IntroductionFew studies have examined hepatocellular carcinoma (HCC) in Brazil, and the incidence and risk factors for this type of malignancy vary greatly geographically. In this paper, we report several risk factors associated with HCC diagnosed at the University Hospital in Vitória, ES, Brazil.MethodsWe reviewed 274 cases of HCC (January 1993 to December 2011) in which hepatitis B (HBV) and C (HCV) virus infection and chronic alcoholism were investigated. A diagnosis of hepatocellular carcinoma was confirmed by histology or by the presence of a characteristic pattern on imaging.ResultsHCC with associated liver cirrhosis was noted in 85.4% of cases. The mean ages of men and women were 56.6 years and 57.5 years, respectively. The male-to-female ratio was 5.8:1. Associated risk factors included the following: HBV, 37.6% (alone, 23.4%; associated with chronic alcoholism, 14.2%); HCV, 22.6% (alone, 13.5%; associated with chronic alcoholism, 9.1%), chronic alcoholism, 17.1%, non-alcoholic steatohepatitis, 2.6% and cryptogenic, 19.3%. The male-to-female ratio was higher in cases associated with HBV or chronic alcoholism compared with HCV-associated or cryptogenic cases. In 40 cases without associated cirrhosis, the male-to-female ratio and mean age were lower than those in cirrhosis-associated cases.ConclusionsThese results demonstrate that the main risk factor associated with HCC in the State of Espírito Santo is HBV. Chronic alcoholism is an important etiological factor, alone or in association with HBV or HCV infection.

Para estudar a mortalidade e conferir a etiologia da cirrose lançada nas Declarações de Óbito (DO) no Espírito Santo, Brasil, foi feita a revisão das DO (2000 a 2011) e de prontuários dos falecidos com investigação de alcoolismo e hepatites B e C. Entre 218.410 DO foram identificados 3.554 mortes por cirrose. A mortalidade anual foi 19,8/100 mil homens e 4,31/100 mil mulheres, sem variação anual significativa e sem alteração significativa após correção por CID R98 e R99. Em 49% dos DO a causa da cirrose foi identificada: alcoolismo 85% e hepatite B ou C 15,7%. As etiologias nos 262 casos revisados foram: alcoolismo 40,5%; hepatite B ou C 26,7%; outras causas 3,8%; criptogênicas 10,6%. A média anual de anos potenciais de vida perdidos foi 5946 e 1739 anos, respectivamente, para homens e mulheres. A taxa de mortalidade por cirrose no Espírito Santo é intermediária em relação a outras regiões do mundo; alcoolismo e hepatites B e C são as principais etiologias. É provável que alcoolismo seja superestimado e hepatites B e C subestimadas como causa de cirrose nas DO.

To study mortality from liver cirrhosis in Espírito Santo State, Brazil, we reviewed death certificates (DC) from 2000-2010 and medical records of deceased patients with investigation of alcoholism and hepatitis B or C. From a total of 218,410 DC, 3,554 deaths from liver cirrhosis were retrieved. The annual mortality rate was 19.8/100,000 for men and 4.31/100,000 for women, without significant changes after correction for ICD-R98 and R99 and without a significant increase in the annual percentage change. In 49% of death certificates, the aetiology of cirrhosis was defined: of these alcoholism in 81.5% of cases and viral hepatitis in 15.7%. Aetiology was confirmed in 262 reviewed records, including alcoholism (40.5%); hepatitis B or C (26.7%); other (3.8%); and cryptogenic (10.6%). The mean annual potential years of life lost were 5,946 years and 1,739 years for men and women respectively. The mortality rate from cirrhosis in Espírito Santo State is intermediate in relationship to worldwide data; alcoholism and hepatitis B or C were the main aetiologies; probably alcoholism is overestimated and hepatitis B and C viruses are underestimated as causes of cirrhosis registered on death certificates.

