S0001-600220030001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000100001 Nutrientes como fármacos Padilla Cuadra Juan Ignacio ,CCSS Hospital R. A Calderón Guardia 03 2003 2003 45 04 04
S0001-600220030001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000100002 Ácido Fólico: nutriente redescubierto Suárez de Ronderos María del Pilar ,Universidad de Costa Rica Facultad de Medicina Escuela de Nutrición San José Costa Rica 03 2003 2003 45 05 09

Las funciones que en el organismo humano ejercen los folatos, referentes a la formación de eritrocitos y leucocitos en la médula ósea y a la prevención de daños en el desarrollo del tubo neural del niño durante la gestación, han sido bien estudiadas. En los últimos años, se han venido identificando funciones relacionadas con la salud cardiovascular y el desarrollo de enfermedad tumoral de los individuos. A este respecto, en esta revisión la autora pretende resaltar las funciones que ejercen los folatos en la salud humana, relacionadas con los niveles de homocisteína en suero y con la síntesis y reparación del ADN, lo cual ha sido relacionado respectivamente con el desarrollo de enfermedades cardiovasculares y algunos tipos de cáncer en humanos.

Folate functions as an enzyme co-substrates in biosynthesis of DNA and RNA, in the formation of both red and white blood cells in the bone marrow and for their maturation, and its importance in the embryogenesis, have all been well studied. Folate-responsive homocysteinemia, a condition associated with elevated risk for occlusive vascular disease; and the impaired biosynthesis of DNA and RNA, thus reducing cell division, wich is most apparent in cells with rapid multiplication rates (ephitelial cells of the stomach, intestine, vagina, uterine cervix); are the subjects of this review.

