Combined Liver and Kidney Transplantation in a Multicenter Transplantation Program in Chile

INTRODUCTION

Combined liver and kidney transplantation (CLKT) is an exceptional therapeutic procedure limited to a few diseases with advanced compromise of these organs. Hyperoxaluria type I and polycystic disease are the most frequent indications. The aim of this article was to report our indications and results of CLKT in a multicenter transplantation program in Chile.

MATERIAL AND METHODS

Our Excel database was reviewed to select patients who were treated with CLKT between 1993 and July 2004.

RESULTS

Among 242 liver transplantations (LT) and 48 kidney transplantations (KT), 7 were CLKT, representing 2.8% of LT and 14.5% of KT. Four patients were women and 3 were male of average age 46.8 years. One patient was a child. Most frequent indications were chronic renal failure associated with terminal liver disease and polycystic disease. One patient needed liver retransplantation due to hepatic vein thrombosis. One patient had a biliary fistula and another had a urinary fistula, treated conservatively. Acute liver rejection took place in 3 cases, 1 of which required antibodies. Two patients died, 1 due to aspergillosis and the other due to vascular complications in the transplanted liver. Actuarial survival rates were 71.4% at 1 and 5 years. Chronic renal failure is not a contraindication to LT.

CONCLUSION

CLKT is an acceptable option for these patients.

Living Related Liver Transplantation. Why This Option Has Been Discarded in a Pediatric Liver Transplant Program in Chile

Living related living transplantation (LRLT) has opened new possibilities for planning transplantation in better conditions for children with emergency situations and chronic liver diseases. Since we began the LRLT program in 1999, we have performed 57 pediatric liver transplants, 17 (29.8%) using living related donors (LRD). The aim of this study was to analyze the reasons why LRD were discarded as a therapeutic option. All pediatric patients were prospectively included in our Microsoft Excel database that was reviewed for obtaining information about causes why the LRLT could not be done. LRLT was proposed in 28 cases and performed in 17 (60.7%). The reasons for LRD rejection were: parent's fear of surgical complications in four cases; drug abuse in two; a mother without family support; medical reasons in two; and only one, due to anatomical reasons and in one case, cadaveric graft transplantation was performed while completing the father's evaluation. From these eleven cases, the indications for liver transplant were acute liver failure (ALF) in seven, biliary atresia in three, and Alagille syndrome in one. Nine were transplanted with cadaveric organs, but two patients with ALF died awaiting a liver. Efforts should be made to clarify the advantages and the disadvantages of LRD in each case, allowing parents to make a free, well-informed decision.

[Chronic hepatitis C and celiac sprue: an infrequent association]

Celiac sprue (CS) has been described in association with hepatitis C virus (HCV) as another immunologic manifestation of this infectious disease. We report 2 patients, a 42-year-old woman and a 59-year-old man, with chronic HCV hepatitis. Upper digestive endoscopy and duodenal biopsy were performed to investigate diverse symptoms. The results of histological analysis and serological study were compatible with CS. The association between both diseases, including immunological aspects and the implications of anti-HCV treatment, is discussed.

Histological inflammatory changes after surgery at the epithelium of the distal esophagus in patients with Barrett's esophagus: a comparison of two surgical procedures

There are many reports concerning the surgical treatment of patients with Barrett's esophagus, but very few focus on histological changes of inflammatory cells in squamous and columnar epithelium before and late after classic antireflux or acid suppression-duodenal diversion surgery. We evaluate the impact of these procedures in the presence of intestinal metaplasia, dysplasia and Helicobacter pylori in the columnar epithelium. Two groups of patients were studied, 37 subjected to classic antireflux and 96 to acid suppression-duodenal diversion operations. They were subjected to endoscopic and histological studies before and at 1, 3 and more than 5 years after surgery. Manometric evaluations and 24 h pH monitoring were performed before and at 1 year after surgery. The presence of inflammatory cells at both the squamous and columnar epithelium was significantly higher at the late follow up in patients subjected to classic antireflux surgery compared with patients subjected to acid suppression-duodenal diversion operations (P < 0.02 and P < 0.001, respectively). Intestinal metaplasia, present in 100% of patients before surgery, had decreased significantly at 3 years after surgery in patients subjected to acid suppression-duodenal diversion operations compared with classic antireflux procedures, 75% versus 53%, respectively (P < 0.001). The presence of Helicobacter pylori did not vary before or after surgery in either group. In conclusion, acid suppression-duodenal diversion operations are followed by a decreased presence of inflammatory cells in both squamous and columnar epithelium compared with classic antireflux surgery in patients with Barrett's esophagus. Intestinal metaplasia and dysplasia and inflammation findings were also less common after acid suppression-duodenal diversion operation.

Epidemiology and results of liver transplantation for acute liver failure in Chile

Acute liver failure (ALF) is a severe, life-threatening condition associated with a high mortality rate. The objective of this study is to present the experience of a Chilean liver transplant program with orthotopic liver transplantation (OLT) for ALF. All patients with the diagnosis of ALF evaluated in our program between January 1995 and May 2003 were included in the analyses of etiology and outcomes. Candidates for OLT activated on a national waiting list were transplanted with cadaveric or living-related donor (LRD) organs. Twenty-seven patients age 1 to 19 years (median, 7.4 years) were transplanted at a median weight of 30.7 kg including 17 cadaveric and 10 with LRD livers. Most frequent etiologies were hepatitis A in 10 cases (37%) and unknown in 12 (48.1%). One donor experienced superficial phlebitis. Four patients were retransplanted (14.8%). Twenty patients are alive with 1- and 5-year survival rates of 74.1% At a median follow up of 34 months (range = 2 to 120). Seven patients died due to sepsis, multiorganic failure, graft primary nonfunction, intracranial hemorrhage, and intraoperative cardiac arrest. This experience revealed results comparable to international reports, allowing survival of patients destined to die.

Outcomes of orthotopic liver transplantation in Chile

Our liver transplant program was started in 1993 in a private clinic and a public hospital. Thereafter, a rapid increase in adults and pediatric candidates for this therapeutic option lead to this analysis of results in 165 orthotopic liver transplants (OLT) in 143 patients between November 1993 and December 2002. Seventy-four OLT were performed in 66 adult patients and 91 in the pediatric group. Liver grafts came from cadaveric donors in 145 cases (74 adults and 71 children). The technique of living-related donor was utilized in 20 pediatric cases. Main indications for OLT in the adult group were HCV cirrhosis, primary biliary cirrhosis; biliary atresia and acute liver failure were the indications in pediatric patients. Retransplantation was needed for 23 patients, including 9 adults and 14 children. The most frequent causes of death were sepsis, graft primary nonfunction, and vascular complications. Actuarial survivals at 1 and 5 years were 80.7% and 72.6% for the adult group and 82% and 74.8% for the pediatric group, respectively. Our results are comparable to those published by large, experienced, international centers, with much better financial support.

