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Ethanol abuse is the most prevalent cause of liver cirrhosis in Spain. Genetic polymorphisms affect the activity of the enzymes involved in ethanol metabolism and in processing the toxic by-products generated in the liver. N-acetyltransferase 2 (NAT2) is a polymorphic phase 2 enzyme not involved in these processes, but recent data suggest that the most prevalent slow acetylator genotype protects against the risk of advanced alcoholic liver disease (ALD). We have identified six single nucleotide polymorphisms (SNP) at the NAT2 gene locus in order to disclose whether such an association exists.Genomic DNA from 95 ALD patients (15 with superimposed hepatocellular carcinoma (HCC)) and from 258 healthy individuals was analysed for SNPs at the coding region of the NAT2 gene by means of allele-specific polymerase chain reaction.There are no differences in the relative frequencies of the eight identified NAT2 alleles (including the wild-type allele) nor in the distribution of predicted phenotypes (54% of slow acetylators in each group). Twelve patients with HCC (80%) were slow acetylators (P0.05).There is no relationship between the NAT2 genotype and the risk of ALD. Slow acetylator genotype may predispose to the development of HCC in severe ALD patients not infected by the hepatitis C virus.

Introduction: There exist a great variability in the manometric findings between patients with anal incontinence (AI) and healthy subjects. The correlation between the pressures of the anal canal and the AI is not exact by the wide rank of normal values. Objectives: Prospective study to evaluate differences in the pressures of the anal canal and in rectal sensitivity in patients with AI, chronic constipation (CC) and healthy subjects. Material and methods: Ninety four patients with AI, 36 patients with CC and 15 healthy subjects were included. The following data were obtained: age, sex, resting pressure, anal canal length (ACL), squeeze maximum pressure (SMP), squeeze pressure duration (SPD), first sensation, urge and maximum tolerated volume (MTV). Statistical study: test of Kruskal-Wallis, test of Mann-Whitney, and multinomial logistic regression test. Results: There were significant differences in the resting pressure (p < 0.001), the ACL (p < 0.001) and the SMP (p < 0.01) in the group of AI with respect to the other two groups. The volume for the first sensation was significantly lower in the healthy subjects than that in the other two groups (p < 0.05). The urge volume and the MVT were smaller in the group with AI with respect to the other groups (p < 0.001). In multivariate analysis the age, the resting pressure and the volume for the first sensation and urge increase the relative risk for AI. Conclusions: The greater age, the decrease in anal canal resting pressure and the alteration of rectal sensation increase the risk for AI.

nearly all the data on the efficacy of combined antiviral therapy on chronic hepatitis C genotype 4 have been obtained in countries of Middle East. Genotype 4 is quite unusual in Spain. We report our experience in a group of Spanish patients treated with homogeneous criteria.between 2001 and 2007 we have treated 30 patients with chronic hepatitis C genotype 4 (20 males) with pegylated Interferon alpha-2b (26 cases) or alpha-2a (4 cases) combined with ribavirin at a weight-adjusted dose. Results of therapy are known in all patients and liver biopsy is available in 24 cases.ten patients (33.3%) obtained sustained viral response (SVR: HCV-RNA undetectable in blood 6 months after the end of therapy), 12 were primary non-responders, 4 relapsed after reaching undetectable HCV-RNA at the end of therapy and 4 interrupted the treatment due to severe adverse events. These results are very close to those obtained in 355 patients infected with HCV genotype 1.HCV genotype 4 should be considered as "difficult to treat". The better results of therapy in other geographical areas (Middle East) may be due to a different distribution of the subtypes of HCV genotype 4.