 Folatos ácido fólico homicisteina enfermedad cardiovascular enfermedad tumoral Mahan Arlin Nutrición y dietoterapia de Krause Nutrición y dietoterapia de Krause 2000 Décima edición Editorial Interamericana McGraw- Hill Casanueva kaufer-Horwitz Perea-Lizano Arroyo 2001 Segunda edición Editorial Panamericana Whitney Sizer Nutrition: Concepts and controversies Nutrition: Concepts and controversies 1997 Séptima edición Brouwer I Dusseldorp M Thomas C Durán M Hautvast J Eskes T Steegers-Theunissen R Low-dose folic acid supplementation decreases plasma homocysteine concentrations: a randomized trial American Journal of Clinical Nutrition 1999 66 Majumdar A Chemo preventive role of folic acid in colon cancer Chemo preventive role of folic acid in colon cancer 2000 Detroit^eMichigan Wayne State University School of Medicine Bloom H Determinants of plasma homocysteine American Journal of Clinical Nutrition 1998 67 Boushey C Quantitative assessment of plasma homocysteina as a risk factor for vascular disease JAMA 1995 274 Clarke R Daly L Robinson K Naughthen E Cahalane S Fowler B Grahan I Hiperhomocysteinemia: as independent risk factor for vascular disease New England Journal of Medicine 1991 324 Brönstrup A Hages M Prinz-Langenohl R Pietrzik K Effects of folic acid and vitamin B12 on plasma homocysteine concentrations in health y, young women American Journal of Clinical Nutrition 1998 68 Guttormsen A Schneede J Ueland P Retsum H Kinetics of total plasma homocysteine in subjects with hiperhomocysteinemia due to folate or cobalamin deficiency American Journal of Clinical Nutrition 1996 63 Brattström L Cuskelly G Den Herjer M Naurath H Pietrzick K Saltzman E Ubbink J Lowering blood homocysteine with folic acid based supplements:Meta analysis of randomized trials British Medical Journal 1998 316 Nygard O Refsum H Ueland P Volsett S Major lifestyle determinants of plasma total homocysteine distribution: The Hordaland Homocysteine Study American Journal of clinical nutrition 1998 67 Selhub J Rosenberg I Serum total homocysteine concentrations in the third national Health and Nutrition Examinatiion survey (1991-1994): population reference ranges and contribution of vitamins status to hingh serum concentrations Ann Intern Med 1999 131 Lowering blood homocysteine with folic acid based supplements: meta analysis of randomised trials British Medical Journal 1998 16 Beresford S Boushey C Preventive Nutrition:the comprehensive guide for health professionals Preventive Nutrition:the comprehensive guide for health professionals 1997 Editorial Human Press Inc Rimm E Walter C Willet M Frank B Sampson L Grahan A Manson J Hennekens Ch Stampfer J Folate and vitamin B12 from diet and supplements in relation to risk of coronary hearth disease among women JAMA 1998 279 ^s5 Ridker P Manson J Buring J Shih J Matias H Hennekens Ch Homocysteine and risk of cardiovascular disease among post-menopausal women JAMA 1999 281 ^s19 Mohan Stansby Nutritional hiperhomocysteinemia, evidence mounts for its role in vascular disease British Medical Journal 1999 318 Wald D Bishop L Wald N Randomized trial of folic acid suplementation and serum homocisteyne levels Ann Intern Med 2001 161 Morrison H Schaubel D Desmeules M Wigle D Serum folate and risk of fatal coronary heart disease JAMA 1996 275 Robinson K Arheart K Refsum H Low circulating folate and vitamin B6 concentrations: risk factors for stroke, peripheral vascular disease , and coronary artery disease Circulation 1998 97 Rimm E Willet W Hu F Folate and vitamin B6 from diet and suplements in relation to risk of coronary heart disease among women JAMA 1998 279 Kangn S Wong P Malinow M Hiperhomocysteinemia as a risk factor for occlusive vascular disease Ann Rev Nutr 1992 12 Stamler S Slivka A Biological chemistre of thiols in the vasculature and vascular related disease Nutrition Reviews 1996 54 Ubbick J Will an increases dietary folate intake reduce the incidence of cardiovascular disease Nutrition Reviews 1996 54 Wattenberg L Inhibition of carcinogenesis by minor dietary constituents Cancer Research 1992 52 Folic acid for the prevention of neural tube defects Pediatrics 1999 104 ^s2 Hall J Folic acid: the opportunity that still exists Canadian Medical Association Journal 2000 162 Fairfield K Fletcher R Vitamins for chronic disease prevention in adults JAMA 2002 287 ^s23 Garland C Barret-Connor E Rossef A Dietary vitamin and calcium and risk of colorectal cancer: a 19 year prospective study in men Lancet 1985 1 Molloy A. M Scott J. M Folates and prevention of disease Public Health Nutr 2001 4 ^s2B Prinz-Langenohl R Fohr I Pietrzik K Beneficial role for folate in the prevention of colorectal and breast cancer European Journal of Nutrition 2001 40 ^s3 Szarka C Grana G Chemoprevention of cancer Curr. Prob. Cancer 1994 18 Nensy Y Arlow F Majumbar A Aging: increased responsiveness of colorectal mucosa to carcinogen stimulation and protective role of folic acid En:Dig. Dis. Sci 1995 40 Meenan J O’Hallinan E Scott J Weie D Epithelea cell folate depletion occurs in neoplastic but not adjacent normal colon mucosa Gastroenterology 1997 112 Kim Y Solomon R Choi S Dietary folate protects against the development of macroscopic colonic neoplasms in a dose dependent manner in the dimethilhidrazine rat model Gastroenterology 1994 106 Lashner B Red blood cell is associated with development of dysplasia and cancer in ulcerative colitis Cancer Res. Clin. Oncol 1993 91 Zhang S Hunter D Hankinson S Giovannucci E Rosner B Colditz G Speizer F Willet W A prospective study of folate intake and the risk of breast cancer JAMA 1999 281 Fuchs C Willet W Colditz G Hunter D Stampher M Speizer F Giovannucci E The influence of folate and multivitamin use on the familial risk of colon cancer in women Cancer Epidemiol biomarkers prev 2002 11 ^s3 Lashner B Heidenreich P Su G Effect of folic supplementation on incidence of dysplasia and cancer in chronic ulcerative colitis: a case controlled study Gastroenterology 1989 97 Su L Arab L Nutritional status of folate and colon cancer risk: evidence from NHANES I epidemiologic follow-up study Ann Epidemiol 2001 11 Cravo M Mason J Yoheshwar D Folate status and adenomatous colonic polyps: a colonoscopically controlled study Dis, Colon Rectum 1995 38 James S Basnakian A Miller B In vitro folate deficiency induces deoxynucleotide pool imbalance, apoptosis, and mutagenesis in chinese hamster ovary cells Cancer res 1994 94 Zhang S Hunter D Hankinson S A prospective study of folate intake and risk of breast cancer JAMA 1999 281 Boppana S Sarkar F Liu L Li Y Khan A Kucuk K Mahacala K Jaszewiski Folic acid: Regulation or growth of colon and gastric cancer cell lines Gastroenterology 114 Buttherworth C Effects of folate on cervical cancer, synergism among risk factors Ann NY Acad Sci 1992 669 Muir C Folate deficiency and cervical dysplasia Journal of the American Medical Association 1992 267 Giovannucci E Stampher M Colditz G Hunter D Fuchs C Rosner B Speizer F Willet W Multivitamin use, folate and colon cancer in women in the Nurses Heath study Ann Intern Med 1998 129
S0001-600220030001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000100003 Lo que el médico debe saber sobre los genes Jaramillo-Antillón Juan ,Academia Nacional de Medicina 03 2003 2003 45 10 14