Prevalence of intestinal metaplasia according to the length of the specialized columnar epithelium lining the distal esophagus in patients with gastroesophageal reflux

The diagnosis of Barrett's esophagus is based on the presence of intestinal metaplasia (IM) at the distal esophagus. The aim of this study was to determine the prevalence of IM in patients with symptoms of gastroesophageal reflux in whom endoscopically a segment of distal esophagus was covered by columnar epithelium (CE). In a prospective, descriptive and transversal study, 492 patients (33%) from 1480 patients with gastroesophageal reflux, in whom endoscopic evaluation demonstrated the presence of a short-segment CE measuring less than 3 cm or a long-segment CE measuring more than 3 cm, were evaluated. From each patient, several biopsy specimens were taken, which were stained with hematoxylin-eosin and Alcian blue pH 2.5. Out of 492 cases, 421 patients (86%) presented with a short-segment CE and 71 patients (14%) had a long-segment CE. Among these 71 cases, 38 had a 3-6 cm-length CE, 21 patients had a 6.1-10 cm-length CE and 12 patients had CE more than 10.1 cm in length. Endoscopic short-segment CE was six times more frequent than long-segment CE. The prevalence of IM was 35% among patients with short-segment CE and increased progressively according to the length of CE, being 100% in patients with > 10 cm in length. Therefore, true short-segment BE was three times more frequent during endoscopic studies than long-segment BE. Dysplasia in the metaplastic epithelium also increased parallel to the length of the CE. True BE (presence of IM at the columnar epithelium lining the distal esophagus), was present in 13.6% of all patients with symptoms of gastroesophageal reflux submitted to endoscopic evaluation. Short-segment BE is three times more frequent than long-segment BE, and endoscopic and bioptic evaluation is fundamental in all cases with gastroesophageal reflux who exhibit some segment of the distal esophagus lined by columnar epithelium, even if it is > or = 1 cm long.

Late follow-up of polypoid lesions of the gallbladder smaller than 10 mm

OBJECTIVE

To determine the variation in number, size, and symptoms in patients with polypoid lesions of the gallbladder.

SUMMARY BACKGROUND DATA

A polypoid lesion is any elevated lesion of the gallbladder mucosa. Several studies have been reported in patients undergoing cholecystectomy, but little information exits regarding the natural history of these lesions in nonoperated patients.

METHODS

A total of 111 patients with ultrasound diagnosis of polypoid lesions smaller than 10 mm were followed up by clinical evaluation and ultrasonography. Twenty-seven patients underwent cholecystectomy.

RESULTS

There was no difference in terms of gender. Nearly 80% of the lesions were smaller than 5 mm; they were single in 74%. In nonoperated patients, 50% remained of similar size at the late follow-up, 26.5% increased in number and size, and 23.5% shrank or disappeared. Among the operated patients, 70% corresponded to cholesterol polyps. None of the patients developed symptoms of biliary disease or gallstones or adenocarcinoma.

CONCLUSIONS

Ultrasound is useful in the follow-up of patients with polypoid lesions of the gallbladder. Lesions smaller than 10 mm do not progress to malignancy or to development of stones, and none produced symptoms or complications of biliary disease.

[Endoscopic coagulation with argon plasma, a therapeutic option in gastric antral vascular ectasia]

BACKGROUND

Gastric Antral Vascular Ectasia or Watermelon stomach is a rare cause of chronic gastrointestinal bleeding, often presenting as a chronic iron deficiency anemia. This condition can be associated with some other diseases such as cirrhosis, autoimmune diseases and others. We report two patients treated with Argon Plasma Coagulation, a 68 years old male with an ethanol related cirrhosis and a 72 years old female with an idiopathic Gastric Antral Vascular Ectasia. The characteristic endoscopic features were mistaken for many years as gastritis. Both patients presented with severe anemia requiring multiple transfusions as treatment. Due to the poor operative risk, both patients were treated with Argon Plasma Coagulation with good results.

Prevalence of Barrett's esophagus by endoscopy and histologic studies: a prospective evaluation of 306 control subjects and 376 patients with symptoms of gastroesophageal reflux

The classic endoscopic diagnosis of a Barrett's esophagus (BE) is based on the finding of > or =3 cm, of distal esophagus covered by specialized columnar epithelium. However, currently, it is based on the finding of intestinal metaplasia (IM) at the squamous-columnar mucosal junction, independent of its extent. The aim of this study was to determine the prevalence of Barrett's esophagus by endoscopic and histological findings in control subjects and in patients with symptoms of gastroesophageal reflux (GER). Three hundred and six control subjects and 376 patients with symptoms of gastroesophageal reflux were included in this prospective study. Patients with Barrett's esophagus were classified in three groups as follows. 1. Intestinal metaplasia at the cardia. When endoscopy showed non-Barrett's esophagus, but histological intestinal metaplasia was found. 2. Short-segment Barrett's esophagus. When <3 cm, was covered with tongues or finger-like or creeping substitution of distal esophagus. 3. Long-segment Barrett's esophagus. When > 3 cm, of distal esophagus was covered by specialized columnar epithelium. Two biopsies at the antrum, four biopsies at the squamous-columnar junction and one or two at the distal esophagus were taken. In control subjects, 1.6% showed histological IM at the esophagogastric junction. In patients with GER without esophagitis or with erosive esophagitis, IM was found in 18% and 10.7% respectively. 'Short-segment' Barrett's esophagus was three times more frequent than 'long-segment' Barrett's esophagus. Patients with Barrett's esophagus were significantly older than the other groups. The presence of complications or erosions, peptic ulcer or stricture were significantly more frequent among patients with 'long-segment' Barrett's esophagus (p < 0.0001). The prevalence of dysplasia was similar in all groups of patients with Barrett's esophagus. Complications such as ulcers, stricture and dysplasia were exclusively seen among patients with BE, whereas non-Barrett's patients did not exhibit these complications. In control subjects, IM can be found in a low percentage of cases. Among patients with symptoms of GER, the classic endoscopic diagnosis of a Barrett's esophagus can underestimate this condition in 80% of the cases. Patients with intestinal metaplasia at the cardia already present 17% of the cases with low-grade dysplasia. In all patients with symptoms of GER, systematic biopsies at the squamous-columnar junction should be taken.