To determine the prevalence of Helicobacter pylori infection in the healthy population of Madrid Autonomous Community (AC).A descriptive, cross-sectional study where Helicobacter pylori infection is diagnosed by means of the 13C-urea breath test.A total of 618 subjects were studied. Among these, 481 were considered evaluable with a prevalence of Helicobacter pylori infection of 60.3%. In this cohort 36.4% were men and 63.6% were women, with a prevalence of 60.6 and 60.1%, respectively, and no relevant differences between both subgroups. The median age of patients was 37.5 years (range 4-82), and a statistically significant linear relationship between Helicobacter pylori infection and age (linear chi2 =33.31; p0.001) was established -chances of infection increase with age. Prevalence increases with age and peaks at 60 to 69 years (83.3% infected). For 169 subjects (35.1%) education level was unknown, and no relationship between this level and Helicobacter pylori infection was found.The study shows that the prevalence of Helicobacter pylori infection in the healthy population of Madrid AC is high (60.3%), progressively increases with age, and peaks in people in their sixties. The sample showed no differences regarding sex or education level.

lack of evidence in most clinical situations regarding irritable bowel syndrome (IBS) enhances the importance of an expert s opinion, which will guide management and even the concept underlying the disease.to delve into the knowledge and degree of agreement on main clinical skills for this syndrome among physicians involved in its management.two rounds of a Delphi survey were conducted on 100 physicians: general practitioners (GPs) and gastroenterologists. The questionnaire evaluated agreement among participants in some aspects regarding the definition, diagnosis, and treatment of IBS.fifty-five percent of participants completed the two-round survey. Agreement was achieved regarding the definition of typical symptoms and red flags characterizing IBS. Although there was no consensus regarding the appropriate management of patients without alarm symptoms, the performance of a colonoscopy on any patient presenting red flags was suggested. Patients were thought to require a wider examination when older than 40. A well defined line of IBS treatment was not found, albeit most physicians tended to choose it depending on the main complaint.interviewed physicians showed adequate theoretical knowledge of IBS, but lack of uniformity on diagnosis and treatment approach reflects the controversial day-by-day management of this syndrome.

Evolution of bowel habit in irritable bowel syndrome (IBS) is not well known.To evaluate the change over time of bowel habit in IBS patients followed-up during 1 year.Five hundred and seventeen patients with IBS were prospectively included in an observational study with five evaluations over a 1-year period. Symptoms were recorded daily in diary cards during four 4-week periods along the study. Bristol Stool Scale (BSS) was used to define bowel habit.Four-hundred patients completed the study. Rome II showed low-moderate agreement (42%) with BSS to define bowel habit. Frequency of constipation and diarrhoea showed little changes throughout the study. Over 50% of the patients had the same bowel habit when each diary was compared with the next one. A third of patients maintained the same habit throughout the study. Most changes occurred from/to mixed or unsubtyped IBS. Only 14% of cases changed from constipation to diarrhoea or vice versa. This change was associated to female gender (OR: 2.65).The frequency of constipation and diarrhoea remains relatively stable over time. Changes in IBS subtypes are common, but changes between constipation and diarrhoea are rare. Alternating IBS is more frequent in women.

To study whether any relationship exists between the C282Y and H63D mutations of the HFE gene, iron liver content, and the severity of histological damage in patients with hepatitis C virus (HCV)-induced chronic hepatitis.In 72 patients diagnosed with HCV-chronic infection, naïve for antiviral therapy, and undergoing liver biopsy, the Knodell index was established, a morphometric evaluation of hepatic hemosiderin deposits was performed by using a semiautomatic method of image analysis, and mutations of the HFE gene were identified through a polymerase chain reaction on leukocyte genomic DNA by using specific restriction enzymes. The control group for the distribution of HFE genetic variants was composed of 181 healthy individuals with the same ethnic and geographical (white Spaniards) origin.(Cases/controls): 1. Genotype distribution: a) mutation C282Y: no homozygotes, 6/23 heterozygotes, 66/158 without the mutation (not significant, n.s.); b) mutation H63D: 2/5 homozygotes, 26/52 heterozygotes, 44/124 without the mutation (n.s.). compound heterozygotes 2/6. 2. Allele frequencies: a) mutation C282Y: 0.042/0.064 (n.s.); b) mutation H63D: 0.208/0.171 (n.s.). Four C282Y heterozygous patients had stainable liver iron (p=0.015 vs patients without mutations). Sixty-six patients were not carriers of the C282Y mutation; among them, 26.9% of 26 carriers and 15% of 40 non-carriers of the H63D mutation had liver stainable iron (n.s.). Knodell index score, gender, age at diagnosis, mode of transmission, and serum and liver iron values were not related to the HFE genotype.our results suggest that the C282Y mutation, but not the H63D mutation, of the HFE gene is frequently associated with stainable iron in the liver in HCV-related chronic hepatitis. The HFE genotype is not related to the histological severity of the disease.

