diagnosed of parasite infection.

CONCLUSIONS

Symptoms suggestives of functional gastrointestinal disorders are frequent in developing regions and its was in relation to intestinal parasites.

[Prognosis in dyspeptic patients under the age of 55]

BACKGROUND

We studied the evolution and diagnostic tests performed in patients with dyspepsia aged less than 55 years.

PATIENTS AND METHOD

We included 289 patients under age 55 with clinically manifest dyspepsia who were referred for specialized digestive evaluation from the primary care setting.

RESULTS

One half of patients consulted again in the course of the study for the same symptoms. In 131 patients (45%), an endoscopy was proposed at some stage during the study. Gastroduodenal pathology was identified in 37% of the patients who underwent an endoscopy.

CONCLUSIONS

In these patients, the approach adopted by the gastroenterologist must comprise assessment of the symptoms with endoscopy.

[Peutz-Jeghers syndrome associated with multiple epithelial tumors]

The association between Peutz-Jeghers syndrome and multiple epithelial neoplasias is infrequent. Tumors of the gastrointestinal tract, genitals and breast are common in this syndrome and tumors of the kidney and biliary tract are exceptional. We present the case of a 68-year-old woman with Peutz-Jeghers syndrome who presented with right kidney carcinoma and numerous small, bilateral tumors of the sex cords with annular tubules of the ovary. Right nephrectomy, double annexectomy and total hysterectomy were performed. The patient died two years later following the development of rectal carcinoma diagnosed by sigmoidoscopy and biopsy and an episode of obstructive jaundice compatible with cholangiocarcinoma.

The rendezvous technique for the treatment of choledocholithiasis

BACKGROUND

The rendezvous technique combines endoscopy with percutaneous transhepatic cholangiography to facilitate cannulation of the bile duct when previous attempts have failed.

METHODS

Over a 7-year period, a total of 1753 ERCPs were performed. Twelve of these patients with a diagnosis of choledocholithiasis were poor candidates for surgery. Percutaneous transhepatic cholangiography as well as ERCP with precut papillotomy failed to resolve biliary obstruction. In a further 2 cases the percutaneous approach was used by means of a T-tube positioned at a prior cholecystectomy.

OBSERVATIONS

The combined procedure was successful in 13 patients (93%). It was unsuccessful in 1 patient because of a stone lodged distally near the papilla. There was only 1 complication (7%), a retroperitoneal perforation that occurred during papillotomy; no mortality was directly attributable to the technique.

CONCLUSIONS

The rendezvous technique is recommended for patients who are not eligible for surgery when ERCP is unsuccessful and when it is impossible to resolve biliary obstruction by percutaneous transhepatic cholangiography.

Squamous cell carcinoma of the oesophagus in a patient with Klippel-Trenaunay syndrome

The Klippel-Trenaunay syndrome (KTS) is a rare disorder characterized by a triad of port-wine stains, varicose veins, and bony or soft tissue hypertrophy of one extremity. Digestive bleeding is the most commonly observed gastrointestinal manifestation. In rare cases, the syndrome is associated with malignancies. We report the case of a 38-year-old woman with KTS and dysphagia caused by an oesophageal squamous cell carcinoma.

[Comparative study of the eradication of Helicobacter pylori: ranitidine bismuth citrate versus omeprazole plus two antibiotics for seven days]

AIMS

To compare the efficacy of ranitidine bismuth citrate (RB) combined with two antibiotics during seven days in comparison with OCA-7 for treatment of Helicobacter pylori.

METHODS

In a randomized clinical trial 200, consecutive patients infected by Helicobacter pylori were studied prospectively. One of two regimens was given for 7 days; OCA-7 (omeprazole 20 mg b.i.d., amoxycillin 1 gr b.i.d., clarithromycin 500 mg b.i.d.) or RBCA (RB 400 b.i.d., amoxicillin 1 gr b.i.d., clarithromycin 500 mg b.i.d.). Eradication was defined as a negative breath test one month after therapy.

RESULTS

112 male and 88 female with a mean age of 48 years (range 18-82). 100 patients were randomized to OCA-7 and 100 patients to RBCA-7. Overall 186 patients completed the treatment. Intention to-treat eradication was in the group OCA-7 of 72% and 73% in group RBCA-7. Per-protocol eradication was in the group OCA-7 of 78% and 77% in group RBCA-7 (p = 0.3). Five patients in the group OCA-7 and nine in the group RBCA-7, had side effects, three of these patients did not complete therapy by diarrhea.

CONCLUSIONS

RB with two antibiotics is as effective and safe as OCA-7 for the eradication of Helicobacter pylori.