Comparison of clinical, endoscopic and functional findings in patients with intestinal metaplasia at the cardia, carditis and short-segment columnar epithelium of the distal esophagus with and without intestinal metaplasia

In recent years, the diagnosis of short segments of intestinal metaplasia lining the distal esophagus has increased. The aim of the present study was to determine the clinical, endoscopic, histologic and functional results in patients with intestinal metaplasia at the cardia (IMC), carditis and short-segment columnar epithelium (CE) lining the distal esophagus with and without intestinal metaplasia. Four groups were studied: 48 patients with carditis, 105 patients with IMC, 78 patients with short-segment CE (SSCE) without IM and 69 patients with short-segment CE with IM. All had clinical questionnaire, endoscopic and histological evaluation, manometric studies and measurements of acid and bilirubin exposition of the distal esophagus over 24 h. Patients without IM were found to be younger than those with IM. Erosive esophagitis was observed in similar proportions, but hiatal hernia was present in patients with SSCE with or without IM. Patients without IM had mainly cardial mucosa more than fundic mucosa. However, patients with IM had almost exclusively cardial mucosa. Low-grade dysplasia was observed only in patients with IM. Manometric evaluation demonstrated a structural defective lower esophageal sphincter in all groups. Acid and duodenal exposures of the distal esophagus over 24 h were significantly greater in patients with SSCE with IM. In the presence of pathologic gastroesophageal reflux (GER), there are several histological changes at the mucosa distal to the squamous columnar junction. The first metaplastic change is one from fundic to cardial mucosa and, when duodenal reflux occurs, a second metaplastic change to intestinal metaplasia from cardial mucosa occurs. Therefore, in all patients with symptoms of GER, biopsies specimens distal to the squamous columnar junction should be taken routinely.

[Retractile mesenteritis. Report of 4 cases]

Retractile mesenteritis is a rare condition in which the inflammation process of the mesentery is the characteristic pathological. The histologic changes are variable proportions of fat necrosis, chronic inflammation and fibrosis. The clinical presentation of this process is diverse, also the natural history is variable, ranging from a benign to fatal disease. We reviewed 4 cases of retractile mesenteritis and evaluated the clinical manifestations. There was no gender predominance. The patients aged range was 63-69 years (average 65) Patients more often presented with abdominal mass (cases n: 1 and n: 4), and chronic diarrhea (cases n: 1 and 3). The etiology is unknown, the treatment is empirical, including corticosteroids, colchicine, immunosuppressive drugs and oral progesterone.

[Prevalence of cardial or fundic mucosa and Helicobacter pylori in the squamous-columnar mucosa in patients with chronic patological gastroesophageal reflux without intestinal metaplasia comparated with controls]

BACKGROUND

The mucosa distal to the endoscopic mucosal change zone can have easily diagnosed early alterations, in patients with chronic gastroesophageal reflux.

AIM

To determine the type of mucosa existent in the zone distal to the squamous-columnar junction in patients with chronic gastroesophageal reflux without intestinal metaplasia.

PATIENTS AND METHODS

One hundred thirty four controls and 208 patients with chronic gastroesophageal reflux lasting two years were studied. Forty three of these patients had a normal endoscopy, 54 had an erosive esophagitis and 111 had a short columnar epithelium covering the distal esophagus, without intestinal metaplasia. In all subjects, four biopsies were obtained from a zone distal to the squamous-columnar junction and two from the distal gastric antrum.

RESULTS

In 59% of control subjects, fundic mucosa was present in the zone distal to the squamous-columnar junction. Cardial mucosa was present in the rest. In patient with chronic gastroesophageal reflux, cardial mucosa was predominant. Helicobacter pylorii infection decreased along with increasing extension of cardial mucosa covering the distal esophagus.

CONCLUSIONS

In patients with chronic gastroesophageal reflux there is a metaplasia of fundic mucosa towards cardial mucosa. On the other hand, Helicobacter pylorii infection decreases gradually.

[Clinical and endoscopic findings and magnitude of gastric and duodenal reflux in patients with cardial intestinal metaplasia, short Barrett esophagus, compared with controls]

BACKGROUND

The diagnosis of patients with short segments of intestinal metaplasia in the distal esophagus, has increased in recent years.

AIM

To assess the clinical, pathological and functional features of patients with esophageal intestinal metaplasia.

PATIENTS AND METHODS

A prospective study was performed in 95 control subjects, 115 patients with cardial intestinal metaplasia and 89 patients with short Barret esophagus with intestinal metaplasia. All had clinical and endoscopic assessments, esophageal manometry and determination of 24 h esophageal exposure to acid and duodenal content.

RESULTS

Control patients were younger and, in this group, the pathological findings in the mucosa distal to the squamous-columnar change, showed a preponderance of fundic over cardial mucosa. In patients with intestinal metaplasia and short Barret esophagus, there was only cardial mucosa, that is the place where intestinal metaplasia implants. Low grade dysplasia was only seen in the presence of intestinal metaplasia. Gastroesophageal sphincter pressure decreased and gastric and duodenal reflux increased along with increases in the extension of intestinal metaplasia.

CONCLUSIONS

These findings confirm the need to obtain multiple biopsies from the squamous-columnar mucosal junction in all patients with gastroesophageal reflux symptoms, for the detection of early pathological changes of Barret esophagus and eventual dysplasia.

[Prevalence and genotypes of hepatitis C virus in blood donors and in patients with chronic liver disease and hepatocarcinoma in a Chilean population]

BACKGROUND

The impact of hepatitis C virus infection in Chile has not been well established.

AIM

To assess hepatitis C virus infection in normal Chileans and in patients with liver disease.

SUBJECTS AND METHODS

Antibodies against hepatitis C virus were investigated in 21,000 blood donors, 133 patients with non alcoholic chronic liver disease and in 50 patients with hepatocarcinoma. Viral RNA was studied by polymerase chain reaction in all positive blood donors, in 51 patients with chronic liver disease and in all patients with hepatocarcinoma. Hepatitis C virus genotype was established using restriction fragment length polymorphism in 118 RNA positive samples.

RESULTS

In blood donors, a 0.3% prevalence of positive antibodies was found. The figure for chronic liver disease was 53% and for hepatocarcinoma, 48%. Viral RNA was detected in 100% of patients with chronic liver disease and hepatocarcinoma and in 68% of blood donors with positive antibodies. Genotype 1b was identified in all infected patients with hepatocarcinoma, in 86% of patients with chronic liver disease and in 46% of blood donors.

CONCLUSIONS

Hepatitis C virus infection is an important etiologic agent for chronic liver disease in Chile. The predominance of genotype 1b among patients with the most severe form of liver disease is in agreement with observations made abroad.

Histological findings of gallbladder mucosa in 95 control subjects and 80 patients with asymptomatic gallstones

The histological appearance of gallbladder mucosa in 95 control subjects and in 80 patients with asymptomatic gallstones separated according to age and sex was determined in a prospective study. The number and size of stones in the latter group were also analyzed. Among controls, 33% showed abnormal histological findings, mainly chronic cholecystitis, which increased with age and was frequently seen among women. All patients with asymptomatic gallstones showed chronic cholecystitis and/or cholesterolosis, and 5% showed acute inflammatory changes. In 55% of them a single stone was found. These findings suggest that chronic inflammatory changes can occur in the gallbladder mucosa prior to the appearance of macroscopic stones at the gallbladder.