The inflammatory bowel disease is accompanied by cutaneous manifestations in approximately 10% of the cases. Neutrophilic dermatoses are located on the dermis and/or epidermis and are characterised on histological examination by the presence of an infiltrate that consists largely of neutrophils. The prototype of neutrophilic dematoses is Sweetacute;s syndrome; which is rarely associated with Crohńs disease.A 63 year old woman was admitted to hospital with pyrexia, abdominal pain, episcleritis and skin lesions. She presented erythematous lesions on trunk, legs and arms, with tendency towards formation of plaques, nodules and vesicular pustular lesions. Both the colonoscopy and colonic biopsies confirmed the diagnosis of colonic Crohńs disease. Cutaneous biopsies re-vealed an infiltrate consisting mainly of neutrophils. These biopsies, together with clinical details led to the diagnosis of Sweetacute;s syndrome. A methylprednisolone treatment rapidly improved the skin lesions and clinical symptoms. The different clinical forms of neutrophilic dermatosis are an extra intestinal manifestation of Crohńs disease, and are some-times found concurrently in the same patient, which would indicate a common pathogenesis with different clinical presentations (spectrum of neutrophilic dermatoses).

To produce and validate for telephone use in Spain a cross-cultural adaptation of the gastroesophageal reflux questionnaire (GERQ) developed by Locke et al.The Spanish version of the questionnaire was developed through translation, assessment of comprehensibility, back translation, and appraisal of applicability. Subsequently, reproducibility was measured by a test-retest procedure in 125 patients, and concurrent validity was evaluated by comparing self-reported questionnaire data against a gastroenterologist's findings from clinical interviews with 50 patients.The Spanish version showed itself to be easily understandable and widely applicable. Reproducibility for the two cardinal symptoms of gastroesophageal reflux disease (heartburn and acid regurgitation) as measured by the kappa index (95% confidence interval), was 0.85 (0.73-0.97) and 0.81 (0.70-0.92), respectively. With respect to the process of concurrent validation, kappa values (95% confidence interval) for heartburn and acid regurgitation were 0.85 (0.68-1) and 0.91 (0.79-1), respectively. Median kappa for all questions on the questionnaire was 0.75 (range: 0.42 a 1) in the reproducibility analysis and 0.83 (range: 0.44 a 1) in the concurrent validity analysis.The reproducibility and concurrent validity of the Spanish version of the GERQ is excellent and comparable to that of the original English version.

The aim of this study is to report our experience with infliximab and analyse prognostic factors for response in Crohn's disease (CD).Consecutive patients were prospectively enrolled in the study when referred for infliximab infusion. Data collected included indication for infusion, patient epidemiological characteristics, Vienna classification, previous surgery, previous medications and extra-intestinal manifestations. Adverse events and clinical response were tabulated separately for patients with luminal or fistulous Crohn's disease.28 patients were treated (7 with inflammatory and 21 with fistulizing disease). Patients received a total of 116 infusions of infliximab: 57.1% (4 of 7) of patients with luminal disease had complete response within a median of 17.5 days (range 15-28 days), and 62% (13 of 21) of patients with fistulizing disease had complete response within a median of 9 days (range 6-51 days). All patients (5) without relapse received concomitant treatment with immune modifiers. The group of patients with previous resection or perianal fistula repair had complete response more frequently p = 0.03 (OR = 30; IC 95% = 1.47-119.8).Infliximab is safe and beneficial in clinical practice for Crohn's disease. The re-treatment regimen of infliximab is effective in maintaining clinical response. Immunosuppressant therapy may have a role in the duration of maintained clinical remission in patients with fistulizing disease. In patients with perianal fistulizing disease infliximab treatment is more effective when previous resection or fistula repair is present.

