RACIONAL: Bypass gástrico em Y-de-Roux é a operação bariátrica mais comumente realizada. Pequena bolsa gástrica é criada, deixando uma anastomose gastrojejunal estreita, com uma alça jejunal mais comprida. Muito pouco é conhecido sobre o comportamento desta bolsa em anos após o procedimento. OBJETIVO: Determinar através de estudos prospectivos endoscópico e histológico seqüenciais o tamanho da bolsa gástrica, o diâmetro da anastomose e o comportamento da infecção por H. pylori após a operação. MÉTODOS: Em 130 pacientes submetidos ao bypass gástrico foram realizadas várias avaliações sequenciais endoscópica (até 120 meses) e histológica de rotina da bolsa gástrica. RESULTADOS: Após a operação, foram realizadas em média 3,6 endoscopias por paciente. Macroscopicamente quase 95% das pequenas bolsas gástricas eram normais, e o principal achado patológico foi uma úlcera marginal. Esofagite erosiva desapareceu em 93% dos pacientes. Não houve aumento no tamanho orocaudal da bolsa durante o período de observação. Não houve dilatação do diâmetro da anastomose gastrojejunal. Perto de 54% de todos os pacientes tinham mucosa fúndica normal, enquanto 18% tinham gastrite crônica ativa, coincidente com a infecção por H. pylori. Cinco pacientes tinham metaplasia intestinal. CONCLUSÃO: Com base nesta avaliação endoscópica sequencial, não houve aumento no tamanho orocaudal da bolsa gástrica, nem do diâmetro da anastomose gastrojejunal. O comportamento do H. pylori foi inconsistente e difícil de interpretar.

BACKGROUND: Roux-en-Y gastric bypass is the most common performed bariatric surgery. A small gastric pouch is created, leaving a narrow gastrojejunal anastomosis, with a long jejunal limb. Very little is known regarding the behavior of this pouch years after surgery. AIM: To determine through prospective sequential endoscopic studies the size of the gastric pouch, the diameter of the anastomosis, and the behavior of H. pylori infection after surgery. METHODS: In 130 patients subjected to resectional gastric bypass, several routine sequential endoscopic (until 120 months) and histological evaluations of the gastric pouch were performed. RESULTS: After surgery, a mean of 3.6 endoscopies/patient were performed. Macroscopically nearly 95% of the small gastric pouches were normal, and the main pathological finding was a marginal ulcer. Erosive esophagitis disappeared in 93% of the patients. There was no increase in the orocaudal size of the pouch during this period of observation. There was no dilatation of the diameter of gastrojejunal anastomosis. Near 54% of all patients had normal fundic mucosa, while 18% had chronic active gastritis, coincident with H. pylori infection. Five patients had intestinal metaplasia. CONCLUSION: Based on this sequential endoscopic evaluation, there was no increase in the orocaudal size of the gastric pouch nor increase in the diameter of the gastrojejunal anastomosis. H. pylori behavior was inconsistent and difficult to interpret.

Background: Besides the weight reducing effects of gastric bypass, it is also a good antireflux procedure since there is no acid production by the gastric pouch and there is no duodenal reflux due to the presence of a Roux en Y. Aim: To describe the effect of gastric bypass on Barrett esophagus among patients with morbid obesity. Material and Methods: Among 896 patients subjected to gastric bypass, 14 patient with a Barrett esophagus diagnosed with endoscopy and biopsy, were followed. A new endoscopy was performed one to 30 months after the surgical procedure. Results: Short (< = 30 mm) and long segment (> = 31 mm) Barrett esophagi were present in eight and six patients, respectively. Gastroesophageal reflux symptoms relieved in 70% of these cases in a mean lapse of 6.5 months. There was regression from intestinal metaplasia to car-dial mucosa in six patients (75%) with short-segment, and in one patient (16%) with long-segment Barrett esophagus. Conclusions: Gastric bypass in patients with morbid obesity and Barrett esophagus is a very good antireflux operation. This was proved by the disappearance of symptoms in almost all patients and by the regression of the intestinal metaplasia which is time and length dependent.