Para el estudio de la mortalidad por cirrosis hepática en el estado de Espírito Santo, Brasil, se revisaron los certificados de defunción entre 2000-2010 y los registros de los pacientes fallecidos con un historial de alcoholismo y hepatitis B y C. De entre 218.410 certificados de defunción, se recuperaron 3.554 muertes por cirrosis hepática. La tasa anual de mortalidad fue de 19,8/100.000 para los hombres y 4,31/100.000 para las mujeres, sin variación anual significativa y sin cambios significativos, después de la corrección por CID-R98 y R99. En el 49% de los certificados de defunción se definió la etiología: alcoholismo 81,5 % y hepatitis viral 15,7%. La etiología se confirmó en 262 registros revisados: alcoholismo 40,5%; hepatitis B o C en un 26,7%; otras causas 3,8% y en un 10,6% la cirrosis era criptogénetica. La media de años potenciales de vida perdidos fue 5946 y 1739 años para hombres y mujeres. La tasa de mortalidad es intermedia en relación con el resto del mundo; alcoholismo y hepatitis B o C fueron las principales etiologías; el alcoholismo probablemente está sobrevalorado y la hepatitis B o C se subestiman como causa en los certificados de defunción.

Para estudar a mortalidade e conferir a etiologia da cirrose lançada nas Declarações de Óbito (DO) no Espírito Santo, Brasil, foi feita a revisão das DO (2000 a 2011) e de prontuários dos falecidos com investigação de alcoolismo e hepatites B e C. Entre 218.410 DO foram identificados 3.554 mortes por cirrose. A mortalidade anual foi 19,8/100 mil homens e 4,31/100 mil mulheres, sem variação anual significativa e sem alteração significativa após correção por CID R98 e R99. Em 49% dos DO a causa da cirrose foi identificada: alcoolismo 85% e hepatite B ou C 15,7%. As etiologias nos 262 casos revisados foram: alcoolismo 40,5%; hepatite B ou C 26,7%; outras causas 3,8%; criptogênicas 10,6%. A média anual de anos potenciais de vida perdidos foi 5946 e 1739 anos, respectivamente, para homens e mulheres. A taxa de mortalidade por cirrose no Espírito Santo é intermediária em relação a outras regiões do mundo; alcoolismo e hepatites B e C são as principais etiologias. É provável que alcoolismo seja superestimado e hepatites B e C subestimadas como causa de cirrose nas DO.

To study mortality from liver cirrhosis in Espírito Santo State, Brazil, we reviewed death certificates (DC) from 2000-2010 and medical records of deceased patients with investigation of alcoholism and hepatitis B or C. From a total of 218,410 DC, 3,554 deaths from liver cirrhosis were retrieved. The annual mortality rate was 19.8/100,000 for men and 4.31/100,000 for women, without significant changes after correction for ICD-R98 and R99 and without a significant increase in the annual percentage change. In 49% of death certificates, the aetiology of cirrhosis was defined: of these alcoholism in 81.5% of cases and viral hepatitis in 15.7%. Aetiology was confirmed in 262 reviewed records, including alcoholism (40.5%); hepatitis B or C (26.7%); other (3.8%); and cryptogenic (10.6%). The mean annual potential years of life lost were 5,946 years and 1,739 years for men and women respectively. The mortality rate from cirrhosis in Espírito Santo State is intermediate in relationship to worldwide data; alcoholism and hepatitis B or C were the main aetiologies; probably alcoholism is overestimated and hepatitis B and C viruses are underestimated as causes of cirrhosis registered on death certificates.