El evento más trascendental del campo de la medicina en el siglo 21 y tal vez en la historia humana, será el desciframiento completo del código genético y de la acción de cada gen en la conformación y fisiología de las personas y de las proteínas que producen. En los aproximadamente 40 mil genes en nuestros cromosomas está contenido todo el conocimiento de nuestro cuerpo: cómo se forman los órganos, los tejidos, cómo funciona el organismo a través de la vida, por qué envejecemos, el color de la piel, los ojos, cómo llorar, caminar, reír, cómo reproducirnos e incluso en mucho cuán inteligente seremos. El estudio del genoma nos permitirá predecir la aparición de enfermedades monogénicas y el riesgo aumentado de padecer enfermedades de herencia multifactorial mediante marcadores genéticos. Será posible la prevención y tratamiento de enfermedades como el cáncer que por ahora nos parecen increíbles.

The most important scientific medical breakthrough in the 21st century and probably during the history of humanity will be the complete decoding of the human genome, its genes and proteins, and its actions on human physiology. Information for how organs and tissues are formed, why we grow old, the color of our skin and eyes, feeling like crying and laughing, and how intelligent we are is written in the approximately 40,000 genes on our chromosomes. The study on our genome will allow us to predict monogenic disorders and increased risk to multifactorial disorders with genetic markers. The prevention and treatment of disorders like cancer that now seems incredible, will be possible.