[Cholestatic hepatitis associated with piroxicam use. Case report]

Most nonsteroidal antiinflammatory drugs can produce hepatotoxicity. We report a 22 years old female who presented with an acute cholestatic hepatitis after a prolonged period of piroxicam use. Hepatitis was attributed to this drug since all markers for hepatitis virus (A, B, C, E, Epstein Barr, Cytomegalovirus and Herpex Simplex) were negative, autoimmune markers were negative, serum iron and ceruloplasmin were normal, there was a temporal relationship between the administration of piroxicam and the hepatitis, the histological picture was compatible with this etiology and the patient had a favorable evolution after the discontinuance of the drug. This type of hepatotoxicity is not common but it must be born in mind when patients must receive nonsteroidal antiinflammatory drugs for prolonged periods.

'Carditis': an objective histological marker for pathologic gastroesophageal reflux disease

In a prospective endoscopic and bioptic study, 141 control subjects and 359 patients with symptoms of gastroesophageal reflux (GER) were included to determine the prevalence of cardial epithelium inflammation or 'carditis' and to determine the prevalence of Helicobacter pylori in this area. Two biopsies at the antrum, four distal to the squamous-columnar junction and two proximal in the esophageal mucosa, were taken. Patients with gastroesophageal reflux were divided into four groups, according to the severity of endoscopic findings: patients without esophagitis, patients with erosive esophagitis, patients with short-segment and long-segment Barrett's esophagus (BE). Control subjects had normal histological findings at the cardia in 90% of cases, fundic mucosa being present twice as cardial epithelium. Carditis was present in 8% of cases and intestinal metaplasia (IM) in 2%. On the contrary, patients with GER had carditis in nearly 50% of cases. Intestinal metaplasia was present in 12% of cases with GER without esophagitis or erosive esophagitis, in 35% of cases with short-segment BE and in 65% of the cases with long-segment BE. IM at the antrum was present in only 5% of cases. Helicobacter pylori at the squamous-columnar junction was present in 13% of control subjects and in 30% of the patients with GER. It is concluded that carditis is an easy and objective marker for the presence of chronic gastroesophageal reflux and the presence of Helicobacter pylori at this region must be carefully evaluated in order to determine some pathogenic role for the development of Barrett's esophagus.

[Biopsy and endoscopic prospective study of the prevalence of intestinal metaplasia in the gastroesophageal junction in controls and in patients with gastroesophageal reflux]

BACKGROUND

The classic diagnosis of Barret esophagus is based on the finding of three of more cm of distal esophagus covered by specialized columnar epithelium. However, at the present time, it is based on the presence of intestinal metaplasia in the junction of squamous-columnar mucosae.

AIM

To assess the prevalence of Barret esophagus using endoscopic and pathological criteria in healthy subjects and in individuals with gastroesophageal reflux.

PATIENTS AND METHODS

One hundred thirty nine controls and 372 patients with symptoms of gastroesophageal reflux subjected to an upper gastrointestinal endoscopy were studied. Patients with Barret esophagus were classified as having a "mini Barret" when the pathological presence of intestinal metaplasia was the only finding. A "short Barret esophagus" was diagnosed when less than 3 cm were covered with fingerings of mucosal substitutions and "extensive Barret esophagus" when more than 3 cm of esophageal mucosa were substituted.

RESULTS

Two percent of controls, 12.4% of patients with gastroesophageal reflux without esophagitis and 11.7% of such patients with esophagitis had intestinal metaplasia in the gastroesophageal junction. Patients with Barret esophagus were older than the rest of patients. "Short Barret esophagus" is six times more frequent than "extensive Barret esophagus". Esophageal erosions, peptic ulcers and stenosis were more frequent in patients with extensive Barret esophagus. The prevalence of dysplasia was similar in all types of Barret esophagus.

CONCLUSIONS

Intestinal metaplasia was very infrequent in control patients. In subjects with gastroesophageal reflux, classic endoscopic diagnosis may miss up to 80% of patients with Barret esophagus. Thus, gastroesophageal junction biopsies must be obtained in all patients with symptoms of gastroesophageal reflux.

The combination of ursodeoxycholic acid and methotrexate for primary biliary cirrhosis is not better than ursodeoxycholic acid alone

BACKGROUND/AIMS

Many therapies have been tried in primary biliary cirrhosis. It has been suggested that a combination of ursodeoxycholic acid and methotrexate may offer advantages. Because the benefit and safety of this combination is uncertain, we conducted this prospective, randomized, double-blind, controlled trial.

METHODS

Twenty-five patients with well-defined primary biliary cirrhosis were randomly assigned to receive either ursodeoxycholic acid (500 mg/day) plus methotrexate (10 mg/week) or ursodeoxycholic acid plus placebo for a period of 48 weeks. Clinical, biochemical and histologic evolution were assessed.

RESULTS

In both groups the clinical response was similar and heterogeneous. In patients of ursodeoxycholic acid alone group, biochemical and histologic changes were comparable to those of patients of ursodeoxycholic acid plus methotrexate at 48 weeks. The addition of methotrexate was not associated with substantial adverse affects.

CONCLUSIONS

The use of methotrexate in combination with ursodeoxycholic acid was not followed by an additive benefit over ursodeoxycholic acid alone, nor was substantial toxicity added. Unless larger and longer controlled trials with clinical, biochemical and histologic controls show it to be a safe and effective therapy for primary biliary cirrhosis, ursodeoxycholic acid+methotrexate should not be used as a proven and accepted treatment.

Kupffer cell function in thyroid hormone-induced liver oxidative stress in the rat