Para el estudio de la mortalidad por cirrosis hepática en el estado de Espírito Santo, Brasil, se revisaron los certificados de defunción entre 2000-2010 y los registros de los pacientes fallecidos con un historial de alcoholismo y hepatitis B y C. De entre 218.410 certificados de defunción, se recuperaron 3.554 muertes por cirrosis hepática. La tasa anual de mortalidad fue de 19,8/100.000 para los hombres y 4,31/100.000 para las mujeres, sin variación anual significativa y sin cambios significativos, después de la corrección por CID-R98 y R99. En el 49% de los certificados de defunción se definió la etiología: alcoholismo 81,5 % y hepatitis viral 15,7%. La etiología se confirmó en 262 registros revisados: alcoholismo 40,5%; hepatitis B o C en un 26,7%; otras causas 3,8% y en un 10,6% la cirrosis era criptogénetica. La media de años potenciales de vida perdidos fue 5946 y 1739 años para hombres y mujeres. La tasa de mortalidad es intermedia en relación con el resto del mundo; alcoholismo y hepatitis B o C fueron las principales etiologías; el alcoholismo probablemente está sobrevalorado y la hepatitis B o C se subestiman como causa en los certificados de defunción.

OBJECTIVES: To report the etiology of liver cirrhosis cases diagnosed at the University Hospital in Vitoria, Espirito Santo, Brazil. METHODS: The medical charts of patients with liver cirrhosis who presented to the University Hospital in Vitoria were reviewed. Chronic alcoholism and the presence of hepatitis B or C infections (HBV and HCV, respectively) were pursued in all cases. RESULTS: The sample consisted of 1,516 cases (male:female ratio 3.5:1, aged 53.2±12.6 years). The following main etiological factors were observed: chronic alcoholism alone (39.7%), chronic alcoholism in association with HBV or HCV (16.1 %), HCV alone (14.5%) and in association with alcoholism (8.6%) (total, 23.1 %), and HBV alone (13.1%) and in association with alcoholism (7.5%, total 20.6%). The remaining etiologies included cryptogenic cases (9.8%) and other causes (6.0%). The mean patient age was lower and the male-to-female ratio was higher in the cirrhosis cases that were associated with alcoholism or HBV compared with other causes. Intravenous drug abuse and a history of surgery or blood transfusion were significantly associated with HCV infection. Hepatocellular carcinoma was present at the time of diagnosis in 15.4% of cases. Chronic alcoholism associated with HCV infection was significantly associated (p<0.001) with reduced age (at the time of cirrhosis diagnosis) and increased prevalence of hepatocellular carcinoma (p = 0.052). CONCLUSION: Alcoholism, HCV and HBV are the main factors associated with liver cirrhosis in the state of Espirito Santo. Chronic alcoholism associated with HCV infection reduced the age of patients at the time of liver cirrhosis diagnosis.

OBJETIVO: Analisar os resultados do tratamento cirúrgico das formas necrosantes, ou graves, da pancreatite aguda e da forma crônica agudizada. MÉTODO: Foi preenchido um protocolo, de modo consecutivo e prospectivo, de 68 pacientes operados por pancreatite aguda grave e crônica agudizada, no período de 1982 a 2000. Os pacientes foram classificados em três categorias: 1. Pancreatite aguda biliar; 2. Pancreatite aguda de causa indeterminada; 3. Pancreatite crônica agudizada. RESULTADOS: As indicações para o tratamento cirúrgico foram: diagnóstico incerto (32,3%); necrose infectada (60,3%) e para necrosectomia (7,4%). As operações realizadas foram: desbridamento de necrose infectada(70,6%); operações sobre as vias biliares (20,6%) e desbridamento de grandes necroses (7,4%). Os óbitos hospitalares incidentes, por categoria foram: 1. Pancreatite aguda biliar (33,3%); 2. Pancreatite aguda indeterminada (45,0%); 3. Pancreatite crônica agudizada (37,0%). A média de óbitos foi de 38,2%. Vinte e cinco pacientes foram reoperados, uma ou várias vezes, e nestes a mortalidade foi de 40,0%. Os abscessos foram responsáveis por 52,0% dos óbitos e as outras complicações que resultaram em óbitos, sempre evoluiram para infecção. CONCLUSÕES: Ocorreu um alto índice de operações por diagnóstico incerto. Esta indicação deve se restringir aos casos onde não seja possível o diagnóstico diferencial com certas causas de abdome agudo. As indicações para tratar precocemente a litíase biliar devem ser evitadas ou reduzidas a situações específicas. As reoperações são freqüentemente indicadas nesses pacientes e a infecção foi a principal causa de morte.