Antecedentes: El bypass gástrico en obesos mórbidos, además de ser una alternativa de cirugía bariátrica, es un buen procedimiento antirreflujo dado que no hay producción de ácido en el reservorio gástrico y no existe reflujo duodenal debido a la Y de Roux. Objetivo: Describir el efecto que tiene el bypass gástrico sobre el esófago de Barrett (EB) de pacientes obesos mórbidos, además discutir nuevos mecanismos fisiopatológicos implicados. Población: De 896 obesos mórbidos operados mediante bypass gástrico resectivo abierto, se siguieron a los 14 pacientes diagnosticados con EB mediante endoscopia e histología. Resultados: De los 14 pacientes con diagnóstico de esófago de Barrett, ocho pacientes presentaban EB corto (< 30 mm) y seis EB largo (> 31 mm). Los síntomas de pirosis y/o regurgitación presentes se resolvieron en un 70% de los casos en una media de 6,5 meses. Hubo una regresión de la metaplasia intestinal a mucosa cardial normal en seis pacientes (75%) con EB corto y en un paciente (16%) con EB largo. Conclusiones: El bypass gástrico es una muy buena alternativa quirúrgica antirreflujo en obesos mórbidos con EB, demostrado por la desaparición de los síntomas en la mayoría de los pacientes y la regresión de la metaplasia intestinal en la mitad de ellos, dependiendo del tiempo y de la longitud. Lo anterior, postulamos, que no sería debido solamente a que no hay producción de ácido en el reservorio gástrico y a que no existe reflujo duodenal, sino que habrían otros mecanismos fisiopatológicos implicados.

Background: The current treatment recommendation for chronic hepatitis C virus infection is the combination of peginterferon and ribavirin for 24 or 48 weeks, depending on the viral genotype. The aim of the therapy is to obtain a sustained virological response. Aim: To report our experience in the treatment of chronic hepatitis C. Material and Methods: Analysis of 52 patients treated between September 2000 and June 2009. Patients with genotype 1 or 5 were treated with peginterferon alpha 2a (180 ug/week) and ribavirin (1000 mg/day for those weighing less than 75 kg and 1200 mg/day for those weighing more than 75 kg) during 48 weeks. Patients with genotypes 2 and 3 were treated for 24 weeks with the same dose of peginterferon and ribavirin 800 mg /day. Results: Viral genotypes 1, 2, 3 and 5 were present in 81, 4, 11 and 4% of patients, respectively. Twenty four patients (46 %), 18 with genotype 1, achieved a sustained viral response. Age was the only variable that infl uenced the response to treatment. Conclusions: Approximately half of the patients with chronic hepatitis C, achieve a sustained viral response with peginterferon and ribavirin.

CYP2E1 enzyme is related to nonalcoholic steatohepatitis (NASH) due to its ability for reactive oxygen species production, which can be influenced by polymorphisms in the gene. The aim of this study was to investigate hepatic levels, activity, and polymorphisms of the CYP2E1 gene to correlate it with clinical and histological features in 48 female obese NASH patients. Subjects were divided into three groups: (i) normal; (ii) steatosis; and (iii) steatohepatitis. CYP2E1 protein level was assayed in microsomes from liver biopsies, and in vivo chlorzoxazone hydroxylation was determined by HPLC. Genomic DNA was isolated for genotype analysis through PCR. The results showed that liver CYP2E1 content was significantly higher in the steatohepatitis (45%; p=0.024) and steatosis (22%; p=0.032) group compared with normal group. Chlorzoxazone hydroxylase activity showed significant enhancement in the steatohepatitis group (15%, p=0.027) compared with the normal group. c2 rare allele of RsallPstl polymorphisms but no C allele of Dral polymorphism was positively associated with CHZ hydroxylation, which in turn is correlated with liver CYP2E1 content (r=0.59; p=0.026). In conclusion, c2 allele is positively associated with liver injury in NASH. This allele may determine a higher transcriptional activity of the gene, with consequent enhancement in pro-oxidant activity of CYP2E1 thus affording liver toxicity