The influence of thyroid hormone (L-3, 3', 5-triiodothyronine, T3) on Kupffer cell function was studied in the isolated perfused rat liver by colloidal carbon infusion. Rates of carbon uptake were determined from the influent minus effluent concentration difference and the flow rate, and the respective carbon-induced respiratory activity was calculated by integration of the area under the O2 curves during carbon infusion. In the concentration range of 0.2 to 2.0 mg of carbon/ml, livers from euthyroid rats exhibited a sigmoidal-type kinetics of carbon uptake, with a Vmax of 4.8 mg/g liver/min and a concentration of 0.82 mg/ml for half-maximal rate; carbon-induced O2 uptake presented a hyperbolic-type kinetics, with a Vmax of 4.57 mumol of O2/g liver and a K(m) of 0.74 mg of carbon/ml, which significantly correlates with the carbon uptake rates. Light-microscopy showed that carbon was taken up exclusively by non-parenchymal cells, predominantly by Kupffer cells. Thyroid calorigenesis was found in parallel with increased rates of hepatic O2 consumption and thiobarbituric acid reactive substances (TBARS) formation, glutathione (GSH) depletion, and higher sinusoidal lactate dehydrogenase (LDH) efflux compared to control values. In the concentration range of 0.25 to 0.75 mg/ml, carbon infusion did not modify liver LDH efflux in control rats, while it was significantly enhanced in T3-treated animals. In this latter group, higher carbon concentrations (1 and 1.3 mg/ml) led to loss of viability of the liver. At 0.25 to 0.75 mg of carbon/ml, both the rates of carbon uptake and the associated carbon-induced respiratory activities were significantly increased by T3 treatment, effects that were abolished by pretreatment of the rats with gadolinium chloride (GdCl3). In addition, GdCl3 decreased by 50% the changes induced by T3 in hepatic GSH content and TBARS formation. It is concluded that hyperthyroidism enhances Kupffer cell function, correlated with the increased number of liver macrophages observed histologically, which may represent an alternate source of reactive O2 species to that induced in parenchymal cells, thus contributing to the enhanced oxidative stress status developed.

Potentiation of ischemia-reperfusion liver injury by hyperthyroidism in the rat

Parameters related to hepatic oxidative stress, cell injury, and liver histology were determined in control rats and in animals treated with 3,3',5-triiodothyronine (T3), after in vitro perfusion under normoxic or ischemia-reperfusion conditions. Thyroid calorigenesis was found concomitantly with higher rates of hepatic O2 consumption and thiobarbituric acid reactive substances (TBARS) formation, glutathione (GSH) depletion, enhanced TBARS/GSH ratio as indicator of oxidative stress, and higher sinusoidal lactate dehydrogenase (LDH) efflux compared to control values, assessed under normoxic conditions. Perfused livers from control animals subjected to ischemia-reperfusion exhibited significant increases in the TBARS/GSH ratio and in the sinusoidal LDH efflux over values obtained under normoxic conditions, concomitantly with the appearance of small foci of necrotic cells in centrilobular and midzonal areas of the liver lobule. These parameters were further modified in the liver of hyperthyroid rats subjected to ischemia-reperfusion, with elevations in the TBARS/GSH ratio and in the sinusoidal LDH efflux largely exceeding the sum of effects elicited by hyperthyroidism or ischemia-reflow alone. In this situation, liver injury was more pronounced than in control rats, being characterized by multifocal areas of necrotic cells, irregularly distributed in the hepatic lobule, with lymphoid and macrophagic reaction. It is concluded that the concurrence of the hepatic mechanisms related to the oxidative stress underlying thyroid calorigenesis and ischemia-reoxygenation exacerbates liver injury, which seems to be mediated by potentiation of the prooxidant state of the organ.

Prevalence of Helicobacter pylori infection in 190 control subjects and in 236 patients with gastroesophageal reflux, erosive esophagitis or Barrett's esophagus

A prospective study was performed in 190 control subjects and in 236 patients with different degrees of endoscopic esophagitis in order to determine the prevalence of Helicobacter pylori infection at duodenal gastric and esophageal mucosa and its correlation with histological findings. All patients with pathologic gastroesophageal reflux had 24-h pH monitoring studies confirming the presence of acid reflux into the esophagus. Besides the endoscopic findings, biopsies were taken from the duodenal bulb, gastric antrum, gastric fundus and distal esophagus or at the specialized columnar epithelium in patients with Barrett's esophagus. Patients with pathological gastroesophageal reflux were divided into three groups: 55 with absence of endoscopic esophagitis (gastroesophageal reflux), 81 patients with erosive esophagitis and 100 patients with Barrett's esophagus. There was no H. pylori infection present at duodenal or esophageal mucosa or at the specialized columnar epithelium of the distal esophagus in any case. The prevalence of H. pylori infection at gastric antrum was similar in controls and in any group of patients with reflux disease (20-25% of H. pylori infection). No differences in age and sex distribution were seen. H. pylori infection at gastric fundus was very low (less than 5%). The presence of HP infections was correlated with the finding of chronic active superficial or athrophic gastritis while, in the absence of H. pylori infection, gastric mucosa was normal. In the presence of intestinal metaplasia, no H. pylori infection occurred. Based on these findings, it seems that there is no significant evidence for an important pathogenic role for H. pylori infection in the development of pathologic chronic gastroesophageal reflux, erosive esophagitis or Barrett's esophagus, and the presence of antral gastritis in patients with Barrett's esophagus is closely related to the presence of H. pylori infection, and probably not related to an increased duodenogastric reflux.

[Hepatic veno-occlusive disease associated to the use of azathioprine in a renal transplant recipient]

We report a 30 years old male, recipient of a kidney allograft and treated with azathioprine, who eighteen days after transplantation had a clinically asymptomatic elevation of total bilirubin and alkaline phosphatases. Nineteen months later, he presented with mild ascites, with a total bilirubin of 3.5 mg/dl, alkaline phosphatases of 308 U/L (normal < 170 U/L) and a prothrombin time at 55% of control. A liver biopsy showed sinusoidal and perivenular fibrosis without inflammation, compatible with chronic venous obstruction. Hepatic veno-occlusive disease is an infrequent complication of azathioprine use.

The presence of Helicobacter pylori in nonoperated duodenal ulcer patients compared to patients late after highly selective vagotomy

There are many recent studies that clearly suggest that Helicobacter pylori (HP) is an etiological agent for duodenal ulcer disease (1-3). Randomized trials have shown that duodenal ulcers treated by omeprazole or H2 blockers heal faster if HP is eradicated concurrently (4-6). Besides, several studies have demonstrated that eradication of HP significantly reduces duodenal ulcer relapses (7-9). Patients followed up to 7 years after eradication of HP demonstrated that 92% remained HP negative, with only 3% recurrence (10). Highly selective vagotomy has been the treatment of choice for duodenal ulcer patients who are candidates for surgical therapy (11, 12). The late results have shown an approximately 10% recurrence rate 8 to 10 years after surgery (13, 14). We hypothesized that in these asymptomatic cases after HSV, HP probably will exist in a minor proportion of cases, similar to what happens after successful medical antiulcer therapy. Therefore the purpose of the present study was to determine the HP status at the antrum in a group of nonoperated duodenal ulcer patients compared to a group submitted to highly selective vagotomy many years prior to the actual study.