To evaluate the prevalence of rectal hypersensitivity in our irritable bowel syndrome (IBS) patients, the relationship of hypersensitivity to rectal distensibility and the differences in sensitivity among clinical subgroups of IBS.18 healthy subjects and 56 IBS patients (Rome-II criteria; 22 diarrhea-predominant, 15 constipation-predominant and 19 alternating). Rectal sensitivity and distensibility were studied by isobaric phasic distension of a poliethilene bag with a barostat.IBS patients showed a lower threshold for discomfort, pain and maximum tolerate distension, without any differences in rectal distensibility. 64% of IBS patients were hypersensitive. 89% of patients with alternating IBS were hypersensitive while only 68% and 26% of patients with diarrhea-predominant IBS and constipation-predominant IBS, respectively, were. There were no differences in rectal distensibility between hypersensitive and normosensitive patients.64% of our IBS patients show rectal hypersensitivity, apparently not related to rectal distensibility. Hypersensitivity is mostly found in alternating IBS patients, and rare in constipation-predominant IBS.

A Spanish Consensus Conference had been arranged by the Spanish Club for the Study of Helicobacter pylori to encourage the use of eradication regimens in appropriate indications. The aim of our study was to assess whether the publication of these recommendations in November 1999 induced a change on the indications of eradication in the referring primary care district.Patients who had undergone Helicobacter pylori eradication therapy indicated by a gastroenterologist and referred to perform the 13C-labelled marked urea breath test were evaluated. Indications of eradication therapy were analysed and divided in: a) use of Conference recommended procedures (duodenal or gastric ulcer, erosive duodenitis, gastric MALT lymphoma and after resection of gastric adenocarcinoma); and b) other procedures not included in the recommendations (the rest). Indications established during former and latter years of publication of the Club's recommendations were compared.A total of 659 established eradications in 1999 against 537 in 2000, were studied. Regarding established eradications in 1999, 418 out of 659 (63%) followed the recommendations made by the Spanish Club, while 241 (37%) did not. In 2000, the proportion of eradication therapy administered using the recommendations made by the Spanish Club was similar to previous year: 338 (63%) followed the recommendations, against 199 (37%) that did not (p = not significant). In both years, considering those indications not recommended, patients either with superficial chronic gastritis with or without dyspepsia or with gastrooesophageal reflux disease were the main disorders to indicate eradication therapy.The recommendations of the Spanish Helicobacter pylori Study Club have not triggered a significant change after their publication on the indications for Helicobacter pylori eradication therapy in the setting studied.

To evaluate any differences in rectal distension perception between healthy subjects and patients with irritable bowel syndrome (IBS) according to an isobaric distension protocol (progressive or phasic).10 healthy subjects and 41 patients with IBS (Rome II criteria). Rectal distension was performed using a barostat connected to a 500 mL bag, and a progressive distension protocol (continuous distension at a rate of 0.36 mmHg/sec) was compared to phasic distension protocol (distensions for 60 sec with 4 mmHg increases separated by 0 mmHg pressures during 60 sec). Perception was evaluated using three descriptive scales of 7 categories each for perception type, intensity, and affectivity. Perception thresholds were assessed.No significant differences in any perception thresholds were found between control subjects and IBS patients using a progressive distension protocol. Differences in the perception of inconvenient distension and maximum tolerable distension were encountered with the phasic distension protocol. Uncomfortable distension thresholds below those of controls were found in 48.8% of patients with IBS when a phasic distension protocol was used, versus only 9.7% with a progressive protocol.Hypersensitivity in patients with IBS is mainly seen with the use of phasic distension isobaric protocols for affective negative perceptions.

Usually, cytomegalovirus infection dosen't cause symptoms in immunocompetents patients although sometimes can. In alcoholic and cirrhotic subjects can cause several and fatal infections. We describe a case of disseminated cytomegalovirus infection in an alcoholic patient with excellent response to ganciclovir.