Background: Gastrointestinal stromal tumors (GIST) are the most common mesenchymatous tumors of the digestive tract. The pathological diagnosis is based on microscopy and immunohistochemistiy. Aim: To review the experience of our surgical unit in patients with GIST Material and methods: Review of medical records of 15 patients (aged 66+13 years, 11 women), with a pathological diagnosis of GIST, treated between 1999 and 2005. Results: The main presenting symptoms were melena in 40%, hematemesis in 20%, abdominal pain in 60% and anemia in 13%. In only one patient, the tumor appeared as an incidentaloma. All patients underwent upper gastrointestinal endoscopy A CAT scan was done in 87%, a barium swallow in 60% and a digestive endosonography in 20%. Thirteen tumors were located in the stomach and two in the small bowel. Mean tumor diameter was 5.3+1.7 cm. Surgical management was a tumor resection in 40%, a partial gastrectomy in 27%, a total gastrectomy in 20% and an intestinal excision in the rest. Mean hospital stay was 6.9+4.2 days. No postoperative complications were recorded. Conclusions: The main clinical presentation of GIST in this retrospective series was an upper gastrointestinal bleeding. Surgical treatment was devoid of complications

Background: Non alcoholic fatty liver disease (NAFLD) is associated to diabetes mellitus, obesity, disturbances in serum lipid levels, insulin resistance and metabolic syndrome. Aim: To assess glucose tolerance and the presence of metabolic syndrome among patients with biopsy proven NAFLD. Patients and methods: Serum lipid levels, hepatic function tests were measured and an oral glucose tolerance test was performed in 46 patients (mean age 45±12 years, 36 females) without history of diabetes mellitus and with steatosis in a liver biopsy. Results: Mean body mass index of the sample was 37±12 kg/m². Seventeen percent had pure steatosis, 78% had steatohepatitis with or without fibrosis and 50% had fibrosis in the liver biopsy. Glucose intolerance and diabetes was found in 57% and 15% of cases, respectively. The presence of steatohepatitis was higher in diabetics, compared with subjects with glucose intolerance or a normal glucose response (43, 38 and 8%, respectively, p <0.0001). Ninety three percent had a metabolic syndrome and the proportion of biopsies with fibrosis was higher among subjects with more than three diagnostic criteria for metabolic syndrome compared with those with three or less criteria (59 and 46%, respectively, p <0.05). Conclusions: Glucose intolerance, diabetes and metabolic syndrome are common among patients with NAFLD, even when they are not obese

Background: Non alcoholic steatohepatitis is common among patients with morbid obesity. Aim: To assess the prevalence of pathological alterations in the liver in patients with morbid obesity. Material and methods: Prospective study of patients with morbid obesity subjected to bariatric surgery. In the preoperative period serum lipid levels were measured and an abdominal ultrasound was performed in 342. During surgery a liver biopsy was obtained. Results: The pathological study of the liver showed a normal liver in 41 patients (10%), mild steatosis in 130 (31%), moderate steatosis in 59 (14%), severe steatosis in 32 (8%), steatohepatitis in 88 (21%), steatohepatitis with fibrosis in 60 (14%) and cirrhosis in 4 (1%). No association between liver damage and gender, body mass index or serum lipid levels, was observed. The liver was informed as normal on ultrasound examination in 47 of 106 (44%) patients with mild steatosis on pathology. On the other hand, liver was informed as having steatosis on ultrasound in 11 of 23 (32%) patients with pathologically normal liver. The concordance between ultrasound and liver pathology among patients with moderate or severe steatosis was 82 and 96%, respectively. Conclusions: Ninety percent of patients with morbid obesity have liver damage on pathology. Among patients with moderate or severe steatosis, there is a good concordance between ultrasound and pathological findings

Introducción: Las alteraciones de la histología hepática constituyen un hallazgo frecuente en pacientes con obesidad mórbida y pueden correlacionarse con los niveles sanguíneos de lípidos. Objetivos: Determinar la prevalencia de anormalidades histológicas del hígado en un gran número de pacientes chilenos con obesidad mórbida, correlacionados con los niveles de lípidos sanguíneos y con los hallazgos ecográficos preoperatorios. Material y Método: Estudio prospectivo y descriptivo de 414 pacientes con obesidad mórbida sometidos a cirugía bariátrica. En el preoperatorio se determinaron los niveles séricos de colesterol total y triglicéridos y se realizó ecotomografía abdominal para evaluar el aspecto macroscópico del hígado. Resultados: Hubo 90% de pacientes con alteraciones histológicas del hígado, presentando esteatosis leve, moderada, severa o esteatohepatitis. Cirrosis hepática se encontró en 4 pacientes (1%). No hubo diferencias significativas entre hombres y mujeres, entre el índice de masa corporal (IMC) preoperatorio y hallazgos histológicos. Tampoco se encontró correlación entre niveles sanguíneos de colesterol y triglicéridos. La ecotomografía abdominal tuvo una baja sensibilidad para el diagnóstico de esteatosis leve o hígado normal, teniendo una alta sensibilidad para el resto de las alteraciones histológicas. Conclusión: La obesidad mórbida se acompaña de alteraciones de la histología hepática en un 90% de los casos. Los hallazgos ultrasonográficos del hígado permitirían diagnosticar estas alteraciones en un gran número de estos pacientes