[Experience of a single center in liver transplantation in adults and children]

Orthotopic liver transplantation (THO) is the treatment of choice for a variety of liver diseases. The national experience before 1993 has been scarce. In November 1993 we started our experience in THO at Clínica Las Condes, as part of a multiorgan transplant program (liver, kidney, pancreas). Until January 1995 we have performed 14 THO in 13 recipients (one retransplantation), of which 5 were in pediatric cases. The recipients range of age fluctuated between 1 and 61 years. In two pediatric cases a liver allograft reduction was performed. Six recipients (46%) required treatment for acute cellular rejection. One recipient had an hepatic artery thrombosis and had to be retransplanted. There was no operative mortality up to 30 days in cases of primary liver transplants. The retransplanted adult recipient, and another pediatric recipient that died from a late recurrence of a hepatoblastoma, accounted for the mortality of this experience. After an average follow up of 10 months, the actual patient survival in 85%. Of the 11 surviving recipients, 9 are in excellent conditions with a very good quality of life. This experience shows that an active liver transplant program in our country can be successful in obtaining results comparable to those published by very experienced foreign transplant centers.

Influence of hyperthyroidism on lindane-induced hepatotoxicity in the rat

Parameters related to hepatic oxidative stress, cell injury, phagocytic activity, and liver histology were studied in control rats and in animals subjected to L-3,3',5-triiodothyronine (T3) and/or lindane administration. Hyperthyroidism elicited a calorigenic response and increased rates of hepatic O2 uptake, which were not modified by lindane treatment. T3 diminished serum lindane levels as well as those in the liver and adipose tissue, whereas lindane enhanced serum T3 levels in animals given T3. Compared with control rats, lindane significantly increased the rate of formation of thiobarbituric acid reactants (TBARS) by the liver, with no changes in either the reduced glutathione (GSH) content, the TBARS/GSH ratio as indicator of oxidative stress, or in the fractional rates of lactate dehydrogenase (LDH) and GSH efflux from perfused livers as integrity parameters. Hyperthyroidism induced GSH depletion in the liver, with a significant enhancement in the TBARS formation, the TBARS/GSH ratio, and in the fractional LDH and GSH efflux. These parameters were increased further by joint T3 and lindane administration in a magnitude exceeding the sum of the effects produced by the separate treatments. In addition, hyperthyroidism led to Kupffer cell hyperplasia and significant increases in serum glutamate oxalacetate transaminase (GOT) and in hepatic zymosan-induced chemiluminescence, while liver myeloperoxidase (MPO) activity was found unchanged, compared with controls. Rats treated with lindane presented normal liver histology, with no changes in biochemical parameters related to cell injury. The joint administration of T3 and lindane, however, elicited a marked elevation in serum GOT and glutamate pyruvate transaminase (GPT), concomitantly with extensive liver necrosis and the presence of granulomas containing lymphocytes, Kupffer cells and polymorphonuclear leukocytes (PMN). In this condition, hepatic zymosan-induced light emission and MPO activity were enhanced over control values. It is concluded that hyperthyroidism increases the susceptibility of the liver to the toxic effects of lindane, which seems to be accomplished by potentiation of the hepatic oxidative stress status. The latter effect may be conditioned by an enhanced phagocytic respiratory burst activity due to the observed Kupffer cell hyperplasia and PMN infiltration, in addition to the increased production of reactive oxygen species in parenchymal cells.

[Presence of Helicobacter pylori in the duodenum, antrum, and fundus in control subjects and patients with duodenal ulcer, gastric ulcer, gastritis, or erosive duodenitis. Histological analysis of 357 subjects]

The prevalence of Helicobacter pylori infection was studied in 152 subjects with a normal upper gastrointestinal endoscopy, 125 with duodenal ulcer, 25 with gastric ulcer, 46 with erosive gastritis and 9 with erosive duodenitis. Two biopsies from duodenum, antrum and fundus were obtained from each subject during endoscopy for histological diagnosis and Helicobacter pylori search. None of the patients with normal endoscopy and 2% of patients with duodenal ulcers had Helicobacter pylori in duodenal biopsies. These last patients had a significantly higher frequency of Helicobacter pylori in the antrum (71%) than the rest of the studied groups. Five percent of subjects with normal endoscopy and 5% of those with duodenal ulcers had Helicobacter pylori in the antrum. An active gastritis was demonstrated in almost all patients with Helicobacter infection. Intestinal metaplasia occurred almost exclusively in the absence of Helicobacter pylori infection.

[Patients with pathologic gastroesophageal reflux without erosive esophagitis: correlation of the endoscopic and histological aspect of the esophagus]

Eighty four patients with chronic gastroesophageal reflux in whom endoscopy showed a normal or minimally altered esophageal mucosa (hyperemia, erythema or mucosal congestion) were prospectively studied. In each patient, two esophageal biopsies were obtained (1 and 3 cm above the mucosal change zone). Histological esophagitis was found in 28% of patients with endoscopically normal mucosa and in 26% of patients with minimal endoscopical mucosal alterations. It is concluded that the description of these minimal esophageal alterations during endoscopy is subjective, unreproducible and do not clearly indicate the presence of esophagitis. A classification of endoscopical findings is proposed, based on the presence of objective lesions such as erosions or Barrett esophagus.

Acute fatty liver of pregnancy: a clinical study of 12 episodes in 11 patients

Twelve episodes of acute fatty liver of pregnancy (AFLP) were diagnosed in 11 patients during the past 18 years in a general hospital in Santiago, Chile, with a prevalence of 1 per 15,900 deliveries. Acute fatty liver of pregnancy started between the 31st and 38th weeks of pregnancy, with malaise, vomiting, jaundice, and lethargy as the main clinical manifestations. Polydipsia (in nine episodes) and skin pruritus (in seven episodes) were unusual clinical findings. In two patients, pruritus started two and four weeks before AFLP, suggesting that an intrahepatic cholestasis of pregnancy preceded AFLP in those patients. Considering the current prevalence of both diseases in Chile, their association should be considered fortuitous. In another patient, two consecutive pregnancies were affected by AFLP, raising to three the number of reported patients with recurrent AFLP. In 11 episodes, liver biopsies supported the diagnosis of AFLP by showing small and midsized vacuolar cytoplasmic transformation as the most prominent histopathological feature. Positive intracellular fat staining was found in the four samples analysed. Studies by electron microscopy showed megamitochondria with paracrystalline inclusions in four samples. All the mothers survived, but fetal mortality was 58.3%. Several extrahepatic complications delayed maternal recovery for up to four weeks after delivery. This study confirms an improvement in maternal prognosis in AFLP, discusses the possibility of an epidemiological association with intrahepatic cholestasis of pregnancy, and increases the number of patients reported with recurrent AFLP.

[Intestinal malabsorption in patients treated with total gastrectomy]

Weight loss, chronic diarrhea and fat malabsorption are frequent after total gastrectomy. The aim of this work was to study parameters of intestinal absorption and the histology of jejunal mucosa in 26 patients subjected, at least one year ago, to total gastrectomy and without evidences of tumoral relapse. There was a mean weight loss of 9 kg (range 4 to 20) and 46% of patients had intermittent or episodical diarrhea. Hemoglobin was below 12 g/dl in 4 patients, serum albumin was below 3.5 g/dl in 3, serum carotene was below 40 micrograms/dl in 5 and serum iron was below 80 micrograms/dl in 5. Jejunal biopsies were normal and steatocrit was abnormal in all patients. Present findings suggest that fat malabsorption in these patients is intraluminal and due to an unequal mix of pancreatic and biliary secretions, as a consequence of Y en Roux transit reconstruction.