[Krukenberg tumor secondary to gastric carcinoma in a woman in her eighth month of pregnancy]

The association of gastric cancer and pregnancy is rare. The cases reported by non-Japanese authors are unusual. Tumors tend to be in advanced stage when diagnosed since the symptoms of gastric cancer are easily presumed to be secondary to those of normal pregnancy. We report the case of a 43-year-old female with gastric carcinoma presenting as a Krukenberg's tumor in the eighth month of gestation. A healthy child was born and after delivery, partial gastrectomy was performed and adjuvant chemotherapy was administered. The patient died 12 months after diagnosis.

Bochdalek's hernia in adults

Bochdalek's hernia is a congenital hernia of the diaphragm, which is manifested in the early years of life. Its diagnosis is difficult and is based on barium studies. We present an adult patient with Bochdalek's hernia who exhibited a gastric volvulus. The patient had a history of intermittent abdominal pains. In this article, we analyze the diagnostic and therapeutic procedures, laying special emphasis on the importance of early diagnosis in the prevention of complications.

The effects of alcohol consumption upon the gastrointestinal tract

Regardless of the type and dose of beverage involved, alcohol facilitates the development of gastroesophageal reflux disease by reducing the pressure of the lower esophageal sphincter and esophageal motility. Fermented and nondistilled alcoholic beverages increase gastrin levels and acid secretion. Succinic and maleic acid contained in certain alcoholic drinks also stimulate acid secretion. Low alcohol doses accelerate gastric emptying, whereas high doses delay emptying and slow bowel motility. Alcohol facilitates the development of superficial gastritis and chronic atrophic gastritis--though it has not been shown to cause peptic ulcer. Alcoholic beverages, fundamentally wine, have important bactericidal effects upon Helicobacter pylori and enteropathogenic bacteria. The main alcohol-related intestinal alterations are diarrhea and malabsorption, with recovery after restoring a normal diet. Alcohol facilitates the development of oropharyngeal, esophageal, gastric, and colon cancer. Initial research suggests that wine may be comparatively less carcinogenic.

The effects of alcohol consumption upon the gastrointestinal tract

Regardless of the type and dose of beverage involved, alcohol facilitates the development of gastroesophageal reflux disease by reducing the pressure of the lower esophageal sphincter and esophageal motility. Fermented and nondistilled alcoholic beverages increase gastrin levels and acid secretion. Succinic and maleic acid contained in certain alcoholic drinks also stimulate acid secretion. Low alcohol doses accelerate gastric emptying, whereas high doses delay emptying and slow bowel motility. Alcohol facilitates the development of superficial gastritis and chronic atrophic gastritis--though it has not been shown to cause peptic ulcer. Alcoholic beverages, fundamentally wine, have important bactericidal effects upon Helicobacter pylori and enteropathogenic bacteria. The main alcohol-related intestinal alterations are diarrhea and malabsorption, with recovery after restoring a normal diet. Alcohol facilitates the development of oropharyngeal, esophageal, gastric, and colon cancer. Initial research suggests that wine may be comparatively less carcinogenic.

Pyogenic liver abscesses of bacterial origin. A study of 45 cases

OBJECTIVE

to determine the clinical, microbiological, diagnostic and therapeutic characteristics of pyogenic liver abscesses of bacterial origin.

METHODS

retrospective analysis of pyogenic liver abscesses diagnosed at the Aránzazu Hospital in San Sebastián (northern Spain) between 1989 and 1998.

RESULTS

we studied 45 patients with pyogenic liver abscesses of bacterial origin (30 men, 15 women, mean age 61 years 11 months). The site of the liver abscess was biliary in 28.9% of the patients, portal in 11.1%, and unknown in 33.3%. Elevated erythrocyte sedimentation rate (95.5%), leukocytosis (86.7%) and fever (82.2%) were the most frequent clinical and laboratory findings. The abscesses were solitary in 55. 5% of the patients. Echography was diagnostic in 68.4% of patients, and computed tomography was diagnostic in 100%. Cultures of pus from the abscess and blood were positive in 77.1% and 50% respectively. Of the abscesses diagnosed as being of bacterial origin, 44.4% involved multiple organisms. Escherichia coli and Streptococcus milleri were the germs isolated most frequently. Percutaneous drainage was done in 22 patients (48.9%), with satisfactory results in 18. Overall mortality related with abscesses was 15.5%.

CONCLUSIONS

the clinical presentation of pyogenic liver abscess did not vary during the study period. Computed tomography is fundamental for diagnosis and treatment. Percutaneous drainage associated with early antibiotic therapy is the treatment of choice.

[Massive hemorrhage due to esophageal varices as a form of presentation of autoimmune hepatitis]

Autoimmune hepatitis is a necro-inflammatory disease of unknown etiology. An acute or fulminant presentation is rare. We report a 18-year-old man presented with acute variceal hemorrhage. The patient was treated with endoscopic sclerotherapy, somatostatin, balloon tamponade and TIPS. The patient died within a week of massive bleeding and hepatic failure. This patient's history strongly suggests that autoimmune hepatitis can be presented as fulminant hemorrhage. The importance of diagnosis and treatment is emphasized to improve prognosis.