To assess long-term outcome for patients with chest pain in our environment, to estimate direct resource use, and to evaluate the influence of patient views regarding pain origin on outcome.All patients referred to our Department between 1994 and 1998 to undergo pH-metry as a result of chest pain were identified. Those detected were subjected to a structured direct interview on the telephone.104 patients with a follow-up period (since pH-metry) of 3.76 years were evaluated. Thirty nine percent of patients were free from pain (37.5%), and one had died from a seemingly unrelated cause (1%), whereas the rest still suffered from pain. The mean number of visits per patient during the last year was 2.83 to their general practitioner, 1.04 to an specialist, and 0.99 to an Emergency Unit; hospitalisations were 0.26, and ICU admissions 0.09. Patients who trusted medical diagnoses showed better outcomes than those who did not trust or understand them, in association with lower resource use, particularly Emergency Unit use.Patients with chest pain had a favourable life prognosis, but 60% still suffer from pain after nearly 4 years of follow-up, which entails a relevant use of health-care resources. Trust in medical diagnosis seemingly influences outcome, and the use of diagnostic procedures to determine pain origin is thus likely beneficial for patient.

Cutaneous Electrogastrography (EGGc) is a technique used for recording the Gastric Electrical Activity by means of electrodes placed on the abdominal skin. The aim of the present study was to determine normal values in healthy volunteers as well as the influence of factors such as age, gender, Body Mass Index (BMI) and echographic location of the gastric antrum.An abdominal echography was initially performed in 35 of the 44 healthy volunteers in order to locate the gastric antrum and to place along its axis the skin electrodes, whereas in the other 9, the electrodes were placed according to anatomical references. Afterwards, the echography was also performed in those 9 volunteers in order to have all the 44 baseline echographic records. In every case, a record of ambulatory EGGc over 60 minutes was obtained, along with other record over the same period after eating a standard meal. The analysis of data was conducted through visual inspection and combined computer analysis.Eighty per cent of the study subjects showed a dominant frequency ranging from 2 to 4 cpm during both periods. After the meal, the parameters showed a characteristic variation. A significant difference was found when comparing subjects under 40 years of age versus subjects between 40 and 60 years of age in terms of preprandial dominant frequency instability coefficient (DFIC) (p = 0.002) and bradygastria (p = 0.03). Subjects with BMI25 kg/m2 showed preprandially a smaller dominant power instability coefficient (DPIC) (p = 0.035) and a greater Dominant Power (DP) (p = 0.045). In subjects without echographic control, DFIC (p = 0.001), bradygastria (p = 0.016) and tachygastria (p = 0.02) were more frequent, with a shorter period of normogastria (p = 0.001) during the postprandial period.Normogastria is the predominant rhythm in healthy people, although brief dysarrhythmias can be recorded that do not have any pathological meaning. Age and BMI, but not sex, seem to influence the Gastric Electrical Activity. The percentage of gastric dysarrhythmias decreases when the electrodes are placed along the longitudinal axis of the gastric antrum through echographic control.

An association with class II MHC genes has been described in ulcerative colitis, as in other diseases with immunological pathogenesis. Heterogeneous results have been reported, depending on the studied population.To study the importance of these genes in our population, mainly the alleles of group HLA DR2 (gene HLA-DRB1).We studied a total of 107 patients diagnosed of ulcerative colitis and 200 unaffected controls. Complete information about sex, age, family antecedent, age of onset, localization, complications, surgery and treatment was obtained from these patients. DNA was extracted from peripheral blood leukocytes and all the individuals were HLA-DRB1 genotyping.We conclude that a positive association exists between DR15 and ulcerative colitis (p0.05). This positive association was characterized and various clinical parameters were analyzed, being concluded that DR1501 is more frequent in this disease (p0.05) and in benign manifestations; the frequency of the allele DR1502 was also found to be elevated in severe manifestations.