 Cookson W Cazadores de genes Cazadores de genes 1994 Madrid Editorial Pirámide Hamilton WD Extraordinary sex ratios Science 1967 156 Jegalian K Lahn TB Why the Y is so weird Scientific American 2001 284 ^s2 Woese C The universal ancestor The universal ancestor 1998 95 National Academy of Science of the USA Hamilton WD Nar row roads of gene land Nar row roads of gene land 1995 1 Pub. Basingstoke Jaramillo J El cerebro y la mente Las Paradojas de la Ciencia Las Paradojas de la Ciencia 1995 San José Editorial Universidad de Costa Rica Pinker S How the mind works How the mind works 1998 London Penguin Kazazian HH Moran JV The impact of Li retrotransposon on the human genome Nature Genetics 1998 19 Varmus H The Mechanics of Cancer: Illuminating the role of genetic mutations The Mechanics of Cancer: Illuminating the role of genetic mutations 2002 New York Academy of Science Magazine Ridley M Genome Genome 1999 London Fourth Estate Limited Scazzocchio C Alkaptonuria: from humans to moulds and back Trends in genetics 1997 13 Holm Vince Prader-Willi syndrome:consensus diagnostic criteria Pediatric 1993 91 Bickeboller H Apolipoprotein E and Alzheimer disease: genoty-pic-specific risks by age and sex Am J Hum Gen 1997 60 Ridley M The Red Queen: Sex and evolution of human nature The Red Queen: Sex and evolution of human nature 1993 London Viking Ridley M The Year of the Genome DISCOVER 2002 22 ^s1 Martin OP The sickening mind: brain, behavior, immunity and disease The sickening mind: brain, behavior, immunity and disease 1997 London Harper Collins Raleigh MJ McGuire MT Serotonin, aggression and violence in vervet monkeys Serotonin, aggression and violence in vervet monkeys 1994 Master, R.D. and McGuire Jaramillo AJ El Cáncer El Cáncer 1991 I San José Editorial Universidad de Costa Rica Yan Hai Kinzler W Kenneth Vogelstein B Genetic Testing Present and Future Science 2002 289 Slagboom PE Droog S Boomsma DI Genetic determination of telomere size in humans:a twin study of the three age groups Am J Hum Gen 1994 55
S0001-600220030001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000100004 Estudio de la discrepancia entre diagnóstico de defunción clínicos y los hallazgos de autopsia en el Hospital Calderón Guardia Casco-Jarquín Ana María Mita-Albán Luis Carlos ,Hospital William Allen Turrialba ,CCSS Hospital Calderón Guardia Servicio de Anatomía Patológica San José 03 2003 2003 45 15 19

Justificación: Los diagnósticos de defunción clínicos y anatomopatológicos no siempre coinciden. Ciertos grupos poblacionales ( tercera edad ) portan patologías crónicas y complejas, de difícil diagnóstico y manejo, que podrían significar un riesgo más elevado de discrepancias. Por esto, el conocimiento de los factores y las patologías involucrados reviste suma importancia para establecer retroalimentación entre ambas áreas. El objetivo de el presente es conocer cuales son las patologías más frecuentemente asociadas a discrepancia y determinar si existe o no asociación estadísticamente significativa entre esta última y grupos etáreos específicos. Métodos: La magnitud de la discrepancia , su relación con edad, y las patologías más asociadas a ella, fueron estudiadas retrospectivamente en un grupo de 173 autopsias realizadas en adultos durante el año 2000. Se revisaron protocolos de autopsia y expedientes de los pacientes, los datos fueron analizados con el sistema estadístico SPSS. Resultados: Encontramos un 44,8% de discrepancia entre los diagnósticos clínicos y los hallazgos de autopsia. Se encontró una asociación significativa ( p = 0,002 ) y directamente proporcional a la edad. Las patologías más asociadas a discrepancia, en orden descendente, fueron: Infecciones Respiratorias, Miocardiopatías y Neoplasias. Conclusiones: La frecuencia de discrepancias, las asociaciones poblacionales y etiopatogénicas encontradas nos indican la necesidad de una mayor vigilancia en esas áreas y sobre todo de revalorización del procedimiento de autopsia.

Clinical death and anatomopathologic diagnosis do not always coincide. Certain age groups (elderly people) carry chronic and complex pathologies of difficult diagnosis and management, that could mean a higher risk of discrepancy. Therefore, the knowledge of the factors involved in such discrepancies is of great importance to establish feedback between the two areas .The aim of this study is to know which are the clinical diagnosis more frequently associated to discrepancy and to know if there is an association or not between discrepancy and specific age groups. Methods: The magnitude of the discrepancy, its relation with age, and the most relevant pathologies were studied retrospectively in a group of 173 autopsies performed in adults in the year 2000. Protocols of autopsies and files of patients were searched. The data was analyzed by the SPSS statistical program. Results: We found 44,8% discrepancy between the clinical diagnosis and autopsy findings. There was an association (P=0,002) and it was directly proportional to age. The pathologies more related to the discrepancies in descending order were: respiratory infections, miocardiopathies, and neoplasms. Conclusions: The frequency of discrepancies, the population and etiopathogenic associations found ,show the need of greater supervision in those areas and specially the need for reassessment of the autopsy procedure.