BACKGROUND: To evaluate the results of surgical treatment of acute necrotizing pancreatitis, as well as its necrotizing alcoholic form. METHODS: Patients were analyzed according to a prospective protocol. Surgery was performed on 68 patients due to necrotizing acute pancreatitis and acutized chronic pancreatitis from years 1982 to 2000. Patients were grouped into three categories: 1) Biliary acute pancreatitis; 2) Acute pancreatitis of unknown etiology; 3) Necrotizing alcoholic pancreatitis. RESULTS: Patients had the following clinical indications for laparotomy: 1) Uncertain diagnosis (32.3%); 2) Infected necrosis (60.3%); 3) Necrosectomy (7.4%). The surgical findings were: Infected necrosis (70.6%); biliary complicatios (20.6%) and large necrosis 1(7.4%). Global hospital mortality was 38.2%. Individual categories showed a mortality of 33.3% (biliary acute pancreatitis), 45.0% (undetermined acute pancreatitis) and 37.0% (necrotizing alcoholic pancreatitis). Reoperations were indicated once or more times in 25 patients, and among these, the mortality was 40%. Abscesses were the main cause of death (52.0%), and all the other complications that resulted in death invariably evolved to infection. CONCLUSIONS: The indications of early surgical treatment for gallbladder stones, as well as when the diagnosis is not clear, should be reduced to very specific circumstances. Reoperations are common in these patients and infection was the main immediate cause of death.

OBJETIVO: Analisar as indicações, técnicas e resultados do tratamento cirúrgico de 74 pacientes operados por complicações da pancreatite crônica. MÉTODO: Foram pacientes consecutivos, estudados prospectivamente pelo preenchimento de um protocolo individual, no período de 1971 a 2000. Foram realizadas cirurgias de derivação e ressecção. O acompanhamento foi feito pelo agendamento de consultas no ambulatório, por convocação por cartas e telefonemas. RESULTADOS: Dos 270 pacientes com pancreatite crônica, acompanhados pelo Serviço, 74 (27,4%) foram operados. Destes 74 pacientes, 97,7% eram do sexo masculino e a idade variou de 15 a 63 anos, com média de 39,4 anos para alcoolistas e 33,1 para aqueles com outras etiologias. O alcoolismo foi a causa da doença em 68 pacientes (90,5%) e os outros casos estiveram relacionados a hiperparatiroidismo(1), pancreatite hereditária (1), fibrose retroperitoneal (1) e em três casos a etiologia não foi definida. As seguintes causas únicas ou associadas definiram a indicação cirúrgica:1. dor em 44,6% dos pacientes; 2. compressão de vias biliares em 28,4%; 3. pseudocistos em 12,2%; 4. fístulas internas em 10,8%. Cinqüenta pacientes (67,5%) foram submetidos a operações de derivação e 24 (32,5%) a cirurgias de ressecção. Oito pacientes derivados (16,0%) complicaram, ocorrendo três óbitos; dez ressecados (41,6%) complicaram, com cinco óbitos. Os óbitos estiveram relacionados a abscessos, às deiscências e às hemorragias cirúrgicas. CONCLUSÕES: As cirurgias de derivação mostraram-se mais seguras e as complicações que evoluíram com infecção foram as mais graves e ocorreram com mais freqüência nas ressecções.