Background: Primary biliary cirrhosis (PBC) is a chronic cholestatic disease, which can progress to hepatic failure. Aim: To study the clinical presentation, pathological features, treatment and outcome of a group of patients with PBC. Material and methods: Retrospective review of medical records of 115 patients (110 females, age range 30-76 years) with PBC. Clinical presentation, pathological stage, treatment, outcome and eventual use of liver transplantation, were recorded. Result: Seventy eight percent of patients were symptomatic at presentation (itching in 69% and malaise in 62%). Antimitochondrial antibodies were positive in 56%. No clinical or laboratory differences were observed between symptomatic patients or those with positive antimitochondrial antibodies and the rest of the study group. Sjögren syndrome was present in 38%, hypothyroidism in 13%, scleroderma in 7% and rheumatoid arthritis in 5%. Initially, 61% had fibrosis and/or cirrhosis, and ursodeoxycholic acid was indicated in 94% of the patients. Fifteen patients underwent liver transplantation due to upper digestive bleeding or itching. Survival has been 67% at 36 months after transplantation. In one transplanted liver, PBC recurred. Conclusions: An early diagnosis and treatment of a progressive disease such as PBC will reduce the incidence of complications and the use of costly treatments

Background: Obesity is an important risk for pathological gastroesophageal reflux. Aim: To assess the effects of gastric bypass on obese subjects with erosive esophagitis. Patients and methods: Sixty two morbid obese subjects (aged 16 to 70 years, 41 females) with erosive esophagitis at the moment of surgery were studied. These patients were subjected to a gastric bypass with gastric resection. They were followed with upper gastrointestinal endoscopy every one year, looking for the presence of erosions or ulcers in the distal esophagus. Results: The mean follow up period was 21 months. Prior to surgery all patients had heartburn or regurgitation and at two years after surgery, 97% were asymptomatic. Esophagitis was found in 97 and 6.5% before and after surgery, respectively. Two patients had an esophageal ulcer, that healed on follow up endoscopy. There was a 72% reduction of overweight on late follow up. Conclusions: Gastric bypass is effective to control pathological gastroesophageal reflux in patients with morbid obesity

The prevalence of celiac disease (CD) is unknown in Chile. We have recently noted a rise in the number of cases diagnosed among adults. Aim: To describe the clinical characteristics of a group of adult celiac patients. Patients and methods: Clinical data of patients older than 15 years with positive antitransglutaminase or antiendomysial autoantibodies and a duodenal biopsy characteristic of CD were retrospectively reviewed. Age at diagnosis, symptoms and signs and laboratory, endoscopic and histological findings, were analyzed. Results: Thirty seven patients (28 women), were studied. Median age at diagnosis was 41 years (range 15-69). Main symptoms and signs were diarrhea (78%), weight loss (38%) and abdominal pain (38%). Anemia was found in 49%, elevation of ESR in 57%, elevation of alkaline phosphatases in 54%, elevation of aspartate aminotransferase in 38% and a rise in alanine aminotransferase in 27%. Antiendomysial antibodies were positive in 17/22 (77%) and antitransglutaminase in 19/22 (86%) patients. Endoscopic findings were suggestive of CD in 47% of cases and duodenal biopsy showed intestinal villi atrophy in 34 (92%) patients. The three patients with normal histology had positive serology and a good response to gluten free diet. Conclusions: CD should be considered in the differential diagnosis of patients with unespecific digestive symptons, even when they present late in adult life. Serologic markers are a good diagnostic tool. A normal duodenal pathology does not exclude the diagnosis, if other diagnostic features are present