 Autopsia Necropsia Causas de defunción Pujol R Bernet M Castellsagué J Esquius J Análisis de Concordancia entre diagnósticos clínicos y de autopsia en un hospital general Anales de Medicina Interna 1994 11 Madrid Reglamento de Autopsia Hospitalaria y Médico Legal La Gaceta 1987 Yesner R Medical Center Autopsy Costs American Journal of Clinical Pathology 1978 69 Gordana J Damir T Jakiae R Autopsy Findings and Clinical Diagnoses: Retrospective Study of 3117 Autopsies Croatian Medical Journal 1999 40 Chariot P Witt K Pautot V Porcher R Thomas G Zafrani E Declining autopsy Rate in a French Hospital Arch Pathol Lab Med 2000 124 Veress B Alafuzoff I A retrospective analysis of clinical diagnoses and Autopsy Findings in 3042 cases during two different time periods Human Pathology 1994 25 Galloway M The role of the autopsy in medical education Hospital Medicine 1999 60 Hanzlick R Baker P Institutional Autopsy Rates Arch Intern Med 1998 158 Venetia S Datta B N Banerjee A K Banerjee C K Kusum J Bhusnurmath B Autopsy Findings and Clinical diagnoses: A review of 1000 cases Human Pathology 1993 24 Autopsy: A Comprehensive review of current issues JAMA 1987 258 Devers K The changing role of the Autopsy: A social environmental perspective Human Pathology 1990 21 Kiesel E Hanzlick R Case of the month: The Autopsy and New Technology, all that glitters is not a gold standard Arch Intern Med 2000 160 Pastores S Halpern N Autopsies in the ICU: We still need them! Crit Care Med 1999 27 Blosser S Zimmerman H Do autopsies of critically ill patients reveal important findings that were clinically undetected? Crit Care Med 1998 26 Tai D El- Bilbeisi H Mascha E Sanjiv T Weidemann H Arroliga A A study of consecutive autopsies in a medical ICU CHEST 2001 119 Brown H Perceptions of the autopsy Human Pathlogy 1990 21 Collins K Hanzlick R Case of the month: The autopsy and the living Arch Intern Med 1999 159 Belzberg H Rivkind A It always pays to make a diagnosis: To autopsy or not to autopsy Crit Care Med 1998 26 Goldman L Sayson R Robbins S Cohn L Bettmann M Weisberg M The value of the autopsy in three medical eras The New England Journal of Medicine 1983 308 Mort T Yeston N The relationship of pre mortem diagnoses and post mortem findings in a surgical intensive care unit Crit Care Med 1999 27 Durning S Cation L The educational value of autopsy in a residency training program Arch Intern Med 2000 160 Nichols L Aronica P Are autopsies obsolete? Am J Clin Pathol 1998 110 Marwick C Pathologists Request Autopsy Revival JAMA 1995 273 Fernandez P Lazaro A Autopsy as quality assurance in the intensive care unit Crit Care Med 1988 16 Marcus F The lost art of auscultation Arch Intern Med 1999 159 Mangione S Nieman LZ Cardiac auscultatory skills of internal medicine and family practice trainees: A comparison of diagnostic proficiency JAMA 1997 278
S0001-600220030001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000100005 Implementación de un programa de rehabilitación cardiaca (Fase II) en el Hospital Max Peralta Roselló-Araya Marlene Guzmán-Padilla Sonia ,Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud Cartago Costa Rica ,Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud Cartago Costa Rica 03 2003 2003 45 20 24