[Long-term survival of patients with stomach cancer treated with subtotal gastrectomy]

The aim of this work was to determine the 5 and 12 years survival of 233 patients with gastric cancer subjected to subtotal gastrectomy. Patients with early gastric cancer (n = 51) had a 95% survival and those with intermediate cancer (n = 19) a 87% survival. Patients with advanced gastric cancer (n = 163) subjected to curative surgery had a 60% survival, whereas none subjected to palliative surgery survived. Those patients that survive more than 24 months after the surgical procedure, have an excellent long term prognosis.

[Hepatic angiosarcoma: report of 4 cases]

Hepatic angiosarcoma is an infrequent vascular liver tumor of high malignancy. Four patients (two males) are presented, in whom a histopathological study was performed. All patients died and in three a necropsy was executed.

[Post sinusoidal obstruction of the hepatic venous flow associated with antiphospholipid syndrome in 3 cases]

Three cases of post-sinusoidal hepatic blood flow obstruction as the main feature of antiphospholipid syndrome are reported. Clinically, these patients developed jaundice, malaise, ascites and hepatomegaly. Ultrasonography-Doppler and hepatic venography showed small hepatic vein disease in two and partial occlusion in the suprahepatic segment of inferior vena cava in the remaining patient. In all, anticardiolipin antibodies were positive and activated partial thromboplastin time was prolonged. This experience emphasizes that in patients with post sinusoidal portal hypertension, a systematic search for antiphospholipid syndrome must be carried out.

[Morphology of the myenteric plexus of the small intestine in patients with liver cirrhosis]

BACKGROUND

Patients with liver cirrhosis develop small bowel dysmotility of unknown etiology. Morphological features in the enteric nervous system and the intestinal smooth muscle may shed light on pathophysiology of the gut motility disturbances in this disease.

AIM

To investigate the morphology of the myenteric plexuses and smooth muscle layers of the small intestine in patients with liver cirrhosis.

PATIENTS AND METHODS

Full thickness biopsies of duodenum, jejunum and ileum from seven cirrhotic patients and seven controls were stained with several techniques, including silver impregnation. Neuronal counting and light microscopy studies were stained performed.

RESULTS

The neuronal count was not significantly different in patients with cirrhosis compared to controls in duodenal samples (1.6 +/- 0.4 cel/mm vs 1.6 +/- 0.2 cel/mm), jejunal tissue (1.2 +/- 0.3 cel/mm vs 1.4 +/- 0.2 cel/mm), and in ileal specimens (0.8 +/- 0.3 cel/mm vs 0.9 +/- 0.2 cel/mm). In both groups, evidence of fibrosis or inflammation in myenteric plexuses and in smooth muscle was not found. Also, intestinal neuronal dysplasia was absent in cirrhotic patients as in controls.

CONCLUSION

These results suggest that small bowel dysmotility in patients with liver cirrhosis is not related to structural changes in myenteric plexuses or in intestinal smooth muscle noted by light microscopy.

[Microscopic colitis and collagenous colitis. An entity not yet reported in Chile]

Collagenous and microscopic colitis have been described as causes for abundant watery diarrhea with a normal radiologic and endoscopic aspect of the colonic mucosa. Microscopic colitis is characterized by diffuse intraepithelial lymphocytic infiltration and collagenous colitis by thickening of subepithelial collagen layer greater than 15 microns with or without inflammatory changes of the mucosa. Here are reported 5 patients with microscopic colitis and 4 with collagenous colitis. The mean age was 52 years (range 40 to 68) with an equal sex distribution. Diarrhea was of longstanding duration without weight loss, anemia or hypoalbuminemia. Occasionally the volume of diarrhea was over 1 L a day. One patient had steatorrhea that proved resistant to a gluten free diet. Endoscopic and radiologic findings were normal in every patient and the diagnosis was based on typical histology. Azulfidine therapy was successful in 7 patients and prednisone in another. Colonic biopsy should be performed in every patient with chronic diarrhea.

[Peptic ulcer and endoscopic signs of portal hypertension in patients with primary biliary cirrhosis]

BACKGROUND

Controversies exist on the prevalence of peptic ulcer and on the relationship between the presence of portal hypertension associated lesions in the upper gastrointestinal tract and the histological and functional stages of primary biliary cirrhosis

AIM

To evaluate the prevalence of peptic ulcer and endoscopic signs of portal hypertension in subjects with primary biliary cirrhosis.

PATIENTS AND METHODS

A retrospective study based on upper gastrointestinal endoscopies in 36 patients with primary biliary cirrhosis and 45 subjects with chronic active hepatitis.

SETTING

Gastroenterology Center, Hospital Clínico, University of Chile, Santiago.

MAIN RESULTS

No differences were demonstrated between the two groups for the prevalence of peptic ulcer (11% in primary biliary cirrhosis vs 13% in chronic active hepatitis). Esophageal varices were found in 5 of 16 patients (31%) in prefibrotic stages of primary biliary cirrhosis compared with 10 of 20 (50%) in whom fibrosis or cirrhosis were noted; NS. Endoscopic signs suggesting hypertensive gastropathy were present in 2 patients with early primary biliary cirrhosis (13%) and in 5 (25%) in advanced stages.

CONCLUSIONS

Peptic ulcer is not more prevalent in patients with primary biliary cirrhosis than in those suffering from chronic active hepatitis. Esophageal varices and endoscopic stigmata of portal hypertension induced changes in gastric mucosa can be observed in early stages of primary biliary cirrhosis.

[A cooperative study on early and intermediate gastric cancer: clinical, diagnostic and therapeutic aspects]

A cooperative study involving 13 hospitals in Chile allowed the analysis of 353 patients with gastric cancer in early stages. 82 cancers were located at the mucosal level, 151 at the submucosa and 120 reached the muscular layer. There were no differences in age and sex among these groups. Compared to early stage, patients with intermediate stage had a greater incidence of bleeding, anemia and undernutrition and exhibited lower body weight. Endoscopy had a higher diagnostic yield compared to radiological study. The diagnosis was confirmed by biopsy in 95% of patients. Total or subtotal gastrectomy was performed according to the location of the lesion, with a low operative mortality rate. Early gastric cancer accounts for 8 to 10% of all patients with gastric cancer undergoing surgical treatment.

