Martín Tagle

Non-alcoholic fatty liver disease (NAFLD) currently represents an epidemic worldwide. NAFLD is the most frequently diagnosed chronic liver disease, affecting 20–30% of the general population. Furthermore, its prevalence is predicted to increase exponentially in the next decades, concomitantly with the global epidemic of obesity, type 2 diabetes mellitus (T2DM), and sedentary lifestyle. NAFLD is a clinical syndrome that encompasses a wide spectrum of associated diseases and hepatic complications such as hepatocellular carcinoma (HCC). Moreover, this disease is believed to become the main indication for liver transplantation in the near future. Since NAFLD management represents a growing challenge for primary care physicians, the Asociación Latinoamericana para el Estudio del Hígado (ALEH) has decided to organize this Practice Guidance for the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease, written by Latin-American specialists in different clinical areas, and destined to general practitioners, internal medicine specialists, endocrinologists, diabetologists, gastroenterologists, and hepatologists. The main purpose of this document is to improve patient care and awareness of NAFLD. The information provided in this guidance may also be useful in assisting stakeholders in the decision-making process related to NAFLD. Since new evidence is constantly emerging on different aspects of the disease, updates to this guideline will be required in future.

OBJECTIVES: Endoscopic investigation of the small intestine remains the last frontier for gastroendoscopists. We evaluated the diagnostic efficacy and safety of two different push-type, fiberoptic enteroscopes in the investigation of patients with occult gastrointestinal bleeding or suspected small bowel pathology. METHODS: Sixty-six patients (28 men, 38 women; mean age, 68) underwent push-type enteroscopy with either the SIF 10.5L (n = 17; scope length, 2495 mm) or the SIF 3000 (n = 49; length, 2995 mm) enteroscopes (Olympus America, Inc., Lake Success, New York). All patients enrolled had an indication of either occult gastrointestinal bleeding (n = 55) or suspected small bowel pathology (n = 11). Push-type enteroscopy was performed with an overtube and fluoroscopic guidance to better estimate the degree of insertion. Assessments of mucosal visualization, tip deflection, procedure tolerance, and complications were noted. RESULTS: Visualization of the small bowel mucosa and tip deflection was rated excellent in all patients. The mean length of insertion past the ligament of Treitz for the SIF 10.5L was 90 cm and 113 cm for the SIF 3000. Only one complication, a pharyngeal tear, occurred with the SIF 3000. Lesions that may explain the occult GI bleeding were found in 35 out of 55 patients (64%). Twenty-one of these 35 patients (60%) had lesions proximal to the ligament of Treitz, and 14 patients (40%) had lesions distal to the ligament of Treitz. If only distal lesions were considered, the diagnostic yield was 25% (14/55) for occult GI bleeding and 73% (8/11) for suspected small bowel pathology. The most common lesions were arteriovenous malformations (34%), which were successfully cauterized. CONCLUSION: With a relatively high diagnostic yield and therapeutic capability, push-type enteroscopy should play an important role in the investigation and treatment of lesions causing occult GI bleeding and small bowel pathology.

Fascioliasis is highly endemic in the Andean region of South America. Newer serological assays have improved our ability to diagnose acute fascioliasis. The diagnosis was established by Fasciola hepatica serology (Fas2-ELISA or Western blot) in 10 patients. Identifiable exposure included ingestion of watercress (N = 8), alfalfa juice (N = 5), and lettuce (N = 1). Computed tomography of the abdomen showed hepatomegaly (N = 9), track-like hypodense lesions with subcapsular location (N = 8), and subcapsular hematoma (N = 2). Radiologic sequelae included cyst calcifications detectable at least 3 years after treatment. Stool examinations were negative for F. hepatica eggs; serology was positive (Arc II [N = 2], Fas2-ELISA [N = 6], Western blot [N = 2]). The syndrome of eosinophilia, fever, and right upper quadrant pain, elevated transaminases without jaundice, hypodense liver lesions on CT, and an appropriate exposure history suggests acute fascioliasis. Fascioliasis is specifically treatable with a single dose of triclabendazole.