To define the relationship between esophageal dysmotility and severity of gastroesophageal reflux (GER) at the distal and proximal levels.Two-level, 24-hour ambulatory pH monitoring and manometry of the esophagus were performed in 40 patients with abnormal distal acid exposure and in 20 healthy controls. Twenty patients with normal endoscopy or endoscopic evidence of grade I esophagitis were assigned to group 1 and 20 with grade II-III esophagitis were assigned to group 2. We used a dual-site pH probe with antimony electrodes spaced 15 cm apart.Patients had greater acid exposure than controls at both levels. The percentage of distal reflux episodes reaching proximal esophagus was significantly greater in group 1 than in the control group. The most marked reductions in the percentage of time of the pH remaining under 4 were detected in the patients with the most severe distal acid reflux and esophagitis (group 2). The mean lower esophageal sphincter pressure was significantly lower in group 2 than in group 1. The percentage of tertiary waves or nonperistaltic contractions was significantly higher in group 2 than in group 1 and the control group. Patients with milder distal reflux had significantly lower distal and middle esophageal wave amplitudes than controls. There were no significant differences between controls and patients with severe esophagitis in terms of the esophageal peristaltic wave amplitude in the middle third of the esophagus.No correlation was observed between episodes of distal reflux and proximal reflux in GER patients. Esophageal motor activity appears to be an important determinant of the severity and extension of GER in the proximal esophagus.

Gilbert's syndrome is a benign, often familial condition characterized by recurrent but asymptomatic jaundice.To describe the involvement of the reduced caloric intake test, used as a diagnostic test in Gilbert's syndrome.49 patients were diagnosed of Gilbert's syndrome for 6 years. 39 patients took 400 kcal/day for three days. The unconjugated bilirubinemia levels were measured at 0, 24, 48 and 72 hours.The 82.05% of test were diagnostics at 24 hours (p0.001), while it was necessary 48 hours to 100% of tests were diagnostics (p0.05). In any case was necessary to determinate the unconjugated bilirubinemia at 72 hours (p0.5).The best diagnostic efficiency of the reduced caloric intake test is at 48 hours, while the 24 hours determination could be considered diagnostic in a big percentage of the cases. It is not necessary the determination at 72 hours in any case.

Two-level pH monitoring was performed for 24 hours in 20 healthy subjects to document the presence of reflux episodes and to obtain reference values for reflux studies. The pH probes were placed 5 and 20 centimetres above the LES by means of a manometric technique. Significant differences were found at these two levels. At the proximal esophageal level 18 of the 20 subjects had reflux episodes. Five centrimetres above the lower esphageal sphincter the total reflux time was 1.35%, 2.05% in the upright and 0.15% in the supine positions. At 20 centimetres level it was significantly lower: 0.5% the total percent time with pH below 4, 0.8% and 0% in the upright and supine positions respectively. The mean reflux time was about 40% of the distal value, but the same pattern of reflux was observed at two levels of the esophagus. This technique is useful in documenting the cephalad extend of GER and allows to identify normal GER patterns at different levels of the esophagus.

To assess in a multicenter double blind clinical trial the gastroenteroprotective effect of zinc acexamate (ZAC).276 patients with rheumatic disease and history of peptic ulcer or intolerance to nonsteroidal antiinflammatory drugs (NSAID), and requiring treatment with these drugs were included. An initial normal endoscopy was needed for inclusion. Patients were treated with one NSAID (diclofenac, piroxicam, naproxen or ketoprofen) and one capsule (300 mg) of either ZAC (141 patients) or placebo (135 patients) at single nocturnal dose. After 28 days, patients underwent a clinical and endoscopic control.26 patients withdrew from the trial (10 of ZAC and 16 of placebo) and 41 were lost to followup (22 of ZAC and 19 of placebo). Gastroduodenal mucosal damage was graded according to a modified Lanza score. The incidence of gastric ulcer was null with ZAC and 6.0% with placebo (6 cases) (p0.05). The incidence of duodenal ulcer was 0.9% with ZAC (1 case) and 6.0% with placebo (12 cases) (p0.001). Nine patients of ZAC group (8%) and 25 of placebo (25%) presented some gastric damage (p0.001), and 5 (5%) and 19 (19%) respectively presented some duodenal damage (p0.005). After treatment, 88% of patients treated with ZAC and 66% with placebo had a completely normal endoscopy (p0.0005). No major side effects were reported through the study.ZAC has shown to be effective and well tolerated for the prevention of NSAID induced gastroduodenal damage in patients with rheumatic disease at risk. The incidence of gastric and duodenal ulcers decreased in 92% (13 times the risk), when compared to placebo.