Twenty percent of patients with chronic hepatitis C evolve to cirrhosis in 10 to 20 years. The degree of steatosis and hepatic iron stores in liver biopsy increase the risk. Age, high body mass index, diabetes mellitus and alcohol consumption are factors associated to the severity of liver damage. Aim: To study the association of steatosis and increased iron stores in the liver biopsy and age, overweight, alcohol consumption and diabetes with the severity of liver damage in patients with hepatitis C virus infection. Patients and methods: Retrospective study of 84 liver biopsies of patients with chronic infection with hepatitis C virus were studied. The pathological appearance was classified as stage I when chronic hepatitis with mild activity without fibrosis was observed; as stage II when moderate chronic hepatitis with mild fibrosis was observed and as stage III when there was a moderate chronic hepatitis with fibrosis or cirrhosis. The amount of steatosis and iron deposition in the biopsy were also assessed. Results: Forty one percent of patients were in stage I, 32% in stage II and 27% in stage III. Patients in stage I were younger than those in stages II and III (40.7 and 52.2 years respectively, p <0,001). No association between the severity of liver damage and the degree of steatosis, hemosiderosis, body mass index or alcohol intake, was observed. The frecuency of diabetes mellitus increased along with pathological staging (3, 15 and 30% in stages I, II and III, respectively, p <0,05). Conclusions: This study confirms that severity of chronic hepatitis C is associated with age and the presence of diabetes mellitus

Background:Primary sclerosing cholangitis (PSC) is a chronic cholestatic disorder characterized by progressive inflammation and fibrosis of the biliary tract, evolving to cirrhosis. It is commonly associated with inflammatory bowel disease (IBD). Aim: To communicate the clinical characteristics of patient with PSC seen in two reference centers. Patients and methods: Review of medical records of patients with PSC confirmed by liver biopsies. The clinical picture, laboratory abnormalities, imaging studies and treatment were recorded. Results: Thirty three patients (aged 16 to 73 years, 64% female) were identified. They corresponded to 1.7% of liver biopsies done between 1991-2003. Clinical presentation was a cholestatic picture in 40%, right upper abdominal pain in 36%, a dysenteric syndrome in 9% and varied symptoms in 15%. Laboratory tests showed cholestasis in 94% and positive anti ANCA, SMA, ANA and AMA antibodies in 28, 18, 15 and 9% of cases, respectively. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiography were diagnostic in 43 and 58% of patients, respectively. There was an association with ulcerative colitis in 12% of cases. Liver biopsies showed grade I PSC in 76% and grade II-III in 6% of patients. It also showed a concomitant chronic hepatitis and primary biliary cirrhosis in 12 and 6% of cases, respectively. Treatment consisted on ursodeoxycholic acid (UDCA) in 45%, UDCA plus 5-aminosalicylic acid derivatives in 12% and UDCA plus immunosuppresors in 12% of patients. Two patients had to be transplanted. Conclusions: PSC is an uncommon cause of chronic liver disease. It is suspected in cholestatic patients and confirmed with a liver biopsy. It can be associated with other autoimmune hepatic and extrahepatic diseases

The diagnosis of hepatocellular carcinoma in cirrhotic patients has increased, mainly due to early detection using newer imaging techniques. The therapeutic approach depends on the tumor staging and the liver function. Cardiac involvement has a very bad prognosis. We report three males aged 59, 75 and 76 years and two females, aged 64 and 79 years. All had cirrhosis of diverse aetiologies with hepatocellular carcinoma and tumoral invasion of the inferior vena cava and right atrium. Three patients died during hospital stay and two were discharged for conservative management at home. This rare complication has to be considered in cirrhosis (Rev Méd Chile 2004; 132: 1517-22)

We report a previously healthy 29 years old man, presenting with a sudden episode of abdominal pain, mild jaundice, hepatomegaly and ascites. Magnetic resonance imaging study and liver biopsy were compatible with veno-occlusive disease. Incidentally, an ulcerative colitis and portal vein thrombosis were diagnosed. Anticoagulant treatment was started, with good clinical and radiological response. Veno-occlusive disease of the liver must be suspected in cases of liver failure and ascites associated to procoagulant conditions (Rev Méd Chile 2004; 132: 1091-5)