Classification of anemia for gastroenterologists

Most anemia is related to the digestive system by dietary deficiency, malabsorption, or chronic bleeding. We review the World Health Organization definition of anemia, its morphological classification （microcytic, macrocytic and normocytic） and pathogenic classification （regenerative and hypo regenerative）, and integration of these classifications. Interpretation of laboratory tests is included, from the simplest （blood count, routine biochemistry） to the more specific （iron metabolism, vitamin B12, folic acid, reticulocytes, erythropoietin, bone marrow examination and Schilling test）, in the text and various algorithms, we propose a hierarchical and logical way to reach a diagnosis as quickly as possible, by properly managing the medical interview, physical examination, appropriate laboratory tests, bone marrow examination, and other complementary tests. The prevalence is emphasized in all sections so that the gastroenterologist can direct the diagnosis to the most common diseases, although the tables also include rare diseases. Digestive diseases potentially causing anemia have been studied in preference, but other causes of anemia have been included in the text and tables. Primitive hematological diseases that cause anemia are only listed, but are not discussed in depth. The last section is dedicated to simplifying all items discussed above, using practical rules to guide diagnosis and medical care with the greatest economy of resources and time.     

Factors Influencing the Rate of Fibrosis Progression in Chronic Hepatitis C

Alcohol consumption, age at infection, and male gender have been identified as risk factors for faster fibrosis progression in patients with chronic hepatitis C (CHC). Yet the influence of liver steatosis, light to moderate alcohol consumption, or iron overload on this progression remains controversial. To analyze the effect of individual risk factors and their interaction on fibrosis progression in a group of patients with CHC and a definite date of infection, we studied 133 consecutive untreated patients. Covariates included were age, body mass index (BMI), gender, age at infection, alcohol intake, serum lipids, glycemia, serum ALT, AST, GGT, iron, and ferritin, grade and stage (METAVIR and Scheuer), and hepatic stainable iron (Perl's stain). The rate of fibrosis progression was inferred from the METAVIR score. By logistic regression analysis, hepatic steatosis (odds ratio [OR], 3.035; 95% confidence interval [CI], 1.16-7.93), serum ferritin levels higher than 290 ng/ml (OR, 5.5; 1.6-18.65), and light to moderate ethanol intake (1-50 g/day) (OR, 5.22; 1.5-17.67) were independently associated with faster fibrosis progression. There was no effect of interaction between these variables on the rate of fibrosis progression. Liver steatosis, serum ferritin levels, and light to moderate alcohol intake are associated with faster fibrosis progression in chronic hepatitis C. Combination of these factors did not further accelerate this progression. The impact of modification of these factors on progression should be tested in longitudinal studies.     

Tenofovir-based rescue therapy for advanced liver disease in 6 patients coinfected with HIV and hepatitis B virus and receiving lamivudine.

We summarize the clinical history and laboratory results following the introduction of tenofovir among 6 patients coinfected with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) who presented with severe liver disease while receiving lamivudine-based highly active antiretroviral therapy. In all cases, the introduction of tenofovir led to a sustained undetectable HBV and HIV loads, with marked clinical and laboratory improvement in liver function. We provide supporting evidence for the role of tenofovir in the management of advanced HBV infection in HIV-positive patients after the development of lamivudine resistance.     

Recomendaciones del Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) sobre el cribado y tratamiento de la infección tuberculosa en pacientes con enfermedad inflamatoria intestinal

There is evidence that following the recommendations on screening and treatment of tuberculosis infection does not completely prevent the onset of tuberculosis in patients with inflammatory bowel disease. This fact, and the increasing use of new biologics and immunomodulators, has led the Spanish Group Working on Crohn's Disease and Ulcerative Colitis to update their recommendations for the prevention of tuberculosis in patients with inflammatory bowel disease. Diagnostic methods for latent tuberculosis infection, different scenarios in which screening is to be performed, strategies to reduce the risk of tuberculosis once biological treatment is initiated and chemoprophylaxis guidelines for latent tuberculosis infection are reviewed, as well as the management of active tuberculosis during biological treatment. Finally, there is a summary of the current recommendations within the paper and in an algorithm.     

Anticardiolipin antibodies and acquired immunodeficiency syndrome: Prognostic marker or association with HIV infection?

Summary Anticardiolipin antibodies (ACA) frequently appear in patients with autoimmune disorders such as systemic lupus erythematosus, and have also been detected in infections, neoplasia, the primary antiphospholipid syndrome, in association with certain medications and also in subjects without apparent disease. Recently, anticardiolipin antibodies have been described in the acquired immunodeficiency syndrome. Eighty-four human immunodeficiency virus (HIV)-infected patients were studied to assess the influence of risk factors for HIV infection and of the stage of HIV-1 infection on the prevalence of IgG-ACA in HIV-seropositive patients. Patients were divided in two groups, one composed of 38 asymptomatic HIV-infected individuals and the other of 46 AIDS patients. A control group of 42 healthy HIV-negative blood donors was also studied. All subjects of the control group were IgG-ACA-negative. Of the 84 HIV-positive patients, 50 were IgG-ACA positive (59.5%) and 34 IgG-ACA negative (40.5%). None of the HIV-positive patients presented any thromboembolic phenomena. No significant differences were found with respect to sex, risk factors and stage of disease when the presence of IgG-ACA in HIV-positive patients was considered. ACA does not appear to be a pronostic marker in HIV-1-infected subjects. The presence of IgG-ACA is probably related to HIV-1-infection itself, and is indicative of impaired humoral immunity in these patients.

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Anticardiolipin-Antikörper und erworbenes Immunschwächesyndrom: Prognostischer Marker oder Assoziation mit HIV-Infektion?

Zusammenfassung Anticardiolipin-Antikörper (ACA) treten häufig bei Patienten mit Autoimmunkrankheiten wie Lupus erythematodes auf, wurden aber auch im Zusammenhang mit Infektionen, Neoplasien, dem primären Antiphospholipid-Syndrom und bestimmten Medikamenten beobachtet oder bei Personen ohne jegliche erkennbare Erkrankung. Kürzlich wurden Anticardiolipin-Antikörper bei erworbener Immunschwäche beschrieben. Um den Einfluß von Risikofaktoren für eine HIV-Infektion und des Krankheitsstadiums auf die Prävalenz von IgG- ACA zu ermitteln, wurden 84 HIV-infizierte Patienten untersucht. Sie wurden in zwei Gruppen, 38 asymptomatische HIV-Infizierte und 46 AIDS-Patienten unterteilt und mit einer Kontrollgruppe von 42 gesunden, HIV-negativen Blutspendern verglichen. Die Kontrollpersonen waren alle ACA-negativ. Aus der Gesamtgruppe der 84 HIV-positiven Patienten wiesen 50 ACA-IgG auf (59,5%), 34 waren negativ (40,5%). Thromboembolische Phänomene waren bei keinem dieser HIV-positiven Personen zu beobachten. Es bestand keine signifikante Differenz zwischen positiven und negativen ACA-Befunden hinsichtlich Geschlecht der Patienten, Risikofaktoren und Krankheitsstadium der HIV- Infektion. Bei HIV-1-Infizierten scheint der Nachweis von ACA keine prognostische Bedeutung zu haben. Die Antikörper sind wahrscheinlich mit der HIV-Infektion selbst assoziiert und ein Zeichen für die gestörten humoralen Immunfunktionen dieser Patienten.