The use of vasodilators to prevent the rupture of esophagic varices (EV) due to portal hypertension (PH) would reduce the portal pressure (PP) as the result of increased portocolateral flow. Rinsaterine, a 5-HT2 receptor blocker, reduces PP in experimental models of PH. This pilot study was designed to verify if ritanserine has a sustained and additive effect to propranolol on PP in cirrhotic patients with PH. Ten chronic patients with EV, under prophylactic therapy with propranolol and with a suprahepatic venous pressure gradient (SVPG)12 mm Hg, received ritanserine (0.11-0.14 mg/kg/day). One patients completed one month of treatment due to drug intolerance. Nine patients completed one month of treatment; SVPG did not show any significant variation in four patients and decreased 3 mm Hg in five patients, which were treated during 70 days more. After then, HVPG returned to its previous values except in one patient. The long-term association between ritanserine and propranolol does not improve the results of propranolol. However, the initial response observed in all of these patients supports the role of the serotoninergic system in the PH and states the need for further studies on 5-HT2 blocking for the prophylaxis of EV rupture.

Thrombotic thrombocytopenic purpura (TTP) is a syndrome characterized by fever, microangiopathic hemolytic anemia, thrombocytopenia, renal disease and neurologic changes. The development of little thrombi in the systemic microcirculation is thought to play an important role, however the etiology is unknown. We present two cases in which pancreatic disease was the first manifestation of TTP.

The patients with human immunodeficiency virus (HIV) infection have hepatic abnormalities due to infective, neoplastic and toxic disorders. The aim of the present study was to describe the spectrum of liver disease in the HIV infection and to establish the usefulness and indications of hepatic biopsy.The hepatic biopsies prospectively carried out in 50 patients infected by HIV with abnormal hepatic biochemical parameters, fever of unknown origin or space occupying lesions were evaluated.Hepatic granulomatosis was found in 37 patients (74%). In 15 (30%) the culture in Löwenstein medium was positive. The strains were typified as Mycobacterium tuberculosis in 14. This finding took place in 8 out of 18 biopsies carried out because of fever of unknown origin (FUO) (44%). The rate of granulomatosis due to mycobacteria was 40%. Other diagnoses were steatosis in 22 patients, chronic active hepatitis in 10, chronic lobular hepatitis in 3, infiltration by Hodgkin's lymphoma in one and metastatic invasion by non-differentiated carcinoma in one. Hepatic biopsy was diagnostic in 8 out of 18 carried out for FUO (44%) and in 24 out of 30 carried out for abnormal hepatic biochemical parameters (80%).In the evaluated patients with HIV infection, hepatic granulomatosis was the most common finding and was due to mycobacteria in 40%. Hepatic steatosis and chronic active and lobular hepatitis were the most common causes of abnormal hepatic biochemical parameters. Considering the high yield of hepatic biopsy, the authors think that it should be carried out in patients with HIV infection and FUO or unexplained abnormal hepatic biochemical parameters.

A total of 158 patients, aged 19-78 years and with endoscopically verified duodenal ulcer of at least 5 mm in maximum diameter were recruited. 79 patients were randomised to treatment with omeprazole, a proton-pump inhibitor of the parietal cell, and 79 patients were treated with ranitidine. This double blind study is the first clinical trial with omeprazole in Spain. Using "intention to treat" analysis there was no difference in healing rates at 2 weeks between the omeprazole group (70%) and the ranitidine group (59%) with p = 0.13. At four weeks, however, omeprazole healed significantly more patients (92%) than ranitidine (76%) with p = 0.005. Using per protocol analysis a similar result was obtained with no significant difference between omeprazole (71%) and ranitidine (63%) at two weeks (p = 0.3) but significantly greater healing on omeprazole at 4 weeks (97%) compared with ranitidine (83%) with p = 0.008. The influence of additional prognostic factors was assessed using a multivariate analysis. At two and four weeks, there was a significant effect of ulcer size on healing rate. At four weeks there was also a significant effect of treatment. Symptom relief was rapid in both treatments but the omeprazole group had significantly fewer days of pain and better patient's overall evaluation than ranitidine group. No serious adverse events were reported. In conclusion omeprazole healed significantly more duodenal ulcers than ranitidine and symptom relief was more rapid during omeprazole therapy.