Justificación y objetivo: Dentro de la prevención secundaria de las enfermedades cardiovasculares los programas de rehabilitación cardiaca (PRC) juegan un papel muy importante. Se presentan en este artículo los resultados del primer grupo de pacientes participantes del PRC desarrollado en el Hospital Max Peralta de Cartago. Métodos: Se implementó un PRC para pacientes que habían sufrido un evento cardiaco, de enero a diciembre de 1999, el cual consistió de sesiones educativas en forma grupal, tres horas una vez por semana durante tres meses. Al inicio y final se evaluaron el perfil lipídico, la antropometría, la dieta y la calidad de vida. Resultados: Participaron 15 pacientes, con una edad promedio de 59 años, más del 70% presentaron factores de riesgo de enfermedades cardiovasculares. El 59% del grupo presentó obesidad o sobrepeso. Al final del programa, el perfil lipídico mejoró principalmente los valores del colesterol y las LDL, la dieta fue nutricionalmente más balanceada, y la frecuencia en el consumo de frutas, vegetales y lácteos aumentó. Por el contrario la frecuencia de consumo de carnes, dulces, grasas y cereales disminuyó. La calidad de vida mejoró del inicio (96 ±22,9) al final (89,7± 27,3). Conclusión: Con el establecimiento de PRC se observa una clara mejoría del paciente post evento coronario en los aspectos físicos y emocionales. Sin embargo, estos programas son difíciles de implementar en los centros hospitalarios.

Justification and objective: A cardiac rehabilitation program (CRP) plays a very important role in the secondary prevention of cardiovascular diseases. The results obtained by the first group patients of that participated in a CRP developed at the Max Peralta Hospital in Cartago are presented in this article. Methods: A CRP was implemented for patients who had suffered a cardiac event the program, consisted of group educational sessions, held once a week for three hours during three months. The lipid profile, anthropometrics, diet and quality of life were evaluated at the beginning and at the end of the study period. Results: 15 patients participated, the average age was 59 years, more than 70% of them presented risk factors associated with cardiovascular diseases, 59% were overweight or were frankly obese (BMI >25). At the end the lipid profile had improved, mainly cholesterol and LDL levels. They were eating a diet nutritionally balanced, and the frequency of consumption of fruits, vegetables, diary products had increased. On the contrary, the frequency of intake of meats, candies, fats and cereals diminished. Quality Life improved from the beginning (96±22,9) until the end (89,7±27,3). Conclusion: Even though the establishment of CRP in hospitals is difficult, a clear improvement of the patients physical and emotional aspects was observed.

 Programa de rehabilitación cardiaca evento cardiaco lípidos educación nutrición dieta calidad de vida Cardiac rehabilitation program Lipids Education Nutrition Diet Quality of Life Cardiac event Memoria Anual 1999 (San José, Costa Rica) Memoria Anual 1999 (San José, Costa Rica) 2000 Ministerio de Salud Velasco J Maroto J Rehabilitación cardiaca: Evolución histórica y situación actual Rev Esp Cardiol 1995 48 ^s1 Rehabilitación después de las enfermedades cardiovasculares, en especial atención a los países en desarrollo Rehabilitación después de las enfermedades cardiovasculares, en especial atención a los países en desarrollo 1993 831 Pashkow F Issues in contemporary cardiac rehabilitation; a historical perspective J Am Coll Cardiol 1993 21 ^s3 Hedback B Perk J Wodlin P Long-term reduction of cardiac mortality after myocardial infarction:10-year results of a comprehensive rehabilitation programme Eur Heart J 1993 14 ^s6 Lavie C Milani R Benefits of cardiac rehabilitation and exercise training in elderly women Am J Cardiol 1997 79 ^s5 Jiménez M Gómez C Sáenz C Del -campo S Lacasa J Pombo M Calidad de vida y apoyo social en pacientes con infarto agudo de miocardio no complicado Rev Esp Cardiol 1999 52 Tormo V Rehabilitación cardiaca a largo plazo Rev Esp Cardiol 1995 48 ^s1 Sosa V Ubiera J Martínez E Cantapiedra J García M Delcán J Protocolos de rehabilitación hospitalaria en fase I y Fase II Rev Esp Cardiol 1995 48 ^s1 Velasco JA del Barrio V Mestre MV Penas C Ridocci F Validación de un nuevo cuestionario para evaluar la calidad de vida en pacientes postinfarto Rev Esp Cardiol 1993 46 Artigao R Control de factores de riesgo en los programas de rehabilitación cardiaca Rev Esp Cardiol 1995 48 ^s1 Castelli W Epidemiology of coronary disease: The Framingham Study Am J Med 1994 27 Resumen del II informe del Panel de Expertos sobre Detección, evaluación y tratamiento de la hipercolesterolemia en adultos JAMA 1993 269 ^s23 Friedman D Williams A Levine B Compliance and efficacy of cardiac rehabilitation and risk factor modification in the medically indigent Am J Clin Nutr 1997 79 ^s3
S0001-600220030001 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000100006 Acalasia: estudio de 27 casos en el Hospital Calderón Guardia Mainieri-Hidalgo José A. Schmitz-Gerstlauer Iris Mainieri-Breedy Giovanna ,CCSS Hospital Calderón Guardia Servicio Cirugía de Tórax ,Universidad de Costa Rica Cirugía de Tórax ,Universidad de Costa Rica 03 2003 2003 45 25 30

Se estudiaron en forma retrospectiva los expedientes clínicos de 27 pacientes diagnosticados con acalasia en el Hospital Dr. R. A. Calderón Guardia (HCG) vistos durante el período de 11 años comprendido entre 1991 y 2001, encontrando una tasa de 0.3 por 100.000 habitantes la cual es menor que la informada en la literatura. Esto posiblemente debido a que la ausencia en nuestro medio de manometría esofágica dificulta el diagnóstico de pacientes en estadio temprano o con enfermedad leve o moderada. La presentación clínica fue muy similar a la reportada por otros autores con una relación hombre mujer de 1.7 a 1 y edad promedio de 42 años. Los síntomas con un promedio de evolución de 7 años, fueron el más frecuente, la disfagia que se presentó en todos los casos, seguida de vómito, dolor torácico, pérdida de peso y datos de reflujo gastroesofágico. La esofagoscopía y la esofagografía mostraron hallazgos de enfermedad avanzada como dilatación esofágica importante, retención de restos alimentarios y cardias con espasmo que se superó fácilmente al presionar con el endoscopio. El tratamiento que se administró fue solamente médico (Nifedipina o Isorbide) a 6 pacientes, dilataciones y tratamiento médico a 7 y quirúrgico (esofagomiotomía) a 14, a tres de estos se les agregó un procedimiento anti-reflujo. La evolución se valoró con base en datos clínicos, encontrando que todos los pacientes con tratamiento médico y dilataciones continúan sintomáticos y con tratamiento. De los operados hay uno que ha requerido dilataciones 5 y 9 años después de la intervención, dos que no tuvieron procedimiento anti-reflujo, están en tratamiento por este problema y el resto se encuentran asintomáticos sin que se presentaran complicaciones quirúrgicas.

This is a retrospecti ve study of the clinical records of 27 patients diagnosed with achalasia at the Dr. R. A. Calderón Guardia Hospital during a period of eleven years from 1991 to 2001. The ratio was of 0.3 per 100.000 inhabitants which is less than the one found in the literature. This is probably due to the absence of esophageal manometry studies which makes difficult the diagnosis of these patients in early stages or with low or moderate symptoms of the disease. The clinical presentation was similar to that reported by other authors, with a ratio men to women of 1.7 to 1 and an average age of 42 years. The symptoms had an average of 7 years, disphagia being the primary one, present in all cases. This was followed by vomiting, thoracic pain, weight loss and gastroesophageal reflux. The esophagoscopy and esophagogram showed data of advanced achalasia such as esophageal dilatation, retention of alimentary rests, and cardial spasm, wich was easily forced opened with the endoscope. The treatment was only medical (Nifedipine and Isordil) in six patients, dilatations and medical in seven patients, and surgical (esophagomiotomy) in fourteen patients, three of them also had an anti reflux procedure. The patients treated medically and with dilatations continued to be symtomatic. Of the operated ones, there was a patient who required dilatations five and nine years after surgery. Two, who did not have an anti reflux procedure are under treatment for this problem, the rest are asymptomatic without any surgical complications.

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