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Objetivo: Proveer recomendaciones clínicas basadas en evidencia para la evaluación y el manejo de pacientes con hemorragia digestiva alta (HDA) en el seguro social del Perú (EsSalud). Materiales y métodos: Se conformó un grupo elaborador local (GEG-Local) conformado por especialistas en gastroenterología y metodólogos. El GEG-Local formuló 11 preguntas clínicas a ser respondidas por la presente guía de práctica clínica (GPC). Se buscaron y seleccionaron GPC de HDA publicadas a partir del 2012, que respondieran a las preguntas planteadas y obtuvieran un puntaje mayor a 60% en los dominios 1 y 3 del instrumento Appraisal of Guidelines for Research and Evaluation II (AGREE-II). Durante septiembre del 2017 se realizaron búsquedas bibliográficas en Pubmed, para actualizar 9 preguntas clínicas de las GPC preseleccionadas, y para responder 2 preguntas de novo. La calidad de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG-Local revisó la evidencia y formuló las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de evaluación y manejo, usando la metodología GRADE Finalmente, la GPC fue aprobada con Resolución N° 80-IETSI-ESSALUD-2017. Resultados: La presente GPC abordó 11 preguntas clínicas, divididas en cuatro temas: valoración de riesgo, manejo inicial, manejo de HDA no variceal, y manejo de HDA variceal. En base a dichas preguntas se formularon 10 recomendaciones (7 recomendaciones fuertes y 3 recomendaciones débiles), 24 puntos de buena práctica clínica, y 2 flujogramas. Conclusión: Este artículo es el resumen de la GPC de EsSalud, en la cual se valoró la evidencia científica disponible sobre evaluación y manejo de HDA.

Objective: To provide evidence-based clinical recommendations for the evaluation and management of patients with upper gastrointestinal bleeding (UGB) in the Peruvian Social Security (EsSalud). Materials and methods: A local guideline development group (local GDG) was established, including specialists in gastroenterology and methodologists. The local GDG formulated 11 clinical questions to be answered by this clinical practice guide (CPG). We searched and selected CPG of UGB published from 2012, which answered the posed questions and obtained a score higher than 60% in domains 1 and 3 of the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. During September 2017, bibliographic searches were conducted in Pubmed, to update 9 clinical questions of the preselected CPGs, and to answer 2 de novo questions. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG reviewed the evidence and formulated the recommendations, points of good clinical practice and the flowchart of evaluation and management, using the GRADE methodology Lastly, the CPG was approved with Resolución N° 80-IETSI-ESSALUD-2017. Results: This CPG addressed 11 clinical questions, divided into four themes: risk assessment, initial management, management of non-variceal UGB, and management of variceal UGB. Based on these questions, 10 recommendations (7 strong recommendations and 3 weak recommendations), 24 points of good clinical practice, and 2 flow charts were formulated. Conclusion: This article is the summary of the EsSalud' CPG, where the available scientific evidence on evaluation and management of UGB was evaluated.

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OBJECTIVE: To identify the score that best predicts early severity in patients with acute pancreatitis. MATERIALS AND METHODS: A prospective cohort study was performed from December 2009 to December 2011. Cases of pancreatitis were classified as mild or severe based on the organ failure criteria and/or local complications according to the Atlanta Symposium. APACHE-II, BISAP and urea were calculated using data from the first 24 hours. Ranson was calculated using data from the first 48 hours. Hemoconcentratión was assessed 24 hours from admission, after adequate hydration. To assess the predictive value of the different scores the area under the curve ROC was used. RESULTS: 329 patients with acute pancreatitis were included: 214 women (65%) and 115 males (35%). The most common etiology was biliary 245 (74.3%). Two hundred and forty were mild cases of pancreatitis (73%) and 89 were severe (27%). The areas under the curve ROC were: APACHE-II: 0.74; BISAP: 0.78; Ranson: 0.48; urea: 0.70; hemoconcentratión: 0.73. There were 10 deaths (mortality: 3%). There were no significant differences between BISAP and APACHE-II, urea or hemoconcentration, but a significant difference existed with Ranson score. CONCLUSION: BISAP is a simple score that applied early in the emergency room identifies patients with severe pancreatitis with an efficacy similar to APACHE-II, urea and hemoconcentration, and KEY WORDS: acute pancreatitis, BISAP, severity, prognostic scoring.

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We report the case of a patient who initially made the diagnosis of acute hepatitis E virus with a clinical picture of jaundice with elevated liver enzymes and HEV IgM (+), but chronic evolution (More than 6 months) without being an immunosuppressed patient, forced us to exclude different causes that may produce chronic liver disease. And hypergammaglobulinemia was detected in liver biopsy: interface hepatitis, mixed inflammatory infiltrate with predominance of lymphocytes, and presence of portal-portal fibrous tracts, suggestive of severe active chronic hepatitis may be secondary to autoimmune hepatitis associated with hepatitis virus infection E. With these findings, we decided to start treatment for autoimmune hepatitis with prednisone and azathioprine, leading to a decrease in transaminases and coagulation profile to normal, which helped confirm the diagnosis of autoimmune hepatitis and decompensated manifested by acute virus infection of hepatitis E. Full report the case and a review of the literature.

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OBJETIVO: Identificar el indicador que mejor predice la severidad en forma temprana en pacientes con pancreatitis aguda. MATERIALES Y MÉTODOS: Se realizó un estudio de cohorte prospectiva entre diciembre del 2009 y diciembre del 2011. Se clasificó los cuadros de pancreatitis aguda en leve y severa en base a los criterios de falla orgánica o complicaciones locales según el Simposio de Atlanta. Los indicadores de APACHE-II, BISAP y urea fueron calculados usando los datos de las primeras 24 horas de admisión. El indicador de Ranson se calculó con datos de las primeras 48 horas. La hemoconcentración se calculó a las 24 horas de la admisión después de una adecuada hidratación. Para evaluar la capacidad predictiva de los diferentes indicadores se utilizó el área bajo la curva ROC. RESULTADOS: Ingresaron al estudio 329 pacientes con pancreatitis aguda: doscientos catorce mujeres (65%) y 115 varones (35%). La etiología más frecuente fue la biliar 245 (74.3%). Doscientos cuarenta fueron pancreatitis leves (73%) y 89 pancreatitis severas (27%). Las áreas bajo la curva ROC de los indicadores fueron: APACHE-II: 0.74; BISAP: 0.78; Ranson: 0.48; urea: 0.70; hematocrito a las 24 horas: 0.73. Se registraron 10 muertes (mortalidad: 3%). No se observó diferencias significativas del indicador BISAP con el indicador de APACHE-II, con la urea ni la hemoconcentración, pero sí con el puntaje de Ranson. CONCLUSIÓN: BISAP es un score sencillo que aplicado tempranamente en la emergencia identifica pacientes con cuadro clínico severo con eficacia similar al APACHE-II, urea y hemoconcentración; y mejor que Ranson.

OBJECTIVE: To identify the score that best predicts early severity in patients with acute pancreatitis. MATERIALS AND METHODS: A prospective cohort study was performed from December 2009 to December 2011. Cases of pancreatitis were classified as mild or severe based on the organ failure criteria and/or local complications according to the Atlanta Symposium. APACHE-II, BISAP and urea were calculated using data from the first 24 hours. Ranson was calculated using data from the first 48 hours. Hemoconcentratión was assessed 24 hours from admission, after adequate hydration. To assess the predictive value of the different scores the area under the curve ROC was used. RESULTS: 329 patients with acute pancreatitis were included: 214 women (65%) and 115 males (35%). The most common etiology was biliary 245 (74.3%). Two hundred and forty were mild cases of pancreatitis (73%) and 89 were severe (27%). The areas under the curve ROC were: APACHE-II: 0.74; BISAP: 0.78; Ranson: 0.48; urea: 0.70; hemoconcentratión: 0.73. There were 10 deaths (mortality: 3%). There were no significant differences between BISAP and APACHE-II, urea or hemoconcentration, but a significant difference existed with Ranson score. CONCLUSION: BISAP is a simple score that applied early in the emergency room identifies patients with severe pancreatitis with an efficacy similar to APACHE-II, urea and hemoconcentration, and better than Ranson.

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Reportamos el caso de una paciente en quien se hizo inicialmente el diagnóstico de infección aguda por virus de hepatitis E por presentar un cuadro de ictericia con elevación de enzimas hepáticas e IgM VHE (+), pero por evolución crónica (Más de 6 meses) y sin ser una paciente inmunosuprimida; nos obligó a descartar causas diferentes que podrían producir enfermedad hepática crónica. Se detectó hipergamaglobulinemia y en biopsia hepática: hepatitis de interface, infiltrado inflamatorio mixto a predominio de linfocitos, y presencia de tractos fibrosos porta-porta, cambios sugestivos de hepatitis crónica severamente activa que podría ser secundaria a hepatitis autoinmune asociada a infección por virus de hepatitis E. Con estos hallazgos se decidió iniciar tratamiento para hepatitis autoinmune con Prednisona y Azatioprina, produciéndose una disminución de las transaminasas y perfil de coagulación hasta la normalidad, lo que ayudó a confirmar el diagnostico de hepatitis autoinmune descompensada y puesta de manifiesto por una infección aguda por virus de hepatitis E. Presentamos el caso clínico completo y una revisión de la literatura.

We report the case of a patient wo initially made the diagnosis of acute hepatitis E virus with a clinical picture of jaundice with elevated liver enzymes and HEV IgM (+), but chronic evolution (More than 6 months) without being an immunosuppresed patient, forced us to exclude different causes that may produce chronic liver disease. And hypergammaglobulinemiawas detected in liver biopsy: interface hepatitis, mixed inflammatory infiltrate with predominance of lymphocytes, and presence of portal-portal fibrous tracts, suggestive of severe active chronic hepatitis may be secondary to autoimmune hepatitis associated with hepatitis virus infection E. With these findings, we decided to start treatment for autoimmune hepatitis with prednisone and azathioprine, leading to a decrease in transaminases and coagulation profile to normal, which helped confirm the diagnosis of autoimmune hepatitis and decompesated manifested by acute virus infection of hepatitis E. Full report the case and a review of the literature.

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OBJECTIVE: To assess the efficacy of esomeprazole-based triple therapy in the eradication of helicobacter pylori (HP). METHODOLOGY: A descriptive, prospective study was carried out between the months of June and August, 2008, at the Gastroenterology Service of the Cayetano Heredia National Hospital (HNCH) in which patients with non-ulcer dyspepsia infected with HP (diagnosed bya biopsy) were randomized and divided into two groups: the control group was treated with Amoxicillin (1g VO e/12h), Clarithromycin (500 mg VO e/12h) and Omeprazole (20 mg VO e/12h) and the study group received Amoxicillin (1g VO e/12h), Clarithromycin (500 mg VO e/12h) and Esomeprazole (20 mg VO e/12h); both treatments were administered over a period of ten days. Four weeks after the conclusion of the treatment, each group underwent an endoscopic control, including biopsy tests and breath tests to determine the eradication of the HP infection. RESULTS: A total of 83 patients were included, out of which 42 received triple therapy with Omeprazole (control group) and 41 received triple therapy with Esomeprazole (study group). Five patients of the control group and 7 of the study group were lost in the follow-up stage and 3 patients of the control group and 2 of the study group were excluded due to the lack of a breath test. Out of the 34 patients of the control group, HP was eradicated in 25 of them (73,5%) while out of the 32 patients of the study group, HP was eradicated in 26 (81,2%). The most important adverse effects included: diarrhea, headaches, abdominal pain and constipation. CONCLUSIONS: Treatment with Esomeprazole showed an eradication rate of 8% greater than treatment with Omeprazole and the percentage of adverse effects was similar in both groups.

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OBJETIVO: El presente trabajo tiene como objetivo principal, evaluar la eficacia de la terapia triple con esomeprazol en la erradicación del Helicobacter pylori (Hp). METODOLOGÍA: Se realizó un estudio descriptivo, prospectivo en el Servicio de gastroenterología del Hospital Nacional Cayetano Heredia (HNCH), donde se seleccionaron pacientes dispépticos no ulcerosos con infección por Hp (determinada mediante biopsia) entre los meses de junio a agosto del 2008, a los cuales se les dividió en dos grupos: el ¨grupo control¨ se trató conamoxicilina 1g VO c/12h, claritromicina 500 mg VO c/12h y omeprazol 20 mg VO c/12h, y el ¨grupo en estudio¨ recibió amoxicilina 1g VO c/12h, claritromicina 500 mg VO c/12h y esomeprazol 20 mg VO c/12h, ambos esquemas se dieron por 10 días. A las 4 semanas de completado el tratamiento, a cada grupo se le hizo un control endoscópico con toma de biopsias y test de aliento para determinar la erradicación del Hp. RESULTADOS: Se incluyó un total de 83 pacientes, de los cuales 42 recibieron terapia triple con omeprazol (grupo control) y 41 recibieron terapia triple con esomeprazol (grupo en estudio). Se perdieron en el seguimiento 5 pacientes del grupo control y 7 pacientes en el grupo en estudio. Por no contar con Test de aliento se excluyeron 3 pacientes en el grupo control y 2 pacientes en el grupo en estudio. De los 34 pacientes del grupo control se erradicó el Hp en 25 (73,5%), mientras que los 32 pacientes del grupo en estudio se erradicó el Hp en 26 (81,2%). Los efectos adversos más importantes incluyeron: diarrea, cefalea, dolor abdominal y estreñimiento. CONCLUSIONES: El tratamiento con esomeprazol presentó una tasa de erradicación 8% mayor que el esquema con omeprazol y el porcentaje de reacciones adversas fue similar enambos grupos.

OBJECTIVE: To assess the efficacy of esomeprazole-based triple therapy in the eradication of helicobacter pylori (HP). METHODOLOGY: A descriptive, prospective study was carried out between the months of June and August, 2008, at the Gastroenterology Service of the Cayetano Heredia National Hospital (HNCH) in which patients with non-ulcer dyspepsia infected with HP (diagnosed by a biopsy) were randomized and divided into two groups: the "control group" was treated with Amoxicillin (1g VO e/12h), Clarithromycin (500 mg VO e/12h) and Omeprazole (20 mg VO e/12h) and the "study group" received Amoxicillin (1g VO e/12h), Clarithromycin (500 mg VO e/12h) and Esomeprazole (20 mg VO e/12h); both treatments were administered over a period of ten days. Four weeks after the conclusion of the treatment, each group underwent an endoscopic control, including biopsy tests and breath tests to determine the eradication of the HP infection. RESULTS: A total of 83 patients were included, out of which 42 received triple therapy with Omeprazole (control group) and 41 received triple therapy with Esomeprazole (study group). Five patients of the control group and 7 of the study group were lost in the follow-up stage and 3 patients of the control group and 2 of the study group were excluded due to the lackof a breath test. Out of the 34 patients of the control group, HP was eradicated in 25 of them (73,5%) while out of the 32 patients of the study group, HP was eradicated in 26 (81,2%). The most important adverse effects included: diarrhea, headaches, abdominal pain and constipation. CONCLUSIONS: Treatment with Esomeprazole showed an eradication rate of 8% greater than treatment with Omeprazole and the percentage of adverse effects was similar in both groups.

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A choledochal cyst is a cystic dilation of the intrahepatic or extrahepatic biliary tract. According to the most accepted theory, it is caused by an anomalous pancreatobiliary junction. The most important complications are cholangiocarcinoma, lithiasis, and pancreatitis. Current therapy is surgical resection. Only 20% to 30% of cases are diagnosed in adult life. Two cases of choledochal cysts are reported in female adult patients, one of them in late pregnancy and the other in puerperium. Diagnosis of choledochal cyst in pregnancy and puerperium is an uncommon event, entailing particular considerations regarding symptoms and treatment.

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El quiste de colédoco consiste en la dilatación quística de la vía biliar intrahepática o extrahepática. Según la teoría mas aceptada, es causado por una anormalidad de la unión biliopancreática. Sus complicaciones más importantes son colangiocarcinoma, litiasis biliar, y pancreatitis, y su terapia es la resección quirúrgica. Sólo 20 por ciento a 30 por ciento de los casos se diagnostican en la vida adulta. Se reportan dos casos de quiste de colédoco en pacientes femeninas adultas, una de ellas al final de la gestación, y la otra puérpera. El diagnóstico de quiste de colédoco en la gestación y puerperio es un evento inusual que tiene consideraciones propias en cuanto a presentación y manejo.

A choledochal cyst is a cystic dilation of the intrahepatic or extrahepatic biliary tract. According to the most accepted theory, it is caused by an anomalous pancreatobiliary junction. The most important complications are cholangiocarcinoma, lithiasis, andpancreatitis. Current therapy is surgical resection. Only 20 per cent to 30 per cent of cases are diagnosed in adult life. Two cases of choledocal cysts are reported in female adult patients, one of them in late pregnancy and the other in puerperium. Diagnosis of choledochal cyst in pregnancy and puerperium is an uncommon event, entailing particular considerations regarding symptoms and treatment.

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Estudiamos un grupo de 20 sujetos que cumplían criterios diagnósticos de fibrositis primaria con el objeto de determinar las características clínicas y psicológicas de este síndrome en nuestro medio. Todos los pacientes fueron incluídos en un protocolo prospectivo que comprendía la elaboración de una historia clínica completa y la determinación del perfil psicológico empleando el test de Minnesota (MMPI) y el Test de Zung (A y D). El perfil psicológico de los sujetos con fibrositis fue comparado con dos grupos controles; uno, constituído por pacientes con artritis reumatoide y otro por sujetos sanos. Los síntomas más frecuentes fueron dolor musculoesquelético (100%), alteraciones del patrón de sueño (95%), fatiga matinal (80%), y sensación de hinchazón de tejidos blandos (70%). Encontramos : puntos dolorosos" y el "signo del salto" en la totalidad de pacientes. Las formas de presentación clínica más frecuentes fueron la Generalizada y la Axial. El perfil psicológico de los sujetos con fibrositis mostró alteraciones más definidas y acentuadas en relación a los grupos controles; hallándose valores en rango patológico para las escalas de MMPI de hipocondría, depresión, desviación psicopática, psicastenia y esquizofrenia

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