BACKGROUND: To evaluate the indications, methods and results of the surgical treatment of 74 patients operated on for chronic pancreatitis complications. METHOD: Consecutive patients' charts were studied prospectively, during the years of 1971 to 2000. Surgery was indicated for pain, billiary tract stricture, pseudocysts, pancreatic ascitis and pancreaticopleural fistulas. Pancreaticojejunal anastomosis, billiary tract derivations and resections were performed. Follow-up was achieved through ambulatorial appointments or by mail and telephone calls. RESULTS: Of 270 patients listed with chronic pancreatitis, 74 (27.4%) were operated on. 97.7% of them were males. Patients varied in age from 15 to 63 years old, with an average of 39.4 years for alchoolists and 33.1years for those with pancreatitis of other etiologies. The disease was caused by alchool in 68 patients (90.5%). The other causes were: hyperparathyroidism (1), hereditary pancratitis (1), retroperitoneal fibrosis(1) and in three patients the etiology was unknown. Indications for surgery were: 1. Pain in 44.6% of the patients; 2. Billiary tract stricture (28.4%); 3.Pseudocysts (12.2%); 4. Pancreatic ascitis and pancreaticopleural fistulas (10.8%). Derivations were performed in 50 patients (67.5%), and resections in 24 (32.5%). Complications ocurred in eight patients with five hospital deaths related to abscesses, suture leaking and surgical bleeding. CONCLUSIONS: There was less morbidity and mortality for derivations and than after resections.

The authors report the surgical procedure in two patients with pseudomyxoma peritonei, histologically considered as mucinous adenocarcinoma. In both patients, intestinal loops and other visceras were blocked and it was not possible to localize the tumor's origin. There was, in both cases, a great volume of mucinous ascitis. In the first patient a laparotomy was performed and a drainage by a five centimeters peritoneostomy in the abdominal upper left quadrant. In the second just a peritoneostomy was performed in the same location. The sequential irrigation of the abdominal cavity controlled the ascitis in a few days. Certainly this approach avoided a second procedure to clean the mucinous ascitis.

Foi estudada a associação de infecção pelo Schistosoma mansoni em pacientes portadores de carcinoma hepatocelular (CHC) diagnosticados no Espírito Santo. O diagnóstico de esquistossomosefoi feito pelo exame parasitológico das fezes ou pelos achados histológicos à necrópsia. O diagnóstico de CHC foi feito por laparoscopia e biópsia, somente biópsia ou por necrópsia. Entre 45 casos de CHC, seis apresentavam infecção pelo S. mansoni (13,04%). A ocorrência de infecção esquistossomótica nos CHC HBsAg positivos ou negativos foi semelhante (13,33 e 13,63% respectivamente). A comparação pelo método do qui quadrado não mostrou diferença significativa entre a freqüência de infeccção esquistossomótica nos pacientes com CHC e a freqüência de esquistossomose na população que vive no E. Santo (5,97% entre crianças do curso primário de todas as regiões do Estado e 6,75% entre a população que procura recursos médicos em Vitória, a capital do Estado). Desta forma os autores acreditam que a associação de infecção esquistossomótica e CHC deve ser casual, especialmente nas áreas onde a esquistossomose é freqüente.

The association of Schistosoma mansoni infection with hepatocellular carcinoma (HCC) was studied in Espirito Santo State, Brazil. Schistosoma infection was diagnosed by stool examinations or by histological finding at autopsy. HCC was diagnosed by biopsy, laparoscopy and biopsy or at autopsy. Among 45 cases of HCC six had Schistosoma mansoni infection (13.04%). The occurrence of Schistosoma infection among HCC HBs Ag positive or negative was similar (13.3 3% and 13.63% respectively). The chi squared comparison showed no significant differences between the frequency of schistosomiasis in patients with HCC and the frequency of Schistosoma infection among people living in the Espirito Santo State (5.9% among children of elementary school from all the counties of the State and 6.7% in people that attended medical care in Vitoria, the capital of the State). Therefore, the authors believe that the association of schistosomiasis mansoni with HCC may be casual, specially in areas where the Schistosoma mansoni infection is frequent.