Histological studies of Auerbach's plexuses of the oesophagus, stomach, jejunum, and colon in patients with achalasia of the oesophagus: correlation with gastric acid secretion, presence of parietal cells and gastric emptying of solids

Histological changes in the Auerbach's plexuses of the oesophagus, stomach, jejunum, and colon were analysed in a prospective study in 34 patients with achalasia of the oesophagus. At the distal end of the oesophagus ganglia cells were absent in 91% of cases as well as in the middle third of the stomach (20%). The Auerbach's plexuses were normal in the jejunum and colon. The results of gastric acid secretion showed that the peak acid output was significantly lower in achalasia patients compared with controls (p less than 0.001). There was no correlation between the mean ganglion neuronal count in the gastric plexuses and the rate of gastric acid output (r = 0.33). Gastric emptying of solids was also evaluated, but there was no correlation between gastric emptying and the mean ganglion neuronal count in the gastric Auerbach's plexuses. The rate of gastric emptying of solids was similar in controls and patients with achalasia. These studies suggest that denervation of the oesophagus in patients with achalasia, which is a constant finding in several previous reports may extend beyond the oesophagus to the stomach in nearly half the cases.

[Transvenous hepatic biopsy in patients with blood coagulation disorders]

Severe clotting defects represent the main contraindication to percutaneous liver biopsy. A transvenous liver puncture technique has been developed for patients suffering from blood coagulation disorders. This approach was attempted in 17 of 148 consecutive patients (12%) in whom a needle liver biopsy was indicated. Hepatic tissue samplings were successfully obtained in 16 subjects. The mean size of the specimens was 7 mm. The clinical diagnosis or therapy were modified in 7 patients when the histopathology report was available. No complications related to the procedure occurred. Our early experience suggests that transvenous liver biopsy is indicated in one/ninth of cases in whom hepatic tissue sample is required for diagnosis. This technique is safe, and it has a high success rate to provide liver tissue samples.

[Clinical course characteristics of gastric cancer 1958-1990]

The clinical, surgical and histopathologic characteristics of patients with gastric cancer were compared among 3 consecutive periods from 1958 to 1990. A significant increase in the frequency of location at the upper third of the stomach, a greater proportion of resectable lesions, an increasing tendency towards extended total gastrectomy and a significant increase in the frequency of undifferentiated or diffuse carcinoma were observed. A change in pathogenetic factors along the years may be involved in the differences described.

[Benign polypoid lesions of the gallbladder. Their relation to gallbladder adenocarcinoma]

Out of 12,153 cholecystectomies performed over a period of 10 years, 114 polypoid lesions were found in 81 removed gallbladders (0.7%). 225 adenocarcinomas of the gallbladder were found in the same population (1.85%). The mean age of patients with polypoid lesions was 46 years, with a male to female ratio of 1:2.7. 94% of lesions measured less than 10 mm and only 9.6% were adenomas. Among these, dysplastic alterations were found in all and one had evidence of early adenocarcinoma. The mean age of patients with adenocarcinoma was 62 years with a male to female ratio of 1:6. Residual adenomas were found in 2 cases and multiple adenomas coexisted in another case. Thus, polypoid lesions of the gallbladder are less frequent than adenocarcinoma. Only adenomas show a potential to evolve to malignant lesions, but their low incidence makes them an unimportant precursor of gallbladder carcinoma.

[Incipient and intermediate gastric cancer II. Anatomo-pathological and surgical aspects. Cooperative study in 13 hospitals]

Anatomic and surgical characteristics of 233 pts with early, and 120 with intermediate gastric cancer, from 13 hospitals in Chile are analyzed. 63% had depressed or excavated lesions. Most of the tumors were located in the inferior or middle third, while only 17% of the early carcinomas were found in the superior third of the stomach, specially in the lesser curvature. 5% had residual tumor in the gastric remanent. Histologically, tubular adenocarcinoma was the most common finding. According to Lauren's classification intestinal carcinoma was more frequent than the diffuse type. Surgeons underestimated lymphatic node involvement (macroscopic appreciation) in up to 58% of the cases when compared to the pathologists observation (microscopic appreciation). This was specially true in muscular carcinomas. The incidence of lymphatic metastases was 6% in mucous, 12% in submucous and 57% in muscular carcinoma. The need of complete lymph node dissection of all the lymphatic barriers is emphasized.

[Prevalence of gallbladder neoplasms in cholecystectomies]

The prevalence of gallbladder cancer in 10,468 cholecystectomy patients was studied: 3.4% of the female and only 1.32% of the male population had gallbladder cancer (p < 0.001). The female population had 2.7 times more cholelithiasis, and 7.9 times more cancer than the male population. Cancer incidence increases progressively with age, specially after the 5th decade.

[Primary biliary cirrhosis. The experience in 33 consecutive cases]

Primary biliary cirrhosis is a chronic, progressive and often fatal cholestatic liver disease. We report clinical characteristics and follow up in 33 consecutive patients studied at a single university hospital during the last 10 years. 31 were female (94%) and the mean age was 51 +/- 2 years. At diagnosis, itching was present in 26 cases (78%). Association with autoimmune mediated diseases was frequent. Liver function tests showed marked cholestasis (alkaline phosphatase levels of 439 +/- 58 IU/l, range 90-1335). High antimitochondrial antibody titers and elevation of IgM levels were shown in all cases. According to liver biopsy findings, the diagnosis of primary biliary cirrhosis was an early one during the prospective phase of the study and was made in 8 +/- 1.4% of liver biopsies performed during this period. After a follow up of 27 +/- 5 months, 10 patients have died (30%). Our experience suggests that primary biliary cirrhosis is not an uncommon cause of chronic liver diseases in Chile.

[Ductal epithelial lesions and pancreatic adenocarcinoma]

Epithelial alterations in pancreatic ducts may have a premalignant nature. We compared the incidence of different lesions in 49 pancreatic cancer specimens compared to 100 controls. Simple hyperplasia, mucosecretory metaplasia and pyloric metaplasia were evenly distributed among groups. In contrast, papillary hyperplasia, intestinal metaplasia and dysplasia were significantly more frequent in pancreas with carcinoma. Therefore, these lesions may have a precancerous nature.

[Dieulafoy's vascular malformation as a cause of massive and recurrent gastric hemorrhage]

We demonstrated a Dieulafoy-type vascular malformation in 10 patients with upper gastrointestinal bleeding. Most patients had a history of prior bleeding and were older than 60 years of age. A mean of 2.6 endoscopic examinations had been performed, and a mean of 2500 ml of blood transfused per patient. A localized resection of the lesion was performed in 9 patients and a partial gastrectomy in the remaining. Surgery was performed as an emergency in 5 patients. The lesion was a small, 2 to 5 mm, erosion localized in the subcardial region. The vascular nature of the lesion was confirmed by histologic study in all cases. Postoperative course was uneventful in all patients and no recurrences have been observed.