Publication: Enteropatía hipertensiva en pacientes cirróticos candidatos a trasplante hepático: evaluación endoscópica y relación con el síndrome de hipertensión portal
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2017-08-18
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Universidad Complutense de Madrid
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Abstract
Los pacientes con cirrosis e hipertensión portal pueden desarrollar varices esofágicas, gastropatía hipertensiva y colopatía hipertensiva, manifestaciones que constituyen un problema de gran importancia en estos pacientes, ya que contribuyen de manera clara a su morbilidad y mortalidad. En los últimos años, el desarrollo de nuevas herramientas endoscópicas como la cápsula endoscópica (CE) y la enteroscopia de doble balón ha permitido mejorar la calidad del estudio del intestino delgado y demostrar la existencia de lesiones intestinales en los pacientes con cirrosis e hipertensión portal, que se han denominado “enteropatía hipertensiva” (EHT). La primera descripción de estas lesiones la realizó De Palma en 2005, comunicando la existencia tanto de lesiones de tipo inflamatorio como de lesiones vasculares: angiodisplasias, varices, etc. No obstante, la prevalencia, criterios diagnósticos e importancia clínica de esta condición no son bien conocidos. Por un lado, no existe información detallada sobre la precisión de la CE en el diagnóstico de EHT en los pacientes cirróticos. El único estudio publicado hasta la fecha que evalúa el acuerdo interobservador en la interpretación de los hallazgos de EHT tras el estudio con CE comunica una concordancia del 100%. Sin embargo, este resultado no ha sido validado posteriormente. Tampoco se conoce la prevalencia de esta condición en los pacientes candidatos a trasplante hepático, población extremadamente sensible por su gravedad y por las posibles implicaciones de la EHT durante la permanencia del paciente en la lista de espera. Por otra parte, se desconoce la importancia clínica de esta manifestación endoscópica de los pacientes con hipertensión portal. Mientras algunos estudios no han demostrado una asociación entre la presencia de lesiones intestinales y el valor de la hemoglobina, otros han encontrado sangrado activo en el momento del estudio endoscópico y otros una contribución a la anemia de los pacientes cirróticos debido a las pérdidas crónicas ocultas...
Patients with cirrhosis and portal hypertension are at risk of developing esophageal varices, portal hypertensive gastropathy and portal hypertensive colopathy, all of them increasing morbidity and mortality in cirrhosis. Recently, the introduction of capsule endoscopy (CE) and double-balloon enteroscopy, that allow the visualization of the whole small intestine, have demonstrated that cirrhosis can be also associated with several small bowel abnormalities that have been denominated as “portal hypertensive enteropathy” (PHE). The first description of this entity was done by De Palma in 2005, reporting inflammatory-like lesions such as hyperemia and edema and vascular lesions like angiodysplasia and varices. However, little is known about the true prevalence, diagnostic criteria and clinical significance of this condition. Firstly, there is no information about the diagnostic ability of CE for the diagnosis of PHE in the setting of cirrhosis. Only one study has reported the inter-observer agreement in the interpretation of PHE findings after CE examination showing a concordance of 100%; however these results have never been validated. On the other hand, the prevalence of PHE in patients with cirrhosis candidates to liver transplantation is also unknown, being this population especially important because of the disease severity and the possible implications of this condition during the time in the waiting list. Furthermore, the clinical consequences of PHE have not been fully studied; although some reports failed to show an association between intestinal lesions and hemoglobin levels, many other studies have found active bleeding during small bowel endoscopic exploration, and some others have reported an association between PHE and occult blood loss. Nevertheless, there are no studies aimed to elucidate the potential association between PHE and relevant characteristic findings of decompensated cirrhosis such as bacterial translocation and spontaneous bacterial peritonitis...
Patients with cirrhosis and portal hypertension are at risk of developing esophageal varices, portal hypertensive gastropathy and portal hypertensive colopathy, all of them increasing morbidity and mortality in cirrhosis. Recently, the introduction of capsule endoscopy (CE) and double-balloon enteroscopy, that allow the visualization of the whole small intestine, have demonstrated that cirrhosis can be also associated with several small bowel abnormalities that have been denominated as “portal hypertensive enteropathy” (PHE). The first description of this entity was done by De Palma in 2005, reporting inflammatory-like lesions such as hyperemia and edema and vascular lesions like angiodysplasia and varices. However, little is known about the true prevalence, diagnostic criteria and clinical significance of this condition. Firstly, there is no information about the diagnostic ability of CE for the diagnosis of PHE in the setting of cirrhosis. Only one study has reported the inter-observer agreement in the interpretation of PHE findings after CE examination showing a concordance of 100%; however these results have never been validated. On the other hand, the prevalence of PHE in patients with cirrhosis candidates to liver transplantation is also unknown, being this population especially important because of the disease severity and the possible implications of this condition during the time in the waiting list. Furthermore, the clinical consequences of PHE have not been fully studied; although some reports failed to show an association between intestinal lesions and hemoglobin levels, many other studies have found active bleeding during small bowel endoscopic exploration, and some others have reported an association between PHE and occult blood loss. Nevertheless, there are no studies aimed to elucidate the potential association between PHE and relevant characteristic findings of decompensated cirrhosis such as bacterial translocation and spontaneous bacterial peritonitis...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Medicina, leída el 